AGENDA COMMITTEE OF THE WHOLE September 18, 2018 – …

AGENDA COMMITTEE OF THE WHOLE

September 18, 2018 – 7:30pm

1) Mobile Integrated Health Pilot Program 2) Fiscal Year 2019 Budget – City 3) 2019 Resurfacing & Reconstruction Street Program

September 18, 2018 COMMITTEE OF THE WHOLE

SUMMARY;

The Fire Department has been asked to participate in an Illinois Department of Public Health (IDPH) pilot study program known as Mobile Integrated Healthcare. This has been developed and planned by Northwest Community Hospital and awaiting our commitment.

The basic need is to provide “Community Paramedics” as home healthcare and post-admission advocates for the hospital and the identified “at risk” patient.

Preliminary studies demonstrate that using paramedics in a preventative way can reduce healthcare spending. National EMS Advisory Council reports the following “Field EMS agencies and practitioners can be a powerful resource as the United States struggles to reduce the cost of healthcare through preventative interventions.”

The Illinois Department of Public Health and Northwest Community Hospital’s Emergency Medical Services have developed an approved a Pilot Project to address and study the outcome a Mobile Integrated Healthcare (MIH) plan in the Rolling Meadows and Palatine area.

Specific outcome points have been developed based on the Institute of Healthcare Improvement (IHI) Triple Aim Initiative to optimize health system performance.

In summary, MIH core components and priorities are simply stated to provide the right care, to the right patient, in the right place, at the right time and at the right cost.

I will be presenting a resolution at the next Council Meeting to allow the Fire Department’s involvement and commitment in the one year pilot program.

PLEASE UNDERSTAND THE NEED FOR ACTION AT NEXT COUNCIL MEETING IS NECESSARY IN ORDER TO ACCOMMODATE ALL THE STAKEHOLDERS INVOLVED IN THE PILOT PROGRAM.

Ms. Connie Mattera - MSN the EMS Administrative Director and System Coordinator from NCH is available to provide for additional information.

0

Mobile Integrated Healthcare Using

Community Paramedics

Pilot PLAN – Phase 1 2018

Prepared by:

Connie J. Mattera, M.S., R.N., EMT-P NWC EMSS Administrative Director

Approved by:

Matthew T. Jordan, MD, FACEP NWC EMSS Medical Director

NCH

Steve. Scogna, President and CEO Kim Nagy, RN MSN NEA-BC, Executive VP and CNO

Dina Lipowich, RN, MSN, NEA-BC; Ex Director, Care Coord.

EMS Agencies

Scott Andersen, Chief, Palatine FD Rich May, Chief, Palatine Rural FPD

Terry Valentino, Chief, Rolling Meadows FD

NCH/NWC EMSS MIH Pilot Application 4/21/18

1

Pillars of Excellence for MIH

Why do we exist?

MISSION We exist to care for the right patient, in the right place, at the right time, based on

patient need and choice and at the right cost through a fully integrated Care

Coordination model that incorporates multiple care transitions and disciplines,

including the use of community paramedics.

Where are we headed?

VISION We are viewed as the gold standard of MIH and integrated person-centered care

excellence and quality by our customers and colleagues. Hospital and EMS

System partnership initiatives are collaborative endeavors planned, organized,

implemented, and evaluated by multidisciplinary teams from the hospital and out-

of-hospital communities.

How will we behave?

Shared VALUES - Excellence: We embrace excellence as a core value and are committed

to providing patient care and experiences of exceptional quality through practice excellence and exemplary service. This requires us to innovate and drive forward best-practice evidence-based care.

- Commitment: We are committed to those we serve and their individual needs are at the center of all decisions. This includes providing person-centered, efficient, humanistic and value-based care. Customer satisfaction drives all processes.

- Integrity: We continually strive to do the right things in the right ways.

- Compassion: We genuinely care about the well-being of people.

- Respect and Collaboration: We optimize teamwork and partnerships to deliver optimal outcomes; treating everyone with dignity and respect. Each member of the healthcare team has equal value and an opportunity to contribute to program activities and success.

- Accountability: Each person is accountable for their own actions.

- Citizenship: All business is conducted in adherence with applicable laws, rules, guidelines, and codes of ethics.

- Justice: Fair and equitable due process is offered to all.

- Fiscal responsibility and careful stewardship of all resources is the cornerstone of business planning.

- Advancing Knowledge: We are dedicated to professional development

and the process of applying and sharing knowledge. Our culture values

continuous learning as fundamental to professional growth and clinical

excellence.

These belief statements undergird the foundation of all MIH planning and activities. As we collaboratively

address care navigation and coordination, clinical processes and outcomes, operations, costs,

reimbursement, quality, risk, and patient and stakeholder satisfaction, we strengthen our System of care and

achieve the best possible patient experience.

Eff. 3/18

2

NCH/NWC EMSS MIH Pilot

Table of Contents

Topic Page

MIH Pillars of Excellence: Mission, vision, values .............................................................................................. 1

Table of contents ................................................................................................................................................. 2

Acronyms and Abbreviations ............................................................................................................................... 3

Healthcare Trends and Challenges: External forces impacting MIH planning Person-centered, value-based care; strengthening interdisciplinary integration and collaboration .................. 4

Legislative and Regulatory Authority for MIH ..................................................................................................... 7

Partnership agreements ....................................................................................................................................... 7

Pilot goals and stakeholders ................................................................................................................................ 8

Measures of success / Feasibility assessment ................................................................................................... 9

Alignment with NCH Mission, Strategic goals and objectives .......................................................................... 10

Community needs assessment / market analysis ............................................................................................. 11

Pilot Design and Workflow ................................................................................................................................ 12

Operations management ................................................................................................................................... 15

Medical Direction for MIH .................................................................................................................................. 16

MIH-CP Scope of Practice and Services Provided ........................................................................................... 15

MIH-CP Qualifications and Requirements; recruiting, onboarding, integration, supervision .......................... 15

MIH CP Education .............................................................................................................................................. 16

MIH-CP Credentialing ........................................................................................................................................ 16

Staffing plans (medical and administrative)....................................................................................................... 18

Clinical Care MIH Practice Guidelines and Patient Interaction Plan ................................................................ 19

Medication reconciliation .................................................................................................................................... 21

Patient Education. ............................................................................................................................................. 23

Documentation and IT integration across settings ........................................................................................... 23

Quality Management / Data Collection & Reporting: ....................................................................................... 25

Program Financing and Fiscal Efficiency /Resources for financing; Transition of Care and MIH CPT codes; ............................................................................................. 28

Communications and Marketing ........................................................................................................................ 30

Appendix – IDPH authorization letter ................................................................................................................ 31

Appendix – Residence Safety Assessment Form ............................................................................................. 33

Appendix – Waiver, Release and Hold Harmless Agreement .......................................................................... 34

Appendix – MIH-CP Eligibility and Application: ................................................................................................. 35

Appendix – MIH-CP Curriculum ....................................................................................................................... 37

Plan functions include:

Workflow optimization and staffing that matches demand and capacity for MIH services across pilot patient populations.

Expanded partnerships that use key stakeholder resources to provide community-based support for making health-related

behavior changes and promoting illness/injury prevention.

Integrating data to understand local needs so we appropriately support health promotion and coordinated care management.


3

Acronyms and Abbreviations

ACA Affordable Care Act

AMI Acute myocardial infarction

Benchmarks Global overarching goals, expectations, or outcomes. In the context of the MIH-CP

program, a benchmark identifies a broad system attribute.

BOD Board of Directors

CEO Chief Executive Officer

CMS Centers for Medicare and Medicaid Services

CO Carbon monoxide

COPD Chronic Obstructive Pulmonary Disease

CP Community Paramedic: A state licensed EMS professional that has completed a formal

CP education program and has demonstrated competence in the provision of health

education, monitoring and services beyond the roles of traditional emergency care and

transport, and in conjunction with medical direction. The specific roles and services are

determined by the EMS MD as approved by IDPH.

DC Discharge

ECG Electrocardiogram

ED Emergency Department

EMR or EHR Electronic Medical Record or Electronic Health Record

EMS Emergency Medical Services

EMS MD EMS Medical Director

EPIC Epic Systems is a large, privately held health IT company best known for its electronic

health record system

ETCO2 End tidal carbon dioxide (quantitative and qualitative waveform capnography)

HF Heart Failure

H&P History and physical exam

HRRP Hospital Readmissions Reduction Program

IHI Institute for Healthcare Improvement

IOM Institute of Medicine

MIH Mobile Integrated Healthcare

NAEMSP National Association of EMS Physicians: An organization of physicians and other professionals

partnering to provide leadership and foster excellence in out-of-hospital EMS

NAEMT National Association of EMTs

NEMSIS National EMS Information System

NCH Northwest Community Healthcare

PCP Primary care practitioners

SNF Skilled nursing facility

SOPs Standard Operating Procedures

SpO2 Pulse oximetry

S&S Signs and symptoms

VS Vital signs


4

HEALTHCARE TRENDS and CHALLENGES External Forces Impacting MIH PILOT PLANNING

“Without a doubt, hospitals and health systems are leading the greatest transformation in medical

history. They are working to provide coordinated and convenient care beyond their four walls; care that is

more responsive to patient preferences and community needs than ever before, all with a focus on keeping

people well so that they reach their highest potential for health. And they are doing the hard work of

advancing affordability and enhancing value” (Rick Pollack, President and CEO AHA, 2017).

