Mobile Integrated Healthcare Part 4: Integrating Home Care, Hospice & EMS

Ed's Note: The rapid evolution into community paramedicine and mobile integrated healthcare has been one of the most discussed issues in the EMS arena. Attend the MIH Summit on April 28 in Washington, D.C., and hear from your peers as they share real-life examples of successful programs in action. Visit MIHSummit.com.

The rapidly changing dynamic of America’s healthcare system has created new expectations for many providers. The drive to achieve the Institute for Healthcare Improvement’s Triple Aim—improved care experience for the patient, improved population health and reduced costs—has fostered the creation of many innovative partnerships designed to enhance healthcare across the continuum. This column focuses on the synergistic relationships and integrations developing between EMS-based mobile integrated healthcare (MIH) and the home healthcare industry.

One of the main goals of EMS-based MIH is to navigate patients through the healthcare system, not replace healthcare system resources already available in the community. Home health and hospice are valuable links in the chain of healthcare—and, for qualifying patients, a logical care delivery model that can be enhanced through partnership with the local EMS agency.

The following are some examples of how home health and hospice agencies have integrated with their local EMS provider to create significant benefits for both the agencies and their patients.

Increased Referrals

Home health providers are increasingly being challenged by hospitals and insurers to reduce preventable emergency department visits and hospital admissions. Patients receiving home health services tend to have multiple chronic diseases with polypharmacy and are at significant risk for ED visits and hospital admissions. Under the transitioning healthcare system, hospitals are held financially accountable for certain unplanned readmissions. And, if the hospital is part of a risk-sharing financial arrangement such as an ACO, they are financially at risk for the admission. Consequently, they desire to refer eligible patients to home health agencies that can ensure the patient safely transitions to the home environment without returning to the hospital unnecessarily. A home care agency that can appropriately prevent unnecessary ED visits and admissions gains an advantage over other agencies in today’s new healthcare environment.

MedPAC (the Medicare Payment Advisory Commission) is recommending to CMS that home health agencies also receive penalties for patients who return to the hospital. The policy recommendation outlines a savings to the Medicare program. The estimate for this savings, if approved in 2015, is between $50 million and $250 million. MedPAC suggests with the growth in healthcare utilization and the growing population that penalties to home health agencies for readmissions could save as much as $1 billion dollars by 2020.¹ The financial penalties to hospitals from one of their primary referral sources as well as proposed changes related to hospital readmissions pave the way for partnerships in communities across the United States.

While home care agencies instruct patients to call them for any changes in their condition and routinely staff registered nurses 24/7, 365 days a year, often patients and families call 9-1-1 out of panic as opposed to true medical emergencies. Developing a partnership with EMS first responders in the home care service provides an opportunity for the home care on-call registered nurse to be notified by the first responder while they are en route to the patient’s residence.

Klarus Home Care has this type of innovative partnership with MedStar Mobile Healthcare in Fort Worth and surrounding areas. MedStar enrolls Klarus patients who are in their first-responder service area into their database, which allows the call center to identify that a patient who calls 9-1-1 is on home health services with Klarus. In addition to sending an ambulance, MedStar also dispatches a specially trained mobile healthcare paramedic (MHP) to the scene. The on-scene MHP then works directly on the phone with the Klarus Home Care RN to do real-time care coordination for minor medical issues. Perhaps the patient can be episodically managed at the scene with a follow-up visit by the nurse, thereby preventing an avoidable ED visit or hospital admission.

Hospitals are looking for home health providers who are utilizing innovative approaches and whose data can demonstrate a reduction in avoidable hospitalizations. Partnerships between EMS providers and home health companies can pave the way to providing a more value-based service that drives down overutilization, resulting in lower costs. Klarus Home Care absorbs the costs in their partnership with the first responders to accomplish the goal of reducing hospitalizations from 9-1-1 calls.       

In some cases, when EMS is going through the intake process, the mobile healthcare paramedic trained in patient navigation and program eligibility may identify that the patient qualifies for home health. In this case the MHP can suggest to the patient’s physician that a referral to a home health provider may be appropriate.

