MedStar was hauling Antoine Hall, 32, to the emergency department as much as five times a week.
The Fort Worth resident has type 1 diabetes, high blood pressure, and gastroparesis, a medical condition that results in food remaining in the stomach longer than normal. Because he was not hungry, he was not eating frequently enough to produce sufficient insulin, resulting in a potentially lethal condition called diabetic ketoacidosis. He was admitted to the hospital on about 70 percent of the ED trips.
He was a prime candidate for the Fort Worth emergency medical service’s “EMS Loyalty Program,” aimed at those who are frequent ED users. MedStar personnel met with him twice a week for more than six months. They were able to reduce his nine prescription medications—which were causing side effects—down to two. They also taught him about balancing his diet and about his condition’s warning signs, which he said his doctors never took the time to tell him.
Since “graduation,” he has not been back to the ED for his chronic conditions.
In July 2009, MedStar began a community health program using paramedics to treat and counsel these high ED utilizers. It discovered that 21 people who called 911 as often as twice a week comprised more than 1 percent of its total call volume, at a cost of nearly $1 million.
Patients who have graduated from the CHP reduced their emergency department use by nearly 85 percent in the year after graduation, saving more than $7.4 million in ED charges. MedStar works with the patient and local healthcare providers to reduce the incidence of preventable ambulance responses. CHP now has 264 graduates.
The program includes those who call 911 15 or more times in 90 days. MedStar personnel visit enrollees in their homes, help connect them with healthcare resources, and teach them health self-management skills. Typical enrollment is 30-90 days.
EDs devote significant resources to provide non-urgent care to patients who often would have been better served elsewhere.
According to a 2010 RAND Corp. study, between 14 and 27 percent of ED visits could have been taken care of in a physician’s office, after-hours clinic, or retail clinic, potentially saving $4.4 billion annually. A 2010 Annals of Emergency Medicine study estimated frequent users—studies define “frequent use” as three to five ED visits annually—comprise 4.5 percent to 8 percent of all ED patients, yet account for 21 to 28 percent of all visits.
An estimated 10-40 percent of EMS responses are for non-emergency situations. Emergency responders have been an untapped resource for connecting high-need patients with primary-care services.
One of the biggest barriers has been the lack of reimbursement. Traditionally, EMS responders only are paid if they transport patients. However, policy trends are tilting in favor of programs such as MedStar’s patient-centered care approach. The shift toward value-based purchasing—away from fee-for-service and toward payment based on value and patient outcomes—could create a role for EMS personnel as part of a team that delivers low-cost, high-quality, coordinated care.
MedStar spent $500,000 to start CHP, but it has since gained substantial funding from several sources for this and other associated mobile health initiatives. Besides the high-utilizer effort, MedStar’s other programs include:
- 911 Nurse Triage – Non-emergency 911 callers are referred to a specially trained RN in MedStar’s call center who helps the patient find appropriate resources for their medical issue. The program diverted more than 500 patients who otherwise would have been transported to the ED in the last seven months of 2013.
- CHF Readmission Avoidance – MedStar conducts a series of home visits to educate congestive heart failure patients at risk for a 30-day readmission on appropriate care management. Patients typically are referred to MedStar by the patient’s case manager or primary-care physician. Through 2013, it had no 30-day readmissions for its 24 patients.
- Hospice Revocation Avoidance – MedStar works with hospice agencies to identify and work with high-risk patients to reduce the possibility of having their hospice status revoked by calling 911 for an urgent trip to the ED. Through the end of January, only about 10 percent of high-risk patients had their hospice status revoked.
- Observation Admission Avoidance – Patients who are candidates for 23-hour observation status may instead be referred by the ED physician to MedStar, which provides an overnight visit to do an in-home assessment and coordinate the transition of care back to the patient’s primary-care physician the next day. In its first year, it avoided 53 observation admissions.
Since its inception, MedStar estimates its mobile healthcare programs have saved more than $3.3 million in healthcare expenditures.
The CHP program was initially funded internally by MedStar, but it now has fee-for-service agreements with a local accountable care organization for the observation admission avoidance program, a hospice agency for the hospice revocation program, and with three local hospitals for the 911 nurse triage program. MedStar also has a three-year, $3.5 million grant under the Medicaid 1115a waiver program.
MedStar recently signed an agreement with Klarus Home Health Care to help prevent unnecessary trips to the ED by its 170 clients in MedStar’s service area. The agreement was the first of its kind in the nation.
Every program participant is funded by an outside source, which is highly unusual for an EMS operator, said MedStar director of public affairsMatt Zavadsky.
“Ten years ago, we couldn’t beg for money [from other sources],” he said. “Under accountable care, we now have aligned incentives with all of these other stakeholders. We don’t know what’s in our future. We never thought we’d get this far.”
MedStar, which makes nearly three times the trips it did when it began in 1986, broke ground earlier this month on a 60,000-square-foot facility in southwest Fort Worth that will be twice as large as its current Berry Street location. It expects to be in the new facility in January 2015.
Steve Jacob is editor-at-large of D Healthcare Daily and author of the book Health Care in 2020: Where Uncertain Reform, Bad Habits, Too Few Doctors and Skyrocketing Costs Are Taking Us. He can be reached at firstname.lastname@example.org.