Features of the current US Healthcare System:

Fragmented and disconnected care points

Facility, payer and provider centric – not yet fully person centered

Procedure & illness oriented – not health outcomes-oriented

Evolving to quality and value-orientation

The ACA began major planned disruption of the healthcare system, now impending changes add

more complexity and uncertainty

Healthcare providers need to transition business models

Biggest challenges for healthcare reported by health CEOs (Advisory Board Company, 2017)

Improving ambulatory access (57%)*

Innovative approaches to expense reduction*

Boosting outpatient procedural market share

Minimizing unwarranted clinical variation

Controlling avoidable utilization (49%)*

Healthcare industry trends to follow for 2018 (Market innovation center, Advisory Board Company):

Payment reform

Provider Market

Purchaser behavior

Provider selection

Health care top investment areas over the next three years

Data analytics

Care redesign efforts*

Patient experience improvement*

Care coordination*

Current healthcare priorities

We are at a crossroads on our journey to excellence and must prepare for a future that is rapidly

approaching (if not here already). Best projections indicate that it will be consumer-centric, digitally-enabled,

and highly integrated. This will require us to be internally nimble. Efficient, effective clinical care and service

delivery will be essential, with success rewarded and failure punished through reimbursement

methodologies implemented by CMS and adopted by the health insurance industry.

* Addressed by MIH pilot


5

Need for Quality, Coordinated, Humanistic and Value-based Care

In today’s value-based care economy, hospital ratings and reimbursement are tied to how effectively they address efficiency and cost reduction; patient experience of care; clinical care (Care Coordination); and safety measures. Because today's inpatient length of stay is so short, ensuring efficient care transitions pushes us to design processes and systems that extend beyond the walls of the inpatient hospital. As organizations assume more risk, the need to ensure that the patient is efficiently cared for in the most cost-effective setting is paramount. In fact, some would argue that in the longer term, an inpatient hospitalization represents a process failure, unless the patient cannot be cared for safely and effectively anywhere else. Achieving this vision for cross-continuum care will require everyone to innovate, designing care models and processes that ensure every patient receives the right standard of care, every time and in the most cost-effective setting.

Under CMS’s Hospital Readmissions Reduction Program (HRRP), hospitals are assessed stiff penalties

if a patient is readmitted within 30 days of discharge with an index diagnosis of heart attack, heart failure;

pneumonia; COPD; and hip or knee replacement. While our readmission rates are generally excellent, NCH

has been assessed these penalties in the past.

Further, under current Medicare policies, only 20% of eligible beneficiaries are enrolled in Medicare

Advantage plans and routinely receive care coordination services. This leaves 80% of eligible Americans

enrolled in traditional Medicare without access to care coordination. Yet, patients with five or more complex

chronic conditions account for more than 75% of total Medicare spending.

Current data tells us…

Care transitions are susceptible to lapses in quality and key information

~76% of elderly are confused about or non-compliant with their discharge plan (“discharge amnesia”)

40% of discharged patients 60 years of age or older fall within six months and would benefit from a

home safety check

Improving quality of care for older adults is among the highest priorities for multiple stakeholders (Am

Geriatrics Society, Hartford Foundation Society for Academic Emerg Med, National Institute on Aging, New

Frontiers). A revisit to an emergency department (ED) within 30 days of a previous visit predicts adverse

outcomes in elderly adults (de Gelder et al, 2018). These researchers assessed predictors of ED revisits and

the association between revisits and 90-day functional decline or mortality in elderly patients discharged from

the EDs of one academic and two regional Dutch hospitals.

They reported independent predictors of a 30-day revisit included age, male sex, polypharmacy (may be

proxy for illness severity), and cognitive impairment. Individuals with a revisit were at higher risk of functional

decline or mortality. Risk for revisit or readmission may also be impacted by adherence to discharge

instructions, duration of recovery, living arrangement and functional dependency, medical history, presence

of caregivers, and visits to a primary practitioner shortly after discharge.

To prevent an unscheduled revisit or readmission, we must effectively identify those who are at high

risk to enable individualized discharge planning, early and appropriate coordinated care, and effective use of

community and social resources. Hospital strategies associated with decreased 30-day readmission

rates include:

• Care Coordination teams partnering with primary care practitioners

• Having nurses (and MIH CPs) responsible for medication reconciliation

• Arranging for follow-up visits before discharge

• Having a process in place to send all discharge or electronic summaries directly to the patient’s PCP

• Assigning staff to follow up on test results after patient discharge (Bradley et al, 2013).

Our MIH pilot plan addresses all of those recommendations.

To be sustainable, healthcare systems of the future must be effective, efficient, accountable, safe, and

agile. Stakeholders must align leadership and resources to invest in a value-based payment system that

supports a continuously learning health system (@theNAMedicine). The MIH pilot supports these ends.

Mobile Integrated Healthcare (MIH) and Community Paramedics (CPs)

Paramedicine today is a professional space that begins with emergency medical response and

interventions and expands to assisting individuals, families, and communities in attaining, re-attaining, and

maintaining optimal health (EMS 3.0). EMS is currently a present, expected, respected and welcomed

source of medical care in people’s homes and throughout the community.


6

To meet the complex needs of patients in a value-based economy, EMS must integrate with other

services and systems to optimize patient health while ensuring safety. Multidisciplinary delivery models and

partnerships must be forged using reliable science to strengthen and broaden infrastructure and resources

to coordinate care, monitor patients, and teach self-management skills to improve quality performance and

reduce utilization and cost, while improving patient and provider satisfaction.

Within these integrated models, EMS can effectively fill service gaps to reduce ambulance transports,

ED re-visits, and avoidable hospital readmissions in a reliable and cost-effective manner. Community

Paramedics (CPs) collaborate with primary care practitioners (PCPs) and community healthcare agencies to

deliver a broad spectrum of person-centered preventive and follow up care and help patients navigate the

healthcare system ensuring that they receive the right care, in the right place, at the right time based on

person needs and choice, and at the right cost.

Planning for MIH in Illinois started with a desire to meet the Institute for Healthcare Improvement’s (IHI)

Triple (now quadruple) Aims for US Healthcare (2008):

Improve the patient experience of care, including quality and satisfaction

Improve the health of populations

Reduce the per-capita cost of healthcare (IHI)

Add now the goal of improving the work life of health care providers, including clinicians and staff.

The drivers of patient experience include all aspects of the triple aim: safe, seamless, and personal

care. Of these, personal care may be the most important, focusing on empathy, great communication, and

compassion (Scaletta, 2018). CPs are skilled in these areas.

MIH care models vary remarkably in Illinois and throughout the country and are generally designed to

meet local needs based on local resources. Some only provide home safety checks while others attempt to

prevent frequent 911 calls from “Superuser” patients. In rural areas, CPs provide long-term patient care

using a sophisticated array of diagnostic tools and interventions due to lack of other healthcare resources

and use telehealth technology to communicate with PCPs. Some programs are hospital-based; others

provider-based. Nationally, MIH programs involve community paramedicine, 911 nurse triage, alternate

responses with multi-disciplinary teams, and/or alternate patient destinations. Our pilot has a CP focus. .At

the core, sustainable funding becomes the largest challenge to providing the service over time.

The NCH/NWC EMSS MIH pilot is based on six guiding principles (in no particular order)

Inherently safe and effective Reliable and prepared

Integrated and seamless Sustainable and efficient

Socially equitable Adaptable and innovative

Transformative innovation delivers better value as measured by outcomes, price and customer experience (“2017 CEO Forum Report: Delivering Excellence in the New Healthcare World,” Huron Consulting Group

Inc. and affiliates, Aug, 2017).

Principles of responsible innovation underpinning the MIH pilot:

Clearly identified need Continuous reflexive evaluation

Balancing safety and efficacy Coordinated interdisciplinary action

Generating robust evidence Effective and proportionate oversight

The MIH pilot is an extension of the NCH Clinical Care Coordination

model and is based on community and person needs, regulatory

requirements, national standards, best practice models, and technological

advances while being ever considerate of scare human and economic

resources that must be applied in a manner that promotes the safety,

health and welfare of all persons enrolled.

Pilot EMS organizations will collaborate with NCH to access

resources, including quality education, credentialing of CPs, medical

direction, evidence-based care protocols; coordination of care, qualitative

and quantitative performance measurement and improvement strategies

using national metrics and benchmarks, and reimbursement for costs.

Our ultimate value will be measured by our partners in care, the consumers of our service, and by those

who pay the bills. The MIH Pilot Plan reflects a balance of effectiveness, efficiency and equity.


7

LEGISLATIVE and REGULATORY AUTHORITY

The program operates in full compliance with Illinois laws, rules, regulations, and guidelines that apply

to or support the MIH pilot.

ILLINOIS HOUSE JOINT RESOLUTION HJ0037:

RESOLVED, BY THE HOUSE OF REPRESENTATIVES OF THE NINETY-NINTH GENERAL ASSEMBLY OF THE STATE OF ILLINOIS, THE SENATE CONCURRING HEREIN, that there is created the Mobile Integrated Healthcare Task Force to identify and recommend ways that the State of Illinois can incorporate changes in our health care delivery system in order to increase the collaboration and utilization of our current health care workers while decreasing the associated costs.