Gained Operational Efficiency

Home care agencies not partnered with EMS are often unaware when their patients call 9-1-1 and are taken to the emergency room. The opportunity for the patient to be treated in the home, the least restrictive environment, is lost. This has a direct impact on the home care agencies’ performance and the overall cost to the healthcare system. Additionally, many times the home health agency doesn’t become aware the patient is in the hospital until the nurse goes to the house for a regularly scheduled visit. This creates lost productivity for the home health agency.

Further, it may at times be logistically difficult for a home care agency to make it to a patient’s house at 2 a.m. or on weekends for an unscheduled visit. Nurses available to make these visits in the middle of the night may also be concerned about safety in certain parts of the community. Working with EMS gives the home care agency additional support for their current services.

Consider the accompanying real scenarios of patients enrolled in the Medstar MIH programs with Klarus Home Care and VITAS Healthcare. Both of these examples demonstrate the value to the patient, the home health agency, the hospital and the overall cost to the healthcare system. Integrated mobile healthcare in the Fort Worth market changes the EMS incentive.

EMS-MIH and Hospice Care

The goal of the hospice agency is to help the patient at home transition to their afterlife with comfort and compassion. The family is instructed in the proper way to access the hospice nurse if the patient begins to struggle at home. Unfortunately, in the panic of seeing their loved one struggle, many families call 9-1-1. This starts a domino effect. The EMTs and paramedics assess the patient and find them in clinical distress. The family is scared and cannot locate the DNR. EMS does what it’s trained to do: Start treatment and take the patient to the ED. Once in the ED, the hospital initiates care and the family may decide this is all too overwhelming and voluntarily disenroll the patient from hospice. This is not in the best interests of the patient or the hospice agency. The patient’s wishes are not fulfilled; the hospice agency now has ambulance and ED bills to pay and loses the per-diem fees normally available had the patient stayed on service.

In Fort Worth we see a different outcome from the same scenario thanks to an innovative partnership with VITAS Healthcare. When the family calls 9-1-1, the computer-aided dispatch system notifies the 9-1-1 call-taker that this patient is enrolled in the VITAS partnership. This causes an alternative domino effect: A hospice-trained MHP joins the ambulance response team, and the patient’s hospice nurse is notified of the response. When the MHP arrives on the scene, they assess the patient and determine if the clinical issue is part of the hospice plan of care. If so, they then access the patient’s comfort pack, alleviating the patient’s suffering; remind the family of the goal of hospice care and the wishes of the patient; and inform them the hospice nurse is on their way. They offer to wait with the family until the hospice nurse arrives and release the ambulance back into service. No transport, no disenrollment and the patient’s wishes are achieved.

In the event the patient’s condition on scene is such that management at home is not practical, care coordination occurs between the MHP on scene and the VITAS nurse to have the patient transferred from home to an inpatient hospice unit.

Under this program, in place since 2013, 168 patients identified by VITAS as being at high risk for voluntary disenrollment have been enrolled by VITAS. These patients generated 49 EMS calls, but only 29 were transported. Twelve were transferred to an inpatient hospice unit; 17 were transported to the ED at the insistence of the family and subsequently voluntarily disenrolled from hospice (10%). The rest died peacefully at home in the presence of the hospice nurse and/or the MedStar MHP.

Another benefit for VITAS from this program has been increased referrals. The MedStar MHPs have been trained in the IHI Conversation Project and can work with patients enrolled in their other MIH programs (such as the service’s high-utilizer or CHF readmission-prevention program) who may be appropriate for enrollment in palliative care. Often, as the relationship between the patient, patient’s family and MHP evolves over a series of home visits, the MHP can successfully introduce the conversation the patient or family was not ready to have while in the hospital.

These are just a few examples of how EMS-MIH and home health can work collaboratively. It is not a competitive relationship, but a cooperative one designed to meet the needs of the patient.

