Advocates for Health

     Two years ago, EMS Magazine published a series of articles titled Taking EMS Into Tomorrow (May–Oct. 2006). It generally promoted the idea of EMS providers serving in a public health capacity, assisting with things like injury prevention and disease management and education in addition to providing emergency care. The series generated a lot of feedback—everything from excitement from systems wanting to engage in such community service to cynicism from those who thought EMS should stick to its traditional business of dropping tubes, shocking hearts and hauling folks to the hospital.

     Well, while the debate rages on, there is a group of pioneers in Pittsburgh who are turning the vision of EMS-facilitated illness prevention and chronic disease management into reality with what they call "emergency medicine-based health promotion." Emed Health, part of the Center for Emergency Medicine of Western Pennsylvania, Inc., is actively blending EMS with chronic disease management, health promotion and prevention. According to Executive Director Kelly Close, MD, MPH, "Emed Health's goal is to take healthcare to people where they live and work and empower them with the tools, systems and knowledge to prevent and manage their own health and chronic diseases."

     Emed Health is doing all the things the cynics said couldn't be done. Here's how these pioneers are doing it.

'THE EMS MODEL'
     Emed Health uses what it calls the "EMS model," which entails subcontracting with local EMS organizations to provide services to people in their communities. EMS providers are suited for this role because they are well-integrated into the communities they serve and can be an underutilized healthcare resource, especially in rural communities.

     Emed Health provides the training, patient programs, contracts for services with payers, data tracking and analysis, and quality management systems. The subcontracting model prevents Emed Health from competing with EMS agencies for providers, allows the agencies to determine when and how they will become involved, enables use of agencies' existing malpractice and worker's compensation policies, and provides a scalable model with few fixed costs, since services are only contracted for when there is work. This leads to lower costs to payers and patients and makes it cost-efficient to provide personalized healthcare prevention and disease management services in the community and in patients' homes.

     Emed has contracts with insurers, employers and hospitals to deliver services, which means a sustainable source of income for EMS agencies. It also creates alternative career opportunities within the existing system for EMS personnel who enjoy public health, education and continuity of care, especially if they are among the 27% of providers who leave EMS each year due to injury, burnout or an inability to meet the field's physical demands. Part of the Emed Health vision is that EMS can become a place where people can still work even when they can't lift stretchers anymore. Through prevention, wellness promotion and chronic disease management, Emed creates an interesting alternative career path for EMS professionals while improving the healthcare system for patients and payers alike.

     Emed Health is finding that its patient customers are visiting emergency departments less often and have improved quality of life. The EMS "health advocates" trained to implement the programs get a lot of satisfaction from helping people stay healthy. From a financial perspective, it is less expensive to prevent and manage complications of chronic diseases than it is to treat them over and over again as emergencies.

     "We started getting involved with injury prevention at the university, and it got me thinking about prevention in general," says Paul Paris, MD, FACEP, chief medical officer of the Center for Emergency Medicine (a multihospital consortium in western Pennsylvania dedicated to advancing emergency medicine) and one of the creators of Emed Health. "I started reading about health promotion and wellness and was dumbfounded to discover that 70% of healthcare dollars are spent on caring for patients with chronic diseases, such as asthma, congestive heart failure and diabetes. When you buy a GM car, $1,700 goes toward healthcare costs—more than the cost of the steel in it."

     Anne Boland Docimo, MD, MPA, chief medical officer for the University of Pittsburgh Medical Center (UPMC) Health Plan, says programs such as Emed Health's diabetes prevention and asthma management programs can offset the rising costs of hospital care. "The more patients who receive education on how to manage chronic illness, the fewer patients there will be who develop complications and have higher healthcare costs down the road," Docimo says.

     Here are some of the pioneering programs Emed Health is currently developing. Input from the medical community and the general public is always welcome at www.emedhealth.com.