On March 23, 2015, Jack Fleeharty, Chief of the Illinois Department of Public Health Division of EMS and Highway Safety penned a letter to Valerie Phillips, MD, chair of the Mobile Integrated Healthcare Committee, approving MIH programs in Illinois that follow the state guidelines. See appendix A.

An IDPH MIH Template and Application was updated in November of 2015 and must be submitted to IDPH for approval prior to starting a pilot program.

PARTNERSHIP AGREEMENTS

Affiliation and Business Partner agreements are established with hospitals and MIH community agencies

involved in the MIH pilot. These agreements specify the following:

Agency MIH CPs provide patient care

Agencies provide vehicles/personnel/equipment

Agencies/NCH coordinate patient services

NCH provides education, standards of care, SOPs, medical direction, program oversight and funding

NCH legal representatives work with agency legal counsel to frame business agreements. .

References:

Bennett, K., Yuen, M., Merrell, M. (2017). Community paramedicine applied in a rural community. J of Rural Health. March 23, 2017. doi: 10.1111/jrh.12233 [epub ahead of print].

Bradley, E.H. et al. (2013). Hospital strategies associated with 30-Day readmission rates for patients with heart failure. Circulation cardiovascular quality outcomes, 6; 444-450. DOI: 10.1161/CIRCOUTCOMES.111.000101

de Gelder, J., Lucke, J.A., de Groot, B., Fogteloo, A.J,. Sander Anten, S., Heringhaus, C., Dekkers, O.M., et al. (2018). Predictors and outcomes of revisits in older adults discharged from the emergency department. J of the Am Geriatrics Society. Published on line: 28 February 2018 https://doi.org/10.1111/jgs.15301

Healthcare Financial Management Association. (2016) Health Care 2020: Transformative Innovation.

Health Leaders Media. (January/February 2017). Annual industry outlook: The road to value-based care.

NASEMSO. (2017). State by state community paramedicine-mobile integrated healthcare (CP-MIH) status board. Accessed on line: www.nasemso.org

Scaletta, T. (2018). QUEST: Improving patient and provider experiences. Accessed on line: https://www.medscape.com/viewarticle/893987?nlid=121432_785&src=WNL_mdplsfeat_180327_mscpedit_nurs&uac=1774DY&spon=24&impID=1591632&faf=1#vp_2

Zavadsky, M. (August 14, 2017.) How paramedics helped BlueCross BlueShield of New Mexico reduce ED usage, readmissions. JEMS.com. Retrieved Nov. 20, 2017, from www.jems.com/articles/pt/2017/08/how-paramedics-helped-bluecross- blueshield-of-new-mexico-reduce-er-usage-readmissions.html

Zygowicz, W. (2015). Adapt to demand: Littleton, Colo. fire rescue is rolling out their take on mobile integrated healthcare. JEMS, 40(5):36–41.

For info on IHI Triple Aims see: http://www.ihi.org/engage/initiatives/TripleAim/Pages/default.aspx For info on EMS 3.0 see: http://naemt.org/initiatives/ems-transformation

https://doi.org/10.1111/jgs.15301

http://www.nasemso.org/

https://www.medscape.com/viewarticle/893987?nlid=121432_785&src=WNL_mdplsfeat_180327_mscpedit_nurs&uac=1774DY&spon=24&impID=1591632&faf=1#vp_2

https://www.medscape.com/viewarticle/893987?nlid=121432_785&src=WNL_mdplsfeat_180327_mscpedit_nurs&uac=1774DY&spon=24&impID=1591632&faf=1#vp_2

http://www.jems.com/articles/pt/2017/08/how-paramedics-helped-bluecross-%20blueshield-of-new-mexico-reduce-er-usage-readmissions.html

http://www.jems.com/articles/pt/2017/08/how-paramedics-helped-bluecross-%20blueshield-of-new-mexico-reduce-er-usage-readmissions.html

http://www.ihi.org/engage/initiatives/TripleAim/Pages/default.aspx

http://naemt.org/initiatives/ems-transformation


8

PILOT GOALS

SAFE TRANSITIONS AND VALUE-BASED CARE in the HOME ENVIRONMENT

The overarching goal is to achieve more home and less hospital or skilled nursing facility-based care.

Effective care transitions between clinical settings are pivotal to optimizing population health. The MIH-CPs

are important resources in helping patients bridge these transitions.

PILOT GOALS:

Enhance the NCH Coordinated Care delivery model by establishing partnerships with MIH CPs

Meet the outcome points from the IHI Triple Aim Initiative to optimize health system performance:

- Improve the patient experience of care including quality and satisfaction as evidenced by an increase in patient experience scores that are based on US IOM Quality Chasm key dimensions: safe, effective (evidence-based practice), timely, and efficient care.

- Improve the health of target populations and clinical outcomes via early patient engagement; enhanced understanding/compliance with DC care plans; exploring and overcoming challenges to compliance; identification of therapy failures; closing care gaps, providing effective health coaching, and improving patient quality of life evidenced by a reduction in avoidable hospital and unscheduled ED readmissions by 10% in target patients. Increase engagement with PCPs; support/generate NCH primary care appointments.

- Reduce costs evidenced by a reduction in CMS penalties in target populations by 5%.

Enhance patient safety and reduce home falls and fires via safety/wellness checks; fall abatement strategies, installation of working CO and fire detectors, and community education.

Decrease dependency on the 9-1-1 system; encourage appropriate use of EMS in the target

population evidenced by a reduction in calls to EMS for non-emergency causes to < 5 per year.

The NCH MIH-CP pilot will

Pilot executive steering committee

At NCH EMS Agencies:

Steve. Scogna, President and CEO

Kim Nagy, RN MSN NEA-BC, Executive VP and CNO

Dina Lipowich, RN, MSN, NEA-BC; Ex Director, Care Coord.

Matthew T. Jordan, MD, FACEP; EMS Medical Director

Connie J. Mattera, MS, RN, EMT-P; EMS Admin Director

Scott Andersen, Chief, Palatine FD

Rich May, Chief, Palatine Rural FPD

Terry Valentino, Chief, Rolling Meadows FD

Ken Koeppen (AHFD) (?)

Pilot Stakeholders

Hospital: leadership; BOD; Care Coordinators (C3s/ AC3s)/discharge planners, decision support, risk management,

QMI, legal, community services, home care, elder care; philanthropy, pharmacy, IT, communication hub

Primary Care Practitioners (PCPs); ED physicians and nurses

EMS System: Provider leaders and paramedics; educators

Community partners; elected officials; legal counsel; patients; third party payers

Input was solicited from key stakeholders. Meetings were held with C3s, Director of Care Coordination,

senior leadership, physicians and members of the Foundation to share the MIH proposal and seek their

input. Broader stakeholder meetings will be held to introduce the pilot plan and gain their support.

Create a high-reliability enterprise that integrates with the healthcare continuum by providing access to quality

and affordable post-discharge care…

delivered by CPs within an MIH program to target

populations as they seamlessly transition

between care environments…

with the goal of optimizing their health status, reducing avoidable readmissions,

increasing engagement and experience, and reducing

cost of care.


9

What will success look like?

□ Stakeholders will participate in planning that is tailored to local needs based on the identified scope

of the pilot project and put into place strategies that will achieve full implementation of the pilot.

□ Barriers to innovation are identified

□ The business model delivers measurable value through management and coordination of:

□ Practitioner learning/practice needs

□ Operations and logistics

□ Economies of scale and centralized planning

□ Careful stewardship of all human and economic resources

□ The plan articulates clear values and goals that address stakeholder needs.

□ The plan has a focused scope.

□ The plan clearly defines the population and stakeholders affected by the changes.

□ State and local regulatory, governance, and practice infrastructures are reframed to support

adoption of MIH model.

□ The plan achieves or exceeds all goals and metrics

As barriers are encountered that threaten to derail their progress, stakeholders will contact the executive

leadership team who shall provide assistance or resources, suggests alternatives, and assist in

brainstorming solutions

Feasibility and risk assessment

Potential business feasibility was assessed; as were degrees of risk and possible barriers to implementation.

Probability of achieving overall performance targets was “pressure tested” by evaluating actual outcomes in neighboring Systems and in other parts of the country with similar projects in operation.

Contingency plans are in place if:

Time estimates are too optimistic; Stakeholder review & feedback/approval cycle is too slow; Unexpected resource constraints exist; Technical limitations prevent implementation as proposed; Roles & expectations are unclear; Stakeholder needs are not properly understood; Stakeholders have changing requirements after the pilot has started; Stakeholders add new requirements after pilot has started; Poor communications result in quality problems and rework.

Plans are in place to adjust forecasts due to changes in: planner capacity to create/implement the project; consumer influence, physician influence, impact of clinical innovations, impact of competitive position; and impact related to revenue streams and ROI. Reference: Minnesota Dept of Health Office of Rural and Primary Care Emerging Professions Program. (2016).

Community Paramedic Toolkit. Accessed on line: http://www.health.state.mn.us/divs/orhpc/workforce/emerging/index.html

http://www.health.state.mn.us/divs/orhpc/workforce/emerging/index.html


10

Alignment with NCH Mission, Strategic Goals and Objectives

NCH STRATEGIC PILLARS are integrated within the MIH program:

Population health

A population health strategy powers NCH to coordinate care across the healthcare continuum; improve

health outcomes; and promote economies of scale in a framework that ensures health care diversity,

inclusion and equity. See care model.