Klarus Home Care & EMS Partnership—Actual Patient Experience

• 67-year-old male, DX of cardiomyopathy, chronic heart failure, pleural effusion, diabetes type II.
• Exacerbation of CHF 2x in last 60 days; TX by RN using Klarus CHF protocols: 40 mg IV Lasix.
• Patient calls 9-1-1 due to exacerbation, does not call Klarus.
• Patient IDs as registered Klarus client in 9-1-1 computer system. Specially trained MedStar paramedic added to 9-1-1 response, on-call Klarus RN notified of response while units en route.

EMS Care Coordination With Klarus:

• Paramedic on scene assesses patient and contacts RN.
• Assessment reported to RN: patient short of breath, legs swollen, edema 3+.
• RN advises specially trained paramedic to use CHF protocol and administer 40 mg IV Lasix.
• MedStar verifies CHF orders in Klarus electronic medical record and consults EMS medical director.
• IV Lasix administered.
• MedStar provides follow-up visit later that night, checks potassium, consults on-call physician and adjusts patient’s PO potassium.
• Klarus RN follows up with patient the next morning.

Outcome:

• CHF patient not transported to emergency room.
• CHF exacerbation signs and symptoms eliminated.
• Klarus Home Care & MedStar coordination prevents hospitalization.
• Healthcare system cost savings: $9,203.

VITAS Hospice & EMS Partnership—Actual Patient Experience

• Priority 1 9-1-1 call from caller identified as VITAS hospice client in 9-1-1 CAD.
• Specially trained MHP added to response.
• MHP arrives on scene to find patient home alone.
• Patient relates she became anxious and short of breath and is unable to move from chair to turn on her oxygen on her own.
• Client appears to be weak with limited mobility due to advanced Parkinson’s.
• Paperwork for VITAS is laid out on table with signed DNR.
• She has around-the-clock care with providers obtained by her family, but they leave Saturday mornings and are not generally back until the afternoon.
• Patient relates her caregiver is off today and she is supposed to have a substitute arrive at 11 a.m., but they are late.

EMS Care Coordination With VITAS

• On-scene MHP speaks with VITAS triage nurse and discusses situation.
• The client is on oxygen and relates that prior to EMS arrival she took something for her spasms but is unable to determine what.
• Relates she feels much better now that she has her oxygen on.
• MHP releases ambulance and FD unit, waits for caregiver to arrive and explains the situation.
• Also speaks with VITAS triage nurse.
• Patient left in care of caregiver.
• VITAS does a home visit later in the day.

Outcome:

• Patient stabilized and made more comfortable.
• Wishes of patient and family met.
• Transport to ED, admission and potential voluntary disenrollment avoided.
• Care coordinated with VITAS.

Reference

1. https://www.medpac.gov/documents/reports/mar14_ch09.pdf?sfvrsn=0.

Meredith Anastasio is the managing director at Lincoln Healthcare Group (LHG) and leads the planning of Home Care 100 and Home Care & Hospice LINK. Founded in 1998, LHG has created a successful formula for bringing together senior-level executives. Their conferences provide a private environment where business leaders can meet to discuss current events.

J. Daniel Bruce is the administrator of Klarus Home Care in Fort Worth, responsible for the ongoing relationship with MedStar, and a leader in the development of partnerships to create value-based services. His management experience of more than 25 years includes working as the hospital director of case management at Memorial Medical Center of East Texas; as CEO for SSC, a medical staffing company serving more than 150 counties in Texas; and the development of an innovative home health psychiatric and dementia care program called Safe Choices.

John Mezo is the general manager of VITAS Healthcare in Fort Worth. In this role he manages all aspects of VITAS’ program, overseeing program operations, developing business opportunities, hiring and mentoring new staff and representing VITAS throughout the community. For 23 years John has worked in various management roles in hospice, home health and other healthcare fields. Prior to joining VITAS he served as executive director of Odyssey Hospice in Dallas and before that as regional vice president of CareSouth/MedCare at Home in Dallas.