Paramedics fight to combat ED visits, readmissions

One recurring problem payers and providers grapple with is 30-day readmissions, and the financial penalties associated with them. To help address this issue, and improve patient outcomes, more organizations are turning to community paramedic (CP) programs that enlist the services of EMS teams to answer calls and offer short-term interventions that help divert patients away from emergency departments and funnel them back into appropriate care channels.

Kevin McGinnis, MPS, program manager of Community Paramedicine-Mobile Integrated Healthcare and Rural Emergency Care for the National Association of State EMS Officials, says community paramedicine got its roots in the late 1990s in the Northeast United States and Canada but didn’t come to prominence until the mid-2000s. There are roughly 170 documented CP programs nationwide.

“We can start to help the health system affect savings where others in the traditional healthcare system can’t because we’re in the community 24/7 and we’re used to being in patients’ homes,” McGinnis says. Data suggests CP programs are effective in reducing repeat ED admissions and 30-day hospital readmissions, he adds. “… This is one small solution that the healthcare system can invoke.”

Diversion tactics

CP programs work by allowing EMS personnel to answer emergency calls and assess patients’ needs to determine whether less-costly, more beneficial interventions are appropriate. Patients may need a quick fix for low blood glucose and a referral to an endocrinologist, for example. “They can take care of the issue right then and refer the patient for primary care at a future date. Or they can refer patient to a higher level of care more immediately,” McGinnis says. “It’s very powerful. It’s that triage force. You don’t want triage being done in the ED, you want to come out in front of the ED to do that.”

CP programs are also offering additional services. Dan Swayze, DrPH, MBA, MEMS, vice president and chief operating officer of the Center for Emergency Medicine of Western Pennsylvania, Inc., says that while community programs vary from state to state, most utilize the services of community paramedics for areas within their scope of practice where there are gaps in traditional care, such as for patients without insurance who don’t qualify for home health nurse visits. “Some home nursing agencies are actually contracting with CP services to supplement their care, to help reduce the likelihood their patients will be readmitted to the hospital,” Swayze says.

CP programs are also helping bridge the gap between health and human services, he says. They can provide patient navigation and patient advocacy services for patients who can’t get them on their own or who need help finding the right program.

“Our CPs often accompany patients to their providers’ visits so we can reinforce and translate the next steps in ways the patient will understand when they get back home,” Swayze says. “Once we address the underlying social determinant issues facing the patient, we find that their dependence on 911 and the local emergency department goes down drastically. It’s much more effective to have a paramedic call these patients than it is to continue to react as we have traditionally done.”

He adds that more CP programs are coming from hospitals that operate their own ambulance service. “The medics are already FTEs in the healthcare system and hospital administrators are beginning to realize it’s more cost effective to deploy the medics to the patient based on their predictive and risk stratifications models rather than waiting for the patient to call 911,” he says.

Next: Financial drivers

Financial drivers

Matt Zavadsky is director of public affairs for MedStar Mobile Healthcare, a governmental agency that is the regional 911 EMS provider for 15 Texas cities, including Fort Worth. MedStar also operates a CP program. Zavadsky says EMS teams have traditionally only been paid for transporting patients to the hospital or ED, with no reimbursement for patients treated on the scene without transport.“So we transport them to pay our employees and that’s just silly,” Zavadsky says.

Now, hospitals and payers are using incentives from the ACA earned through lower ED admissions and hospital readmissions to change the reimbursement structure. “Any health system migrating to a population health strategy has to recognize that all their efforts can be thwarted by the patient with a quick call to 911. As systems consider how best to transition to value-based care, they should take a serious look at their local EMS agencies as partners in the process,” Swayze says.

MedStar is paid primarily for 911 ambulance service, Zavadsky says. It also is paid for CP services. Hospitals and other agencies, such as an IPA, pay an enrollment fee for the enrollment.  It also receives per member per month payment from hospice agencies. Third party payers are negotiating with the cost savings plan, though it was not yet in effect at press time, says Zavadsky.

Filling an unmet need

Zavadsky says that patients who are surveyed after hospital stays say they only understand their discharge instructions 40% of the time. They may have questions that only come up after they leave the hospital, then forget by their next appointment. These things that can lead to ED visits and readmissions.

“It’s not that they want to be noncompliant, it’s just that they don’t know any other way to be. Nobody has the time to sit with that patient in an area that’s comfortable for that patient and explain,” says Zavadsky. “We’ve put 3,000 to 5,000 patients through these [CP programs] and 80% of what we’re doing with these patients isn’t clinical. It’s educational.”

Zavadsky says his agency has tracked 475 patients using the CP mobile healthcare services for 24 months and found that EMS calls were reduced by about 55% in patients enrolled in the CP program. That translates to an estimated $8 million cost savings to health systems thanks to the change in the patient’s utilization of services. That estimate, Zavadsky says, is based on ED facility payments and Medicare cost savings and isn’t inclusive of additional costs for lab work or specialist care.

Rachael Zimlich is a writer in Columbia Station, Ohio.