NCH care transition model includes aggressive management of patients at high-risk of readmission

or an ED visit, while ensuring the patient remains clinically stable in an out-of-hospital environment.

Efficient patient education and self-management is achieved through the use of cutting-edge

technology and community-based support systems

Patient access

Patients have access to care when and where they need it

MIH Care model access points: In-patient (IP) discharges and patient transitioning out of home care

Care quality

National benchmarks for quality outcomes in MIH are identified and metrics are designed to measure

pilot outcomes.

Operational excellence

System wide procedures ensure streamlined communication, staff education, contract management,

and an integrated approach to care delivery. See program design.

Customer Service

Internal customer expectations are met or exceeded

External customer expectations are met or exceeded

The program is responsive to customer requests and needs

See pilot metrics in Quality Improvement section

Financial sustainability and stewardship

Return on investment metrics are identified

Labor costs are fair, equitable to job role and allow program to operate within the financial plan

Supply costs are identified and included into the pilot budgetary plan

Throughput costs meet budgetary plan

Hospital cost savings from reducing avoidable utilization is identified and reported

Hospital explores/receives grant funding from insurers/philanthropy to offset initial capitalization and

ongoing operational costs

People

Competent staff ensure clinical and operational excellence

Adequate CPs are recruited, educated, credentialed, supported, deployed, and retained to support

the program goals and staffing plan

CP risks for illness/injury are mitigated during MIH activities


11

COMMUNITY NEEDS ASSESSMENT/MARKET ANALYSIS

The foundation for quality health care practice, education, and systems management is evidence based\

and obtained from rigorous scientific study.

To make care truly person centered, it is imperative to know our patient population. Local needs and potential gaps or opportunities in healthcare delivery were identified by reviewing the NCH Community Needs Assessment document and hospital historical data with respect to readmissions. Projections were made as to how MIH could assist in meeting those needs.

The nature and scope of the pilot was determined by reviewing the IDPH-approved MIH model, analyzing other existing MIH-CP programs, and published literature to review national trends, drivers, and barriers for specific delivery models and service lines. We studied the strategies they adopted to bring value to patients and providers while enabling people to remain in their homes as long as safely possible.

PROJECTED NEED FOR MIH-CPs

According to the U.S. Dept. of Labor Bureau of Labor Statistics, Health Educators and Community Health Workers are expected to grow at a rate of 21% faster than average. This growth is driven by efforts to improve health outcomes and to reduce healthcare costs

1.

Convenience sample discussions were conducted with members of the community to demonstrate that the service characteristics and operational strengths of the pilot program would be positively received by the market.

PILOT AGENCY SELECTION

The pilot agencies were selected based on their expressed desire to participate based on benefits being reported by other MIH programs already in operation. These communities work in a consortium that aligns their practices and shares resources, which allows for a controlled pilot with highly qualified providers in a discrete geographic area with a good representative sample of targeted patients in our primary service area. Each of these communities transport almost exclusively to NCH.

MARKET VOLUME DETERMINATION

The potential market volume was forecasted by gathering data on the patient origins, referral patterns, demographics, diagnoses and readmission rates in 2014 for patients residing in Rolling Meadows, Palatine and Palatine Rural’s service areas. We also collected data on the total population in each community to project potential demand for the service. A reanalysis of these numbers was conducted for 2017 as a baseline against which program outcomes will be measured. Ongoing quantitative (demographics, utilization rates) and qualitative (other care options, clinical or technological advances that may affect demand) assessments will continue to match patient needs and program resources.

Pilot communities Population Zip Codes

Palatine: 68,766 60067, 60074

Inverness (Pal Rural): 17,000 60010, 60067

Rolling Meadows: 24,000 60008

AH (?)

Zip code ED visits Inpatients Outpatients Total 2017 Pilot

diagnosis Readmissions Rate

60004 (AH) 6,874 1,728 828 9,430 1,451 165 11.37%

60005 (AH) 5,013 1,220 571 6.803 997 131 13.14%

60008 (RM) 4,565 890 410 5,865 726 76 10.47%

60010 (PalR) 601 176 82 859 145 22 15.17%

60067 (Palatine) 4,677 1,151 502 6,330 934 116 12.42%

60074 (Palatine) 6,608 1,086 630 8.324 863 112 12.98%

Total 28,338 6,251 3.022 37,611 5,116 622 12.6%

1Bureau of Labor Statistics, U.S. Detp of Labor, Occupational Outlook Handbook, 2014-2015 Edition, Health Educators and Community Health

Workers. Published on line: http://www.bis.gov/ooh/community-and-socia-service/health-educators.htm

http://www.bis.gov/ooh/community-and-socia-service/health-educators.htm


12

PILOT DESIGN and WORK FLOW

The state-approved MIH concept design serves as the basis for the initial pilot project plan. Patients

who have frequent contact with EMS and hospital readmissions often have multiple medical problems, comorbidities and complex psychosocial circumstances. These health issues cannot be solved by a single entity, but require the expertise of a variety of healthcare providers, social services agencies, and community resources. Key partnerships enable MIH-CPs to match each patient’s needs with the right resources (NAEMT, 2015).

The MIH care delivery model will provide end-to-end services within the NCH System of Care, building an access platform with maximum flexibility and a customized approach that meets the needs of patients, families and providers.

The focus of the MIH pilot is to safely transition patients with target diagnoses from hospital to home by adding the option of early home visits by an MIH-CP that is commensurate with a risk assessment, patient need, and program standards of practice.

MIH-CPs partner with and do not compete with existing care delivery models and/or services

The program strengthens our commitment to help patients effectively navigate through their episodes of care and minimize or eliminate health care disparities. It is also designed to help patients develop and execute strategies to optimize their health and engage appropriate social services and support structures to meet their healthcare needs. The team shall consider the different cultures, customs and languages that are unique to our patients and work with them to facilitate the physical, emotional and spiritual dimensions of their healing and/or condition management.

Patient eligibility for inclusion in the pilot:

Age (≥18)

Residence in one of the pilot communities

Diagnosed with one or more of the targeted conditions

TARGET PATIENT POPULATION: Readmission avoidance based on CMS criteria Adults admitted to NCH and discharged with a diagnosis of:

Post AMI

COPD/asthma

Heart failure

Pneumonia (high risk for sepsis)

Post major joint replacement (hip-knee)

Timing and number of anticipated visits is based on a Readmission Risk Calculation completed for every patient discharge. Contributing factors for an unplanned readmission that are documented in the patients EHR (EPIC) are weighted into a percentage score that predicts the patient’s risk as critical, high, medium or low. The Readmission Risk percentage is added to the Post-Acute Transfer Summary. High risk discharge protocols are in development for Homecare, PCPs, SNFs and MIH.

The number of MIH-CP visits will initially be assigned based on the degree of calculated risk. The total number of actual visits may be modified based on PCP or MIH-CP request and as approved by NCH.

Factors contributing to readmission risk (weighted calculations)

Number of past admissions Medical comorbidities Hemoglobin low Sensory impairment

Number of past ED visits Had imaging orders Calcium low On ulcer meds Substance use disorders PO4 tested BUN high Had restraint orders

Number of active med orders Age/gender Creatinine high Dx cancer On antipsychotic meds On anticoagulant(s) INR high Dx of Deficiency anemia

Mental health comorbidity Length of stay On NSAIDS Dx renal failure Had an ECG Weighted Chartson Diagnoses On corticosteroids Prior LOS 10+ days

Dx of electrolyte disorder Has future scheduled appts Cognitive status Income

Risk of readmission prediction

38% - 100% Critical

25% - 37.5% High

13% - 24.5% Medium

0% - 12.5% Low


13

No financial, technical, social, physical, or age-related barriers should exist for those eligible for an MIH-CP response. Qualified practitioners shall assess a patient’s health status, make a determination regarding the most appropriate resources to be mobilized, and implement an effective course of action based on patient and PCP consent and within MIH standing medical orders. Each person enrolled in the pilot will have the opportunity to engage in the process of reaching their highest potential for health.

MIH Pilot WORK FLOW – Referral from in-patient setting

Clinical Care Coordinator (C3) (Unit):

Assess eligibility for inclusion in MIH pilot; rate readmission risk; determine timing and # of visits*

Inform PCP of patient referral and MIH-CP option; gain their consent. (This may be done by HUB C3)

Engage patient/family in discharge care planning; including MIH-CP visit option. Gain their consent.

Determine if community resources such as an interpreter are also needed.

If patient and PCP consent to MIH visit: Notify HUB C3 regarding impending D/C of patient to be

enrolled in the MIH-CP pilot and patient risk level. Assemble patient information and D/C plan; send

to HUB C3 to forward to MIH CP.

Provide D/C instructions to patient/family; include MIH brochure and tell them to expect a call from the

CP within hours of arriving home. Whenever possible, ensure that prescribed medications are filled and

provided to patient prior to discharge.

Inform HUB when patient has been discharged.

*Readmission risk calculation and number of MIH-CP visits

Risk percentages

Risk level Intervention

12.5% or lower Low Visit w/in 24-48 hours of DC 1 visit

13%-24.5% Moderate Visit w/in 18-24 hours of DC 2 visits

25% or higher High Visit w/in 12-18 hours of DC 3 visits/follow up calls

HUB C3

After receiving patient referral to MIH pilot and readmission risk assessment: Contact RPM MIH-CP call center and relay information about enrolled patient; risk level, and requested date and time of 1

st visit;

confirm availability to respond.

