Report Card From Reno

This is where the rubber meets the road: Progress reports with preliminary outcomes from recipients of the first round of CMS Health Care Innovation Award grants are now becoming available. The grants, part of the Accountable Care Act, are meant to encourage compelling new ways to support the Triple Aim and deliver better health, improve care and decrease costs to people enrolled in Medicare, Medicaid and the Children’s Health Insurance Program. After three years it’s time to see if that investment is paying off.

The Regional Emergency Medical Services Authority (REMSA), the sole provider of ground and air ambulance services in the Reno-Sparks, Nev., area, was one of the original 107 organizations to receive a coveted Innovation grant. Project director Brenda Staffan says that, although the results are preliminary, the project has been a success on a number of levels. “We are increasing access to quality care in a safe and reliable way,” she says. “As we continue to put systems in place, we expect even better results.”

For its project, which encompasses three Community Health Programs, REMSA received $9,872,988 through the Health Care Innovation Award program. According to REMSA’s grant application, the overall goal was to reduce patient care expenditures by $10.5 million over three years.

All three programs are designed to accomplish one or more objectives:

• Reduce hospital readmissions;

• Avoid all-cause hospital admissions;

• Reduce ED visits;

• Reduce the cost of care, either directly or downstream.

Nurse Health Line

The first intervention is the Nurse Health Line, created to field low-acuity calls. While some other communities have similar systems, Staffan says REMSA’s is the only one available to date that features a nonemergency phone number broadly marketed to the public.

The nurse navigators are colocated in the 9-1-1 medical communications center. Emergency calls through 9-1-1 that meet the “omega” criteria—meaning a no-acuity condition that does not require transport by ambulance to an ED—are transferred to the Nurse Health Line. “This is still in the pilot phase. Eventually we will stop sending ambulances to those calls,” Staffan says.

Under the program, launched in October 2013, nurse navigators provide 24/7 assessment, clinical education, triage and referral to healthcare and community services. The program has fielded 15,941 calls. “This intervention has experienced extraordinary levels of community demand,” Staffan says.

As a result, 1,149 ED visits and 190 ambulance transports have been avoided, for an estimated savings of $4.3 million in average charges. Staffan notes that charges are not the same as payments, since payers often pay a discounted rate.

Alternative Destinations

The second intervention is Ambulance Transport Alternatives. Paramedics who respond to low-acuity 9-1-1 calls perform advanced assessments in the field and determine whether to transport the patient to an urgent care center or clinic, transport an inebriated patient directly to the detoxification center, or transport a psychiatric patient directly to a mental health hospital. If the patient’s condition warrants, they can still go to the hospital.

Since the launch of this intervention in December 2012, the paramedics have transported 550 patients to alternative destinations. “The volume is slightly lower than we projected,” Staffan says. Getting facilities to participate has been time-consuming. Barriers remain, including the operating hours of participating facilities, facility consent to accept patients, and facility acceptance of a patient’s insurance. “This project has been logistically complex,” she says. REMSA is working to expand the number of alternative destinations from 14 to 16. It started with four.

The good news is that the program has saved $2 million in charges. Even better, the 4.4% repatriation rate is within an acceptable range. Staffan says safety is critical to all three of the interventions, but particular attention was paid to this one. All repatriation transports are reviewed through the CQI process, which includes REMSA’s medical director, Brad Lee, MD. Repatriations have been due to issues regarding facility capacity, a change in the patient’s condition or a request by the patient or family member. Undertriage was not an issue. “There was never an adverse outcome,” Staffan says.

Community Paramedics

The third intervention calls for specially trained community health paramedics to perform in-home delegated tasks to improve the transition from hospital to home, perform point-of-care lab tests and improve care plan adherence. The goal is to reduce costly readmissions and post-discharge complications through community health surveillance, education, home safety and injury prevention. Physicians can contact the community paramedics for after-hours visits to prevent 9-1-1 calls. Special emphasis is placed on frequent 9-1-1 users.

Preliminary results show Community Health Paramedics can safely avert hospital readmissions while simultaneously improving care coordination and patient quality of life and satisfaction. “In the last year we have enrolled 444 patients and made more than 2,020 in-home visits,” Staffan says. Since the Community Health Paramedic program was launched in June 2013, REMSA’s hospital readmission rate has been reduced from an average of 18% to 13%.

Staffan notes these are preliminary outcomes and reflect a best-faith effort to present an accurate description of the programs’ progress. Savings estimates are calculated based upon average charges from data provided by the Nevada Center for Health Statistics and Informatics. They will be updated as new data is identified and methodologies are validated.

“We are still in the process of fine-tuning our data sources,” Staffan says. “While CMS hasn’t officially reviewed these preliminary results, the agency is conducting an independent evaluation that will be published at the end of the grant period.” There is one stat about which she has no doubt: “No adverse outcomes have been caused by these interventions.”

Staffan says the interventions will continue to be refined as acceptance and understanding of the programs increase. “With a strong early foundation supported by these preliminary outcomes, we look forward to working with payers and partners to sustain and expand the gains achieved to the benefit of the entire healthcare delivery system and the patients the system serves,” she says.