ASTHMA
     According to Rodney Jones, vice president of operations for the UPMC's Braddock Hospital, the health disparities in his area are among the worst in America. "We fall below the county, country and world in cardiovascular disease, infant mortality, diabetes and asthma," Jones says. Braddock is the main healthcare provider for a population in which one third of children and half of adults live in poverty. Three quarters of the hospital's patients come in through the emergency department.

     Nationwide, 5%–7% of children suffer from asthma. In the neighborhood served by Braddock, it's 25%. Poverty contributes to the problem, combined with lots of smokers and deplorable living conditions. "We have a large number of asthma patients who come to the emergency department every week," says Jones. "For those who have insurance, 80% are covered by Medicare or Medicaid, and they won't cover people who return to the hospital within 30 days of their last visit." Emed Health created an in-home asthma management program to help Braddock's patients better manage their disease.

     Emed trains paramedics and EMTs from local EMS services to administer the asthma program. The program consists of several home visits in which patients are provided education on their disease, proper use of peak-flow meters, spacers and medications, management of environmental triggers, interacting with physicians and developing action plans, and are given program assessment tools such as satisfaction and quality-of-life surveys.

     Emed also helps with logistical considerations that are often barriers to optimal care. For example, EMS health advocates help patients who have trouble paying for their medications find programs that can assist. They also help them fill out forms for free transportation services so they can see their physicians or get prescriptions filled.

     As an EMT for nearly 18 years, Becky Miller treated people with broken legs, heart conditions and dog bites. Recently, she joined the Emed Health asthma disease management program as a health advocate. "The woman I was working with learned she was taking her medicine wrong—she was totally amazed," says Miller. "She also didn't know she had triggers in her house, like dust and mold."

     Twenty-five patients have been through the program so far. According to one, "I'm not sure I'd still be alive were it not for these people helping me. They taught me how to take care of myself much better than the doctor. I've had asthma most of my life, but it's been getting real bad the last few years. I was going to the emergency department once or twice a week. Since they helped me take better care of myself, I haven't been once."

     John, a paramedic with the local Guardian Angel Ambulance Service, says, "Most patients never really learned how to use their peak-flow meters. We take the time to teach people."

     EMS providers enjoy helping their "frequent fliers." By their providing these patients with the skills necessary to care for their diseases, the patients stay healthier, the EMS system runs fewer calls, and the hospitals provide less uncompensated care.

     Jones says it's better for him financially to pay Emed Health to provide this service for his asthma patients. "It costs us less to provide this program than it does to provide unreimbursed emergency department care to these patients," he says. "We have a commitment to addressing the healthcare disparity in our community. About half of my 700 employees live in this community. Using a unified approach with our employees, 50 other community groups, faith-based organizations and patients, we are going to make this a healthier community."

     Results of the asthma program for uninsured patients have been positive. Patients get surveys at intake and at the end of the home visits. The same survey was also mailed to patients six months after the home visits. A validated Risser satisfaction survey was also administered anonymously at the end of the home visits.

     At the beginning of the study, 60% of participants reported being in an emergency department in the last six months for an asthma-related visit. Three months after starting the program, that figure had dropped to 10%. Similarly, at the beginning of the study, 36% had been hospitalized overnight for asthma-related illnesses, but after three months that figure was down to 5%.

     The satisfaction survey results indicate that participants found great value in the services they received. All patients agreed that their EMS health advocate was understanding in listening to their problems. Patients strongly disagreed that their EMS health advocate was too busy to spend time talking with them, which is a common complaint of patients following traditional healthcare visits. Overall, patients reported they were extremely satisfied with the disease management program.

DIABETES
     In 2004, approximately 23,000 Pennsylvanians were hospitalized for diabetes-related problems, costing about $673 million. Emed Health modified the National Diabetes Education Program to help keep front-line emergency workers and their families from developing this deadly disease. The program's initial focus was on the personnel and families of EMS, fire and police departments. Participants for the intervention group were recruited from two rural counties that had among the highest rates of diabetes in Pennsylvania. To qualify for the study, participants had to have metabolic syndrome, consisting of an elevated body mass index plus at least three of the following: 1) elevated glucose (but not yet diabetic), 2) high blood pressure, 3) abdominal obesity, 4) low HDL (good cholesterol) and 5) high LDL (bad cholesterol).