Send DC packet & PCP contact information via secured fax to MIH CP call center; confirm receipt

Contact RPM call center to confirm patient DC when it has occurred. MIH-CP - Prior to 1

st (enrollment) visit

Confirm availability for desired 1st visit date/time with RPM MIH-CP call center

Make initial contact with patient/caregiver after D/C notification to confirm 1st visit date and time. CPs

respond to locations where patients are located, so they shall confirm address and receive any specific instructions relative to parking; access; presence of animals, etc. Reaffirm with client the name of the CP, type and markings of MIH response vehicle and uniform that will be worn by the CP.

Review D/C packet and access patient record in EPIC (if needed); contacts HUB C3 if further questions MIH-CP - During and after each visit

Review care plan w/ patient/caregiver, confirm understanding.

Provide general and disease-specific assessments and care within scope of practice and MIH CP Standard Operating Procedures (SOPs); determine if patient is meeting discharge plan and clinical goals to include, but not limited to, weight, vital signs, physical exam findings; perform medication reconciliation, assess compliance with performing self-assessments/care; diet, movement and mobility , sleep and rest patterns, pain management, assigned exercises, ability to perform activities of daily living etc.; answer questions; provide health coaching as needed; complete home safety check

Rate patient acuity (see below); make appropriate notifications to PCP or EMS for 911 transport. If unclear as to direction or best way to proceed, may seek rapid consult from EMS MD via cell phone or EMS Admin Director.


14

MIH CP Acuity rating after assessment / related actions

Emergent (high risk): Patient currently unstable

Acute deterioration; call 911; EMS transports to NCH ED; fax report to PCP; Call HB

Urgent (rising risk): Patient currently stable; Not meeting outcome targets

VS stable: Phone PCP office, fax report, PCP to contact pt/MIH CP; MIH CP to notify Hub, alert to access ImageTrend report

Routine (low risk): Patient currently stable; meeting outcome targets

Fax report to PCP; notify Hub to access ImageTrend report; answer questions, provide coaching/further instruction on self-care to patient / care giver

Note if community resources or care navigation are needed. Contact:

If non-urgent transport to another location is needed, CP shall offer transportation options to the patient. Document in ImageTrend software. Send PDF of EMR with CP contact information to PCP via secured

fax; notify HUB of new electronic entry

Note in MIH records if PCP changes care plan

Last (graduation) visit: provide MIH CP satisfaction questionnaire to patient Primary Care Practitioner – Communication linkages and further orders

Review patient information from MIH CP

Determine if changes are needed to patient care plan or earlier office visit is advised; enter determination into patient record

Contact patient if changes are needed urgently (prior to scheduled office visit)

If additional MIH visits/calls are desired: contact NCH HUB HUB C3 after each MIH-CP visit and determination by PCP

Access MIH CP EMR report

Drop into EPIC notes section

If PCP requests additional visits; contact Ex Dir Care Coord for approval. If approved, contact MIH-CP for their availability.

Future expansion of the program may include direct referrals from PCPs, home health organizations,

hospices, law enforcement agencies, mental health care facilities, nursing homes, Public Health agencies,

community health clinics, urgent care facilities, social services agencies, or addiction treatment centers.

This will be contingent on securing a sustainable funding source.


15

OPERATIONS MANAGEMENT

Management structure and reporting relationships

The EMS MD provides medical oversight for the program. (See MIH Medical Direction)

The EMS MD collaborates with NCH senior leadership, the EMS Administrative Director, pilot Agency

leaders and Provider EMSCs, and CPs to advance the System toward achieving its MIH strategic goals and

initiatives in compliance with the Pilot Plan, stakeholder expectations and within full legislative, regulatory,

and accreditation compliance.

The pilot plan uses the expertise of hospital leaders with respect to planning, business development,

community relations, physician relations, QMI, e-Business and marketing.

SUPPLIES AND EQUIPMENT

Location and administrative space requirements (for administration and service delivery) at the hospital and

EMS agencies were identified and determined to be adequate for the MIH pilot needs.

Vehicles

MIH Response vehicles shall be an SUV or car that is wrapped/painted with the MIH/RPM logo and

deployed based on the operational plan.

New MIH vehicles must be inspected, licensed and put into service with appropriate IDPH sys-

mods filed/approved, and insurance and maintenance plans in place.

They are stocked, and housed in thermally controlled garage space so equipment is kept at

allowable temperature ranges.

Supplies/equipment brought to home

Supplies/equipment to be carried on MIH vehicles are commensurate with the practice standards approved

by the EMS MD and within the scope of practice for CPs. For the pilot, these include, but may not be limited

to the following:

Stethoscope; Sphygmomanometer

ECG monitor capable of obtaining BP, SpO2, ETCO2, rhythm strip and 12L ECG

Peripheral and central sensors for SpO2

NC ETCO2 sensor

Scale

Communications device to make phone calls and access a web browser

Electronic device that allows creation of the Image Trend MIH CP ePCR

Electronic device that allows for contact with an interpretter

Home safety check forms

Hold harmless agreements for home safety check

Patient education materials; community resource fliers, pill sorters


16

MEDICAL DIRECTION for the MIH Program

“The EMS Medical Director or "EMS MD" is the physician appointed by the Resource Hospital who has

the responsibility and authority for total management of the EMS System” (Title 77: Public Health

Subchapter f: Emergency Medical Services and Highway Safety. Part 535 Emergency Medical Services

Code Section 535.100).

Community Paramedics must operate under the authority of a Resource Hospital EMS MD within the Illinois EMS Act and Rules. Reporting structure relationships currently in place for the EMS System are retained for the MIH pilot. All medical orders must be given/approved by the EMS MD or his designee.

“The Department recognizes the MIH committee has made a tremendous effort to keep this program within the current scope of practice of EMS providers who function under the medical direction of the EMS System Medical Director. Additionally, based on the program, the Department understands that no EMS provider will receive nor act upon any orders, whether verbal or written, from any of the collaborating physician(s). All medical orders to EMS Providers must exclusively originate from the EMS System, under the authority of the EMS Medical Director. The collaborating physician(s) may give instructions directly to the patient or the patient’s authorized care provider, but not to the EMS Provider. EMS Providers are not authorized to take medical orders from anyone other than the EMS Medical Director or his/her designee, as described within the EMS Act and the Local System Program Plan” (Jack Fleeharty, former Chief, IDPH Div. of EMS).

For the MIH pilot, the System EMS MD is responsible for the following:

Collaborating on the design, operation, evaluation and QM activities

Determining scope of practice of CPs

Affirming competency of CPs

Protocol development/approval

Development/approval of care plans

Phone or telemedicine consultation as needed

Approving alternate destinations/ dispositions of patients (future)

MIH CP SCOPE of PRACTICE

National trends: “EMS agencies may expand their services to include: community health screenings,

injury prevention initiatives, mitigation strategies for chronic repetitive patients, assistance programs to

improve patient compliance with healthcare plans, well-being checks, mechanisms to route patients to the

appropriate segment of the healthcare system, expanded on-scene care to eliminate the need for transport,

and strengthening bonds between patients and primary care practitioners” (Robbins, 2017).

NWC EMSS MIH-CPs function with all rights and privileges granted by their paramedic license plus

they hold specialty credentials. They operate within MIH policies and protocols that are approved by the

EMS MD and approved by IDPH. MIH-CP practice is an extension of usual and customary paramedic

duties. The EMS MD may choose to establish clinical competencies for CPs that may or may not be more

expansive or restrictive than their usual EMS scope of practice based on national, regional, state, or other

jurisdictional guidelines and with IDPH approval.

In MIH, there is a shift from episodic evaluation and care independent of a patient’s existing medical

plan to longitudinal monitoring and adjustment of care as part of that plan (NAEMT, 2015). CPs transition

from emergency/unscheduled responses with ED on-line medical control to scheduled responses

functioning within the MIH SOPs and communicating with other members of the care team based on

changing patient needs.

In crafting the MIH pilot, best practice models were researched for scopes of practice, standing

medical orders, care navigation options, and program policies.

After the pilot is launched and data support modification or extension to the plan, a defined process

has been identified to add new services/functionality and to expand the pilot to other agencies/hospitals

as needed.


17

MIH CP EDUCATION

The System must ensure that alterations in expectations of EMS personnel to provide health care

services are preceded by adequate education and preparation. Community paramedics shall be educated and competencied to the NWC EMSS MIH standards of practice for the level of service they are providing. Desired outcome: The MIH CP Education program prepares EMS personnel to provide competent,

compassionate and person-centered care within the MIH scopes of practice.

Achieving educational objectives in all domains of learning is fundamental to competent MIH-CPs. Curriculum design, lesson plans, teaching methods, and assessments and measurement tools reflect local need, national recommendations and guidelines, and the National EMS Education Standards.

All MIH education shall be submitted to IDPH for site code approval in compliance with the EMS rules and System policy. The initial pilot education shall consist of 40 hours of classroom content. This may increase in the future as the CP scope of practice and program outreach expands.

Reference:

University of Pittsburgh Dept. of Community Medicine (EM Program). (2015).Proposal to develop a bachelor of science degree in community health. Shared with NCH program by Walt Alan Stoy, PhD, Professor and Program Director, Emergency Medicine Program.

