Alternatives to the ED

The Regional EMS Authority (REMSA) of Reno, NV, has received a $9.9 million grant from the Center for Medicare & Medicaid Innovation to develop new care pathways for patients beyond going to hospital emergency departments. Once these are developed, this project will create a template for reimbursement of ambulance services by Medicare/Medicaid that does not necessarily involve transport of patients to EDs.

“There are three elements to this grant,” explains Mike Williams, REMSA’s vice president of operations. “One involves an alternative phone number to 9-1-1 to call and access medical care. The caller will get a nurse advice-type line, and through a call triage system, the call-taker will be able to direct the caller either back into the 9-1-1 system for complaints of an urgent/emergent nature or, in the second part, into our community paramedic program, which will allow an advanced practice paramedic (APP) to be sent to determine the third part: if they need transport to a hospital, an urgent care center or their physician’s office, or perhaps don’t require transport at all.”

The program will also encompass the local CMS-approved medical home program for chronically ill patients. Under the medical home program, patients have a primary care “home” physician and a team of nurses, social workers and now APPs to coordinate their care through that physician. It will take about a year to add the alternative pathway system to REMSA’s communications center.

“We are going to start with patients who have physicians so there will be closer control over who calls and under what circumstances,” says Williams. “Then it will spread to the general public as we do public education on the project. People who might typically call 9-1-1 will now have alternatives. We believe this will be the new wave of healthcare, giving patients options that allow for a more appropriate care response, if needed, and a lower-cost, more convenient medical approach.”

The second part of the program is sending an APP to evaluate the patient’s condition and determine what pathway the patient should follow to receive care. The APP could be sent after a call to the alternative phone number or as scheduled by the patient’s physician, medical home or hospital system referral. The training curriculum used for the APP will be the one developed by several universities currently used in Eagle County, CO. It will be taught through the REMSA education department in partnership with the University of Nevada, Reno School of Community Health Sciences.

This part also involves APPs monitoring and following up with patients who have been discharged from hospitals. They will help these patients with new medications, making sure they take them in the right amounts at the right times, etc. They can also ensure patients comply with other discharge instructions, hopefully preventing the need for return visits.

“Decreasing the readmission rate has gotten us support from the local hospital community,” Williams says. “This grant will create partnerships between REMSA and all the hospital systems in the Reno area. One of the aims of the program is also to reduce the number of unnecessary ER visits that can delay care for all ER patients.”

One of the things that make this program different from other community paramedic programs is its connection to the Centers for Medicare and Medicaid Services (CMS) and reimbursement. One part of the grant is a study to see how costs can be decreased and savings accrued for the medical centers, CMS and REMSA. This is part of the incentive to cooperate in the process. CMS is looking at this as an experiment, and there will be a lot of data sharing to make sure that what we believe will happen actually does. The university is also assisting with data analysis.

“Many EMS, hospital and other services in Canada and the U.S. are working with REMSA to ensure wherever possible that we provide the best healthcare model and can demonstrate a better approach that reduces costs while improving care,” says Patrick Smith, REMSA’s president and CEO. “We anticipate that research data will be published at the end of the grant that anyone can access and use for similar programs.”

The CMS Innovation Center’s three-part aim for the grant is to enhance quality, improve access and lower cost. Williams says the program may produce savings with uninsured and/or homeless populations by ensuring they can reach alternative, cost-effective medical care before small problems become large.

“The vision of this program is to improve healthcare, be more convenient for people and reduce costs,” Williams says. “The money from the grant is intended to develop and establish the infrastructure of the program, not to reimburse us for the costs of the services provided. This program is envisioned to create a care and reimbursement mechanism that has never been considered before by CMS. This is a huge mind-set change for CMS, healthcare practitioners, REMSA and the entire EMS industry. We think it will be a game-changer for EMS in the future.”

CMS Project Description

Title: REMSA Community Health Early Intervention Team (CHIT)
Geographic Reach: Nevada
Funding Amount: $9,872,988
Estimated 3-Year Savings: $10,500,000

Summary: The Regional Emergency Medical Services Authority of Reno, Nevada, in partnership with Renown Medical Group, the University of Nevada-Reno School of Community Health Sciences, the Washoe County Health District, and the Nevada Office of Emergency Medical Services, is receiving an award to create a Community Health Early Intervention Team (CHIT) to respond to lower-acuity and chronic disease situations in urban, suburban and rural areas of Washoe County. CHIT is designed to reduce unnecessary ambulance responses, as well as hospital admissions and readmissions, while improving the patients’ healthcare. A central component to the success of CHIT is the adoption of a new non-emergency phone number to provide an alternative pathway to care for patients with lower-acuity problems. Goals of this initiative include reductions in non-urgent emergency department visits, unreimbursed emergency department costs, hospital admissions, and hospital readmissions, as well as decreased hospital stays, fewer ambulance transports, and improved overall health care and continuity of care. —https://innovations.cms.gov/initiatives/Innovation-Awards/nevada.html

The Safest Transport: An added benefit of early-intervention teams

The safest transport is one that never happens. The same can be said for the safest 9-1-1 response. And that’s a likely added benefit of the Community Health Early Intervention Team (CHIT) trial happening in Reno.

The CHIT—a joint effort of local 9-1-1 provider REMSA (the Regional Emergency Medical Services Authority) and other key local and state health-system players—will respond to lower-acuity and chronic disease situations across Washoe County, working to improve patients’ health and prevent calls to 9-1-1 (citizens will get a nonemergency advice number instead that can route them appropriately). Goals of the project include reductions in unnecessary ED visits and costs as well as hospital admissions and readmissions, plus decreased hospital stays and fewer ambulance transports.

The savings aren’t expected to be huge at first: around $10.5 million over three years on an expenditure of $9.9 million. But the money will help train a whole new workforce of community paramedics, communicators, CQI coordinators, an educator, an outreach coordinator, an IT specialist, a statistician, an administrative support specialist, and a project director. These are potentially force multipliers that can accrue bigger savings once institutionalized.

Even more important, they may help save lives, if they can catch little problems before they become big ones. A home visit from a community medic days before a hot 9-1-1 response for a problem grown critical benefits the safety of providers and the public as well as patients.

Barry D. Smith is ground CQI coordinator for the Regional Emergency Medical Services Authority (REMSA) in Reno, NV. Contact him at bsmith@remsa-cf.com.