     Fifteen intervention group members participated in 12 classes (taught by EMS health advocates who went through the National Diabetes Education Program curriculum) and were given free gym memberships. During these classes the public safety workers learned about diabetes prevention, such as how to eat right, use a pedometer, exercise regularly and utilize a food diary to track their intake. Eight control group members received information and free gym memberships, but no classes or health coaching. All participants were screened three and six months after starting the program.

     Although six-month results have yet to be measured, at three months the mean weight loss was 16.1 lbs. in the intervention group and 11.3 lbs. in the control group. One patient, police officer Mike Parlak, is much less likely to develop diabetes since completing Emed Health's prevention program (see Table I). Parlak knew he was overweight and had high cholesterol, but didn't know he had an elevated fasting glucose level and several other risk factors that increased his chances of diabetes.

     "My doctor had been after me to lose weight and exercise more, but I had no idea I was at such high risk for developing diabetes," Parlak says. "The classes were really helpful—no one was judgmental, and we were all very comfortable discussing our progress. The best part was getting weighed each week. I loved to see the results of my hard work paying off."

     Three months later, Parlak has lost weight and lowered his blood pressure, cholesterol and fasting blood sugar, significantly reducing his odds of becoming a diabetic. He's gained knowledge he'll be able to use for a lifetime. "I weigh myself every day," he says. "If I see my weight creeping up, I exercise a little longer and eat a little more carefully.

     "A little work and education about proper eating habits and dedication to the program can change lives," Parlak adds. "I honestly feel better, have more energy and enjoy doing all the activities that were difficult for me when I was overweight and out of shape."

     Once the final results of the program within the EMS and public safety community are available, Emed Health hopes to implement the program more widely in other businesses and systems.

HEALTH & WELLNESS
     Some of Emed Health's programs' most important work has been in identifying at-risk individuals so they can be educated about changing their behaviors before they develop serious diseases. The majority of the health screenings have been performed in partnership with the UPMC Health Plan. Emed has provided glucose, blood pressure, cholesterol and carbon monoxide testing for more than 17,000 people in the last year through this program. The success of these screenings has in large part been due to the vision and coordination of the UPMC Health Plan, one of the top-ranked health insurance programs in the country.

     The program's top officials recognize that health promotion saves money by improving retention, morale, turnover and productivity rates. Rose Gantner, EdD, the UPMC Health Plan's senior director of health promotion, says a roughly 3:1 return on investment in health education can be expected in about two years, mostly from decreased absenteeism and turnover, but also from reducing the number of sick and unhealthy people who come to work anyway and perform suboptimally. For more information about the value of health promotion in the workplace, see the Wellness Councils of America's website, www.welcoa.org.

     Gantner says that "Sixty percent of all illness can be changed with lifestyle modifications. Physical, mental, emotional, spiritual, occupational and family dimensions all can impact health. We have found that 80% of health plan dollars are spent on people who are high risk. Our goal is to keep the low- and moderate-risk people from becoming high-risk." A key part of achieving that goal is identifying those people and educating them before their conditions develop into something more serious.

     During these screenings, Emed's EMS health advocates measure body mass index, heart rate, cholesterol, carbon monoxide, glucose, HDL, LDL, triglycerides and blood pressure. Height and weight measurements are used to calculate body mass index (BMI). At the end of the screening session, health educators from UPMC Health Plan provide participants with educational materials and counseling about their risk factors and the need to follow up with their primary care physicians. Patients can have their results sent to these physicians.