MIH-CP CREDENTIALING

The practice of EMS is complex, dynamic, and diverse. It is historically built upon the domains of

education and licensure. The public is best served when EMS providers receive externally accredited education, are nationally certified, state licensed, and credentialed by the local EMS MD (NAEMT/NAEMSP position statement, 2016).

While paramedics in Illinois are licensed by IDPH, they are awarded practice privileges by the local EMS Medical Director (EMS MD). The diversity of clinical and operational protocols, scopes of practice, and equipment used in MIH programs across various EMS Systems requires local verification of the EMS provider’s clinical and operational abilities. Credentialing as a Community Paramedic (CP) must occur at the EMS System level.

The EMS MD has the final authority and accountability for credentialing and providing medical direction to MIH-CPs in the NWC EMSS and shall be actively involved in the clinical credentialing process.

MIH-CP credentialing follows a process that substantively helps to promote the practice of paramedicine on par with the legitimacy that hospital medical staff credentialing promotes for the practice of hospital-based medicine.

After appropriate education, evaluation and measurement, successful candidates will be credentialed as CPs in the NWC EMSS by Dr. Matthew T. Jordan, EMS MD, attesting that they possess required competencies in all three learning domains. Both initial and ongoing assessment of these competencies shall be important components in verifying the provider’s continued practice privileges.

Credentialing involves at a minimum

1. Demonstration of sufficient cognitive knowledge; 2. Demonstration of mature, responsible affective ability; 3. Demonstrated competency for all involved psychomotor skills; and 4. Demonstrated ability to integrate the three domains in thinking critically and acting responsibly

during the provision of clinical care

The MIH-CP credentialing processes shall be fair, consistent, objective, and based on clearly communicated, evidence-based performance standards that are accessible to any EMS provider seeking clinical credentialing as a CP from the NWC EMSS MD.

A CP application and Practice Agreement has been created based on national models and local needs – See appendix. Recognition as a CP in the NWC EMSS will be granted for a period of no less than two years before renewal or recredentialing is required. The credentialing process shall undergo continuous review to ensure that education and measurement activities are adaptive to the evolving practice of MIH.


18

STAFFING PLANS (Medical and administrative)

The MIH pilot uses people, processes and technology to maximize efficiencies while preserving

effectiveness to achieve outcome goals. All needed human resources are forecasted, resourced, and

implemented before launching the pilot. Staffing must match capacity and demand for MIH services across

pilot patient populations.

MIH staffing resources includes the following:

EMS MD, EMS Administrative Director, data collection/reporting resource persons; program leaders

Community Paramedics

Community Services rep (translator)

C3s at NCH (Unit and HUB)

Agency MIH call center personnel

Secretarial support at NCH and the EMS agencies

Community paramedic duty assignments and response

For the pilot, CP on-call and response are outside of the usual and customary paramedic duty schedule.

Routine MIH response: One MIH-CP will respond in a specially branded vehicle (non-

ambulance) wearing their usual duty uniform and department identification.

If there is a known language barrier, all attempts will be made to have a community service

member affiliated with NCH who is an approved translator accompany the CP. Other options

include the use of an electronic device to access an appropriate interpreter while on site.

MIH responses/CP time aliquots – depends on whether an enrollment or follow-up visit

Average 1.6 -2.5 hours:

Enrollment visit patient care contact time: 1-1.5 hours; follow-up visits: 40 minutes.

If translation services are required, the visit may take longer to allow for 3-way communication.

30 min for travel (round trip)

30 min for documentation and communication with HUB/PCP

Service volumes and capacity: Based on the market analysis and projected volumes; initial staffing will

need to cover at least 4 visits per day with surge capacity for 8 visit/day if personnel and resources

allow.

Anticipate 40 visits per month

480 visits within the pilot year (may be very high estimate for first year)

CP resources: The staffing plan will require a minimum of 6 to 9 credentialed CPs (2-3 per shift)

Hours of operation and staffing plan:

M-F from 0900-1700: A minimum of one CP scheduled and available to complete visits.

Initially, a second CP shall be on-call to cover a surge in needed visits for high risk patients until

actual program needs are established.

Sat-Sun 0900-1300: One CP on–call for high risk visits only

Staffing schedule: A monthly staffing schedule shall be created at least 30 days in advance and

provided to the EMS MD (designee) and NCH Hub.

Cross coverage and mutual aid

In the future, Communities/Provider agencies may join together in public/private MIH partnerships to provide cross-coverage within their jurisdictions (much like the MABAS plan).


19

CLINICAL CARE: MIH Practice Guidelines and Patient Interaction Plan

The System is committed to providing safe, timely, competent, compassionate, efficient, effective,

equitable, cost-effective and person-centered care to serve the health care and wellness needs and wishes

of our patients. As patient populations become increasingly diverse, providing culturally competent care is

more important than ever (H&H Networks; The 2018 Environmental Scan).

Service level commitments

MIH CPs shall provide care, treatment, or services in accordance with orders or prescriptions, as required by law, regulation, and local policy and procedure.

Clinical excellence is the uncompromising cornerstone for our existence

Standing medical orders/Standard Operating Procedures (SOPs) for MIH are evidence-based, justifiable based on community health care needs, and defined by the NWC EMSS EMS MD.

MIH assessments and care shall be subject to ongoing evaluation to determine its impact on target patient outcomes. The System shall follow evolving literature and make practice changes to the MIH-CP protocols as needed.

The MIH program advocates for a Just Culture and fosters mindfulness in the CPs. Weick and Sutcliffe describe mindfulness in terms of 5 components:

1. A constant concern about the possibility of failure 2. Deference to expertise regardless of rank or status 3. Ability to adapt when the unexpected occurs 4. Ability to concentrate on a task while having a sense of the big picture 5 Ability to alter and flatten the hierarchy to fit a specific situation

Mindfulness throughout the System considers, but moves beyond, events and occurrences. Everyone is continually learning, adjusting, and redesigning systems for safety and managing behavioral choices (Boysen, 2013).

Clinical services provided by MIH-CPs are broadly grouped into three categories:

Assessment and evaluation:

Customary scene safety assessment when arriving, prior to entering, and while inside the home

Review of hospital discharge instructions and health targets with patient/caregiver. An individual has the right to get involved in the development and implementation of his/her person-centered plan of care which includes establishing goals (CMS regulatory text of tag F553). . Identify each person’s highest practicable level of well-being by exploring the seven dimensions of wellness (see below). Support clients in setting their own health goals.

General patient assessment:

H&P based on patient diagnosis and DC plan that may include, but not be limited to: weight, VS; SpO2; ETCO2, ECG, S&S peripheral edema; breath sounds, neuro assessments for cognitive impairment; wound healing, symptoms of infection/DVT

Medication reconciliation and compliance: Ensure that current prescriptions are filled; being taken as prescribed; and old/expired meds are appropriately removed from home/discarded. Ensure ongoing medication access/delivery from hospital or selected pharmacy. The MIH program partners with the NCH pharmacy director or designee to secure pill sorters for distribution prn and to identify electronic drug information resources that work on devices with a browser to use as references for CPs

Assess that needed medical resources are available in home: Batteries for medical devices; home oxygen, ambulation aids; need for hospital bed?

Psychosocial needs assessment for community/ social services resources: Transportation, nutrition, heat & utilities. Take the initiative to ask patients what they need. Coordinate care with available community services as part of scheduled follow up care.


20

Disease-specific patient understanding and compliance with DC instructions:

Demonstrated ability to do self-assessments/care, e.g. glucose checks, peak flow monitoring; MDI/ nebulizer/ incentive spirometry use; dressing changes/wound management; DVT prophylaxis

Prevention and Education

Understanding and compliance with making healthy choices re diet, social habits, and exercise. Provide resources/coaching as needed.

Assess ability to perform activities of daily living: Mobility – must they climb stairs to bed or bathroom; are they able to do that safely? Are they able to dress themselves, make meals, eat independently, do personal hygiene and toileting, and oral care?

Home safety check; fall analysis and risk abatement; see form

Post-visit communication and follow up with PCP. All communication shall be “HOT” – honest, open, and transparent.

7 Dimensions of Wellness

Wellness is much more than merely physical health, exercise or nutrition. It is the full integration of

states of physical, mental, and spiritual well-being. This model, used by the University of California at

Riverside, includes social, emotional, spiritual, environmental, occupational, intellectual and physical

wellness. Each of these seven dimensions act and interact in a way that contributes to a person’s quality

of life. See https://wellness.ucr.edu/seven_dimensions.html

Social Wellness: The ability to relate to and connect with other people in our world. Our ability to

establish and maintain positive relationships with family, friends and co-workers.

Emotional Wellness: The ability to understand ourselves and cope with the challenges life can

bring. The ability to acknowledge and share feelings of anger, fear, sadness or stress; hope, love,

joy and happiness in a productive manner.

Spiritual Wellness: The ability to establish peace and harmony in our lives. The ability to develop

congruency between values and actions and to realize a common purpose that binds creation

together.

Environmental Wellness: The ability to recognize our own responsibility for the quality of the air, the

water and the land that surrounds us. The ability to make a positive impact on the quality of our

environment, be it our homes, our communities or our planet.

Occupational Wellness: The ability to get personal fulfillment from our jobs or our chosen career

fields while still maintaining balance in our lives. Our desire to contribute in our careers to make a

positive impact on the organizations we work in and to society as a whole.

