Doing More with Less Affords Emergency Medical Services Agencies Challenges and Opportunities

By: James McLaughlin

Ute Pass Regional Health Service District (UPRHSD) and its preceding entities have provided emergency medical and ambulance transport services to portions of Teller, Park, Douglas, and El Paso Counties for nearly 40 years.  Currently the district covers 539 square miles and is the soul ambulance provider for 19,000 residents.  Historically, the health service district has been sustained by patient and insurance billing supplemented by a 3.99% mill levy on property owners. However, as the structure of health insurance has changed, the district has seen a steady decline in both insurance and private pay revenue streams, while demand for service increased.  In 2011, this meant our agency was being asked to do more every year with fewer resources.  Adding additional pressure to the situation was the looming implementation of the Affordable Care Act.  The organizational leadership believed it would only be a matter of time before ambulance services where forced by The Center for Medicare Medicaid Services (CMS) to meet “deliverables” on established core measures.  Additionally, it was not and still is not clear how CMS planned to fund ambulance service in the future.  It was felt that much of the funding would be diverted away from traditional fee for service models into “value based” capitated models that would be managed by Accountable Care Organizations (ACO’s).

The leadership felt that our organization was not strategically aligned to meet these new challenges so the management developed the Paramedic Advanced Care Team (PACT) and spent the next two years developing four programs that would afford the organization the flexibility to meet the ever changing demands of this rapidly transitioning healthcare system.  Each program had to be evidence-based with clear goals and objectives around delivering healthcare to underserved populations, leveraging underutilized resources.  All four programs are designed to meet the “Triple Aim”, that is they are designed to,

  1. Improve patient and community health and outcomes.
  2. Reduce the cost of healthcare.
  3. Improve the patient experience.

The first program was named the Mental-Health Assessment Plan (MAP) and was implemented on December 1st 2014. MAP was a collaborative effort involving:

  • UPRHSD (our organization)
  • Aspen Pointe Behavioral Health
  • Cedar Springs Behavioral Health
  • Peak View Behavioral Health
  • Colorado State office of Behavioral Health (OBH)
  • Centura Health and their Saint Frances Institute for Medical Direction

Prior to implementation of the program, if a patient was in behavioral crises and called 911 for help a fire engine and ambulance would be dispatched along with 2 to 5 law enforcement vehicles.  The patient would then be loaded into the ambulance (the most expensive form of transport) and taken to a hospital emergency room in Colorado Springs more than 20 miles away.  The downstream costs associated with a behavioral health patient transported to an emergency room averaged over $3000.00.  Under the “MAP” approach, a single paramedic is dispatched in a small secure SUV with 1 or 2 law enforcement officers based on the need.  The client is medically cleared onsite using an evidence-based multipoint checklist.  Once medically cleared, if the client is found to be a danger to themselves or others they are assisted into the back of the secured vehicle and safely transported in the most cost effective manner to a local Crises Stabilization Unit (CSU).  In the year since its implementation the system has reduced behavioral healthcare costs by an estimated $145,000.00 in downstream costs and $94,000.00 in billable transport costs.  This cost savings has allowed the district to implement a sliding scale billing system for behavioral health clients based on total annual household income reducing the financial burden on those least able to surmount it.  All of this has been accomplished while obtaining an overall client satisfaction score of 4.8 out of 5, where 5 indicates perfect satisfaction.

The next program implemented was the Physician Oversight Program (POP).  The goal of this program has been to work with our high system utilizer population to reduce their dependency on the 911 system.  Many organizations utilize the term “frequent flier” to identify this population, our organization prefers the term loyalty access customer.  This population is found in most healthcare systems and generally consists of approximately 10% of the actual population but may utilize up to 80% of services.   The goal is to use Motivational Interviewing (MI) to identify barriers the client may have to accessing healthcare through conventional methods.  Then the PACT paramedic works with the client to overcome those barriers.  This is often something as simple as getting the client set up with a Healthcare Exchange Enrollment Specialist or a Primary Care Physician.  However, if needed the paramedic will work with the patient’s Primary Care Provider and the medical director to develop client specific protocols that establish alternative treatment modalities or destinations for the client. This program has been very successful as well with 75% of all clients enrolled in the program having no reported 911 calls after 30 days of enrollment.  While it is difficult to track the true cost savings of this program at this point, it is clear that there is a cost benefit as well as a humanitarian benefit to the client.  It is hoped that in the near future this program can be expanded to bridge the gap in care between a patient being seen in an acute care setting and when they are able to follow-up with their primary care provider.

The Home Health Assistance Program (HHAP) has not started yet.  But will be focused on providing care to patients during the transition from the hospital to home or assisted living facility.  The goal will be to reduce the risk of 90 day hospital readmissions for bundled payment populations.  This should include heart failure, hip and knee replacement, brittle diabetic issues, adult and pediatric obstructive airway disease and chronic pain sufferers that do not qualify for home healthcare services.

The goal of this program is to leverage the trust the community has in emergency service providers by utilizing MI to:

  • Perform home safety and needs assessment evaluations in the home of newly discharged patients.
  • Review discharge instructions with the patient in their home within 24 hours of discharge.
  • Identify possible risk factors related to transitions in care.
  • Introduce client to the green light, yellow light, and red light testing approach.
  • Help client identify internally motivated goals and objectives for improved health and wellbeing.
  • Provide client with a 7 digit access number to request on-sight assessment and assistance 24 hours a day to reduce emergency room dependency and the possibility of disease exacerbation.

The final program is the Community Health Improvement Project (CHIP).  This program is all about working with other community partners to help improve the overall health and wellness of our community members.   The first phase of this program has already been activated that is the immunization referral project.  Every patient encountered through the ambulance operations is evaluated for current vaccinations status.  If they are not up to date, the report is flagged for immunization referral to the PACT paramedic.  This referral process is cautiously being expanded to include:

  • Uninsured and under insured patients
  • Patients without primary care providers
  • Patients at high risk for falls
  • Patients in need of medical alert systems
  • Patients that display a need for home healthcare that meet the definition of home bound.

These programs are all flexible and utilize the paramedic’s current scope of practice to help meet the growing medical and mental health needs in our community.  These programs have been well received by our local partners and our patients.  Because these programs utilize existing staff with additional training they have all been relatively budget neutral with the added benefit of serving as a force multiplier.  Our agency is already mandated to respond on these patient populations.  This program allows UPRHSD to answer the call in a predictive and controlled manor before the crises stage reducing cost and improving outcomes as well as satisfaction.   In short this project is a shining example of the triple aim in action and prepares our community for future healthcare changes such as “ColoradoCare”, the proposed statewide Colorado single payer health insurance plan.