     Participants in the program get to make a difference in people's lives in a way many medical providers don't. They've helped a pregnant woman with a high CO level find a gas leak in her home, sent people to the emergency department with hypertensive emergencies and discovered people with new-onset diabetes. In fact, according to satisfaction surveys from over 4,000 people screened, they were extremely happy with the EMS health advocates and the results they received. On a scale of 1–5, with 1 being poor and 5 being excellent, EMS health advocates were rated 4.9+ out of 5 for professionalism and 4.8 for their quality of work.

     Screening participants are taking action to improve their health. Four fifths said they learned something they didn't know through the screening process, and only 6% said they didn't plan to do anything with the information they received. The rest (94%) planned to take action on or otherwise use the information they learned about their health in the screening process.

FLU SHOTS
     By partnering with the EMS agencies, hospitals and insurers, Emed Health's health advocates have been able to vaccinate more than 10,000 people in the last year in clinics, hospitals and other sites around the city. Over 6,000 of these doses were administered to the special-needs populations (poor people or disabled people over the age of 65) of health insurers or flu clinics, and 3,800 were administered to nurses, doctors and other clinical staff through a roaming paramedic hospital program.

     This roaming system was implemented because the hospitals had a vaccination rate of less than 40% among healthcare providers—a number that was even lower for ICU and emergency department staff because they were too busy to leave their units to attend free flu clinics. Medics delivered vaccines to personnel in eight hospitals. The hospitals saw increases in vaccination rates of almost exactly the number of flu vaccines given by the roaming paramedics, meaning the program likely captured people who would not otherwise have been vaccinated.

     The program was well received by hospital staff, and there are plans to expand it. Studies have shown that vaccinating healthy workers saves employers $42 per person vaccinated, but it probably saves much more in the hospital setting, where nursing shortages are bad, staff work in close proximity with frequent exposure to the flu, and patients are at risk of contracting the flu from staff.

Other Resources
     www.cdc.gov—The CDC has information on vaccination recommendations, health screening guidelines and chronic disease management.

     www.welcoa.org—The Wellness Councils of America offers information about the costs and benefits of health programs in the workplace.

     www.dmaa.com—The Disease Management Association of America.

     www.nchec.org—The National Commission for Health Education Credentialing offers training and credentialing for health educators.

     https://web.ncqa.org—The National Committee for Quality Assurance is dedicated to developing quality standards and measurements for healthcare entities.

     www.motivationalinterview.org—Resources for clinicians, researchers and trainers on how and when to use this technique to motivate behavior change.

COMING NEXT
     The next major initiatives on the horizon for Emed Health are programs for management of congestive heart failure, COPD and diabetes, secondary fall prevention and general chronic disease management, in addition to expansion of the current asthma management program. According to Paris, of the approximately 60 million people in the U.S. who have hypertension, about half are undiagnosed and will develop CHF, strokes and MIs. Finding these people through screenings and educating them before they develop complications makes sense.

     According to Docimo, insurance companies are interested in working with companies such as Emed to help reduce the billions spent on manageable diseases. "With healthcare costs rising, the focus needs to be on keeping patients well instead of treating them when they're sick," she says. "We try to treat their problems before they reach the ED, because it's obviously a lot more expensive to treat people in the hospital than it is to keep them out of it."

     In some states, legislation may be needed to expand EMS providers' scope of service. Nurses, physicians, insurers and others in the healthcare community need to be educated about the role EMS providers can play in reducing the nearly 120 million ED visits in the U.S. each year. Those who have seen Emed Health's program are convinced it can work.

     "I'm optimistic," says Chris Dell, executive director of suburban Elizabeth Township Area EMS, "that there will be more paramedics and EMTs working with Emed Health and other programs to provide preventative healthcare."

     Special thanks to Kelly Close, MD, MPH, Debra Lejeune, Med, NREMT-P, and Katie Renze from Emed Health for their help.

Sascha Liebowitz is a California-based writer. E-mail sascha.liebowitz@gmail.com.

Mike Taigman is a lifelong student who works with EMS systems worldwide. Contact him at www.miketaigman.com.