Intellectual Wellness: The ability to open our minds to new ideas and experiences that can be

applied to personal decisions, group interaction and community betterment. The desire to learn new

concepts, improve skills and seek challenges in pursuit of lifelong learning.

Physical Wellness: The ability to maintain a healthy quality of life that allows us to get through our

daily activities without undue fatigue or physical stress. The ability to recognize that our behaviors

have a significant impact on our wellness and adopting healthful habits (balanced diet, exercise,

etc.) while avoiding destructive habits (tobacco, drugs, alcohol, etc.) will lead to optimal Physical

Wellness.

References:

Boysen, P.G. (2013). Just culture: a foundation for balanced accountability and patient safety. The Ochsner Journal, 13(3), 400–406.

Weick, K.E., Sutcliffe, K.M. (2001). Managing the unexpected: assuring high performance in an age of

complexity. San Francisco: Jossey Bass.

https://wellness.ucr.edu/seven_dimensions.html

https://wellness.ucr.edu/social_wellness.html

https://wellness.ucr.edu/emotional_wellness.html

https://wellness.ucr.edu/spiritual_wellness.html

https://wellness.ucr.edu/environmental_wellness.html

https://wellness.ucr.edu/occupational_wellness.html

https://wellness.ucr.edu/intellectual_wellness.html

https://wellness.ucr.edu/physical_wellness.html


21

MEDICATION RECONCILIATION

Sixty-six percent of emergency readmissions for patients over 65 years old are due to adverse

medication events. Further, 19% of Medicare discharges are followed by an adverse medical event within 30 days, 2/3 of these are preventable; and 20% of patients do not fill their prescriptions (CPS, 2016). NCH desires to manage the high risk and complex medication regimens, patient specific risk factors, comorbidities and adverse drug events associated with transitions of care.

Most patients have HTN when they reach 70 and are on 10-plus medications. It's been unequivocally shown that polypharmacy is a risk as drug-drug interactions and side effects increase. Anything gained from reducing BP may be eroded by increased risk of falls.

MIH Pilot Medication Reconciliation Goals

Reduce medication issues that could lead to readmissions

Improve patient outcomes by performing medication reconciliation, catching errors, improving safety and compliance, and enhancing communication related to medications post-discharge

Medication reconciliation is a systematic and thorough process to reduce medication discrepancies across transitions of patient care (Brown, 2012). The process is described in the JC Sentinel Event Alert #35 as a comparison of medication orders with a list of medications currently taken by the patient.

For the NCH MIH pilot, the process involves the following steps:

Verification: Consult the list of current medications (prescribed and over the counter) that the patient should be taking based on their discharge plan. Inventory and make a list of the medications present in the home; their concentrations, dose, and expiration dates.

Clarification: Compare the two lists and note discrepancies; determine if drug names (trade vs generic) may be the cause of a discrepancy. Ask patient about discrepancies; confirm medications that they are currently taking; and compliance with dosing.

Reconciliation: The CP shall inform the PCP regarding medication discrepancies. The PCP shall determine if the current prescribed medication list is accurate, document changes in the patient orders and discharge plan, and inform the patient and CP of any changes.

Medication Challenges:

Patients often receive new medications or have changes made to their existing medications at times of transitions in care—upon hospital admission, transfer from one unit to another during hospitalization, or discharge from hospital to home or another facility. Caregivers at transition points may inadvertently omit needed medications, unnecessarily duplicate existing therapies, or note incorrect dosages. These discrepancies place patients at risk for adverse drug events, which are one of the most common types of adverse events after hospital discharge and a key driver of hospital readmissions (Comprehensive Pharmacy Services, )

Patients may not fill their prescriptions

Patients may not understand how or when to take their medications properly

Previous prescriptions or expired medications may still be present in the home so patients have the potential for taking drugs that are not in the care plan. Old prescriptions may have different dosing from the current plan. Meds no longer prescribed or expired need to be appropriately discarded.

Patients may not remember if they took their meds and omit or take additional doses by mistake

Patients may electively skip doses or take additional doses, changing therapeutic blood levels

Patients may have forgotten to bring meds with them when away from home and/or miss multiple doses or they may have been in a healthcare setting that temporarily omitted key medications causing acute clinical signs and symptoms.

Patients may experience other health emergencies due to medication use. Example: Palliative care elderly patients are 40% more likely to experience delirium if taking medications with anticholinergic properties (Zimmerman, 2014). Taking antihypertensive medications may lead to a significantly increased risk for serious fall injuries among older adults with HTN and multiple comorbidities. The risk may be doubled for those individuals who have had a previous fall in the past year (Tinetti, 2014).

Patients may experience unknown altered effectiveness of current medications when taking new meds that impact their action (antibiotics may render BCPs ineffective)


22

CP Best Practice:

Engage pt and/or caregivers/family members in obtaining a Best Possible Medication History

Assess for knowledge deficits regarding medication regimens

Using the MIH-CP Medication Profile Reference Guide, provide education on the importance of maintaining a current and accurate medication history and safe compliance with the prescribed regimen.

References:

Brown, S. (2012). Overcoming the pitfalls of medication reconciliation. Nursing Management, 43(1), 15-17

Comprehensive Pharmacy Services. (2016). Medication reconciliation during transitions of care: how to catch errors, improve patient safety and reduce readmissions. Accessed on line: www.cpspharm.com/beckers

ENA, (2015). Role of the emergency nurse in medication reconciliation. Unpublished position statement.

National Academies of Sciences, Engineering, and Medicine. (2017). Communicating clearly about medicines: Proceedings of a workshop. Washington, DC: The National Academies Press. doi: https://doi.org/10.17226/24814.

Tinetti, M.E., Han, L.; Lee, D.S.H. et al. (2014). Antihypertensive medications and serious fall injuries in a nationally representative sample of older adults. AMA Intern Med, 174(4):588-595. doi:10.1001/jamainternmed.2013.14764

Zimmerman, K.M., Salow, M., Skarf, L.M., et al. (2014). Increasing anticholinergic burden and delirium in palliative care inpatients Palliat Med.; 28(4), 335-341.

http://www.cpspharm.com/beckers

https://doi.org/10.17226/24814


23

PATIENT EDUCATION and INJURY PREVENTION

"In the future, the success of EMS systems will be measured not only by the outcomes of their treatments,

but also by the results of their prevention efforts. Its expertise, resources, and positions in the communities

and the health care system make EMS an ideal candidate to serve linchpin roles during multi-disciplinary

community-wide prevention initiatives. EMS must seize such responsibility and profoundly enhance its

positive effects on community health" (Theodore R. Delbridge, M.D., MPH).

MIH-CPs shall work with patients to inform them about the Safe Communities concepts, and identify

possible community-based, prevention-oriented partnerships.

NWC EMSS will partner with EMS Agencies and System hospitals to promote wellness and the appropriate

use of EMS services. See integration of health services.

The importance of health and wellness is highlighted through educational efforts designed to inform patients about the dangers of smoking, unrecognized diabetes, hypertension, and obesity, etc and promoting the benefits of exercise, healthy stress outlets, etc.

DOCUMENTATION and INTEGRATION WITH HOSPITAL EHRS

The huge growth and reliance on technology in the healthcare industry to facilitate collection, storage,

retrieval, and reporting of patient data has made it imperative to use those cost-effective tools that incorporate uniform data elements, employ standard definitions, integrate information systems with other healthcare providers and public safety agencies, link multiple source databases, and generate valid, reliable, and accurate data.

The System is committed to complying with all Federal and state rules with respect to data collection, storage, security and reporting. Provider agencies and hospitals fully comply with HIPAA Security Rules.

Technologic safeguards: Technologically driven solutions address how PHI is stored, maintained, backed up, and retrieved and must be incorporated into System practice.

Physical safeguards: All System members will continue to ensure the security of buildings and facilities where electronic PHI is stored, transmitted, retrieved, etc. Only those with a legitimate need to access PHI can enter the area where PHI is stored or used. System PHI shall be stored in a secured office or computers containing PHI will be kept in areas where the public and other unauthorized individuals cannot access them.

Administrative safeguards: EMS agencies shall maintain policies & procedures, conduct training, and enforce best practice models in the ways System members protect the security of PHI.

The MIH EHR shall contain information that reflects the person's assessment, care, and services. We will adopt and implement sophisticated systems that support and enhance decision-making in clinical settings. (Futurescan 2017-2022: Healthcare Trends and Implications, AHA’s Society for the Healthcare Strategy & Market Development, 2017).

Demonstrating medical necessity for the services provided to beneficiaries on the front-end can reduce staffing-hours and frustration on the back-end surrounding denied services. Failure to clearly document and support medical necessity for services, in accordance with payer policies, can lead to loss of revenue.

PILOT PROCESSES

CPs will gather, record, and upload patient data using existing ImageTrend software that has been expanded/modified to include MIH data elements. Agreed upon CP data elements will be a collaborative effort within IDPH EMS Regions VIII and IX.

ImageTrend software provides the following functionalities:

- Allows care givers to see a comprehensive healthcare picture so they can tailor assessments and care at each visit

- Encryption of patient reports

- Ease of use and previous user familiarity with software


24

C3s in the hub shall enter MIH data into EPIC for access by the PCPs. Desired future state: Full integration with EPIC software.

The CARS Committee shall continue to monitor and respond to ongoing needs to update and/or revise the MIH-CP Power tools, clinical decision support (validity rules) features, and/or printing options.

The System shall share patient data for quality improvement purposes, achieve economies of scale for financing of MIH ePCR activities, and drive improvements to the Image Trend software.

The System will work with software vendors to develop interfaces between EMS and Hospital EHR software and advocate for linking and/or integrating patient data.

Hospitals and agencies shall conduct MIH-CP data security audits and HIPAA risk assessments designed to find and mitigate vulnerabilities.

References:

Garza, A. (2017). National survey on EMS ePCR usability. Accessed on line: www.naemt.org

Hooten, D. (2017). Best practices in high value EMS. EMS World; accessed on line: http://emsworld.com/node/219383

NAEMT. (2016). 2016 National survey data collection, use and exchange in EMS. Paper published by NAEMT on line.

http://www.naemt.org/

http://emsworld.com/node/219383


25

QUALITY MANAGEMENT and DATA COLLECTION

The ability of MIH-CPs to optimally meet communities' and individual patient's needs is dependent on

evaluation processes that assess and improve the quality of the program. Continuous evaluation is essential to measure the effectiveness and quality of all aspects of the program.

Hospitals must be able to monitor patients in post-acute settings in much the same way they monitor their inpatients. This requires systems that enable real-time data exchange and alerts issued to PCPs when specific milestones are at risk. However, having access to the data is not enough. In a strategic partnership, all parties must review trends, identify readmission causes and understand why specific therapy milestones have not been achieved.

Quality management and data collection for the MIH pilot will be specific to the benchmark being addressed. An interdisciplinary team will review standard data components on a monthly basis. Questions to be answered by QI:

Does MIH produce the desired outcomes?

Does MIH reduce costs with comparable or better outcomes than traditional approaches to care?

Does MIH reduce a patient’s risk for preventable readmissions?

Does MIH connect patients to needed care?

External accountability - Requiring routine and publicly reported performance data shall hold the program accountable and help ensure continual review and enhancement of the system (Hooten, 2017)

"We've made great strides in EMS data collection over the last decade. But it's vital we continue that momentum to make sure we're using the information - whether that's to improve the care we deliver, to ensure the safety of our patients and providers, or to guide public health and prevention efforts," (Noah Smith, EMS Specialist with the NHTSA Office of EMS, 2016).

Institute for Healthcare Improvement (IHI) 2018 Safety resolutions adapted for EMS:

Learn from what goes right, as well as what goes wrong

Move from reactive and responsive to proactive and generative

Invest in quality systems for learning, rather than just individual projects

Shift from fear, blame and liability toward humility, trust and transparency

Understand that quality is more than just the avoidance of mistakes and physical harm, but also the pursuit of excellence and optimal outcomes

The EMS System is data, information, and evidence-driven. Our effectiveness is gauged by a continuous and comprehensive evaluation of all aspects of performance including structural, process, and outcome measures while being highly sensitive to issues of confidentiality.

1. The System emphasizes the value and importance of information and data at all levels of sophistication. Further, we support widespread application of information within EMS agencies and across all components of healthcare and public safety and strives to clarify the role and purpose of national and statewide data collection efforts (Becknell, 2016).

2. The System advances our "information culture" based on the following priorities:

Industry-wide prioritization of information Strong motivation, relevancy and demonstrated improvement Leaders who champion the use of information A data- and information-savvy workforce A continuous feedback loop

3. The System assesses and monitors key competency and practice indicators. Disparate data sources are integrated to provide clinical, operational and financial information to drive better care.

4. Data abstraction capabilities for quality measurement must be in place at the hospital and MIH agencies prior to launching the pilot.

5. First pass review is done at the local level. Second tier review is completed through the System and hospital. Issue escalation procedures are in place for critical failures or gaps in service.

6. The efficiency, effectiveness, and quality of pilot structure, personnel performance, processes, and customer satisfaction shall be measured and reported as an MIH dashboard showing performance/outcomes compared against national benchmarks when existent.

7. The System shall file QI reports with IDPH under the auspices of the approved pilot program on a quarterly basis reporting from the measures below, meeting IDPH-required data reporting for MIH:


26

MIH benchmarks and metrics

Process metrics

P1: Predictive analytics using a validated tool are accurately used to identify patients at higher risk for readmission

P2: Patients meeting inclusion criteria are enrolled in program

P3: Communication flows as designed between IP C3s, IP Hub, PCPs, patients/caregivers & MIH CPs

P4: First MIH CP visit occurs within requested date and time

P5: Home safety risk assessment is completed on first MIH visit

P6: Patient’s acuity status is accurately rated by MIH CP

P7: Assessment, care, coaching provided by MIH CPs is compliant with care plan and within SOPs/procedures. Also report tasks performed on scene; # visits/patient

Outcome metrics

O1: Pts are compliant with care plan after transition to home

O2: Pts meet desired outcomes without preventable complications

O3: 30 day hospital readmissions are reduced in target populations by 10%: Report all Medicare readmission rate; all patient readmission rate and enrolled patient readmission rate by target diagnosis by quarter

O4: Unscheduled ED revisits in enrolled patients are reduced by 10%.

O5: Calls to 911 for non-emergency causes in enrolled patients is reduced to < 5 per year.

O6: Falls are reduced in enrolled patients to ≤2 per year Experience of care and patient satisfaction metrics

E1: HCAHP scores re: readiness for discharge meet/exceed targets set at 75th percentile

E2: Patient experience of care including quality and satisfaction as evidenced by patient experience scores meet/exceed targets set at 75

th percentile

E3: Practitioner, partner satisfaction scores meet/exceed targets set at 75th percentile

Cost of care metrics: (Compare 12 months before pilot launch to 12 months after launch)

C1: Ambulance transport savings (ATS) by reducing multiple responses to recidivists

C2: All-cause hospital admission savings (ACHAS)

C3: Unplanned 30-day hospital readmission savings (UHRS) in target populations by 5%

C4: Unscheduled hospital ED visit savings in enrolled patients (HEDS)

C5: Unplanned skilled nursing (SNF) and assisted living facility (ALF) savings (USNFS)

C6: Total expenditure savings

C7: Reduction from current FY benchmark for post-acute cost of care Other measures identified by operating MIH/CP programs as essential, collectable and highest priority to their healthcare partners

Quality of Care & Patient Safety Metrics

Q1: Primary care utilization – compliance with early PCP visits Q2: Medication inventory and reconciliation Q3: Care plan compliance and patient involvement in setting individualized goals Q4: Provider protocol compliance Q5: Adverse outcomes HRSA recommends the following benchmarks:

100: Assessment: Regular systematic collection, assembly, analysis, and dissemination of information on the health of the community

Benchmark 101 There is a thorough description of the epidemiology of the medical conditions targeted by the community paramedicine (CP) program in the service area using both population-based data and clinical databases.

Benchmark 102 A resource assessment for the CP program has been completed and is regularly updated.

Benchmark 103 The CP program assesses and monitors it value to the constituents in terms of cost-benefit analysis and societal investment.


27

200: Policy development: Promoting the use of scientific knowledge in decision making that includes building constituencies, identifying needs and setting priorities, legislative authority and funding to develop plans and policies to address needs, and ensuring the public’s health and safety

Benchmark 201 CP activities are allowable/supportable within EMS regulations, licensure, certification and scope of practice

Benchmark 202: CP program leaders (sponsoring agency, CP personnel, and/or other stakeholders) use a process to establish, maintain, and consistently evaluate and improve a CP program in cooperation with medical, payer, professional, governmental, regulatory and citizen organizations.

Benchmark 203: The CP program has a comprehensive written plan based on community needs. The plan integrates the CP program with all aspects of community health including, but not limited to: EMS, public health, primary care, hospitals, psychiatric medicine, social service and other key providers. The written CP program plan is developed in collaboration with community partners and stakeholders.

Benchmark 204 Sufficient resources, including those both financial and infrastructure related, support program planning, implementation, and maintenance.

Benchmark 205: Collected data are used to evaluate system performance and to develop public policy.

205.1 The CP program electronic information system (EIS) is used to assess system performance, to measure system compliance with applicable standards, and to allocate program resources to areas of need or to acquire new resources.

205.2 Continuing education for CP providers is developed based on review and evaluation of the EIS data.

205.3 CP leaders, including the multi-disciplinary, multi-agency advisory committee, regularly review system performance reports and system compliance information to monitor CP program performance and to determine the need for program modifications.

Benchmark 206 The CP, EMS, public health, community health, and primary care systems are closely linked and working toward a common goal.

300: Assurance: Assurance to constituents that services necessary to achieve agreed-on goals are provided by encouraging actions of others (public or private) requiring action through regulation or providing services directly.

Benchmark 301 The EIS is used to facilitate ongoing assessment and assurance of system performance and outcomes and provides a basis for continuously improving the community paramedicine.

Benchmark 302 The financial aspects of the CP program are integrated into the overall PI system to ensure ongoing “fine-tuning” and cost-effectiveness.

Benchmark 303 The CP program ensures competent medical oversight.

Benchmark 304 The CP program is supported by an EMS System that includes communications, medical oversight, and transportation; the CP program, EMS System and public health and community health agencies are well integrated.

Benchmark 305 The CP program ensures a competent and safe workforce.

Benchmark 306 The program acts to protect the public welfare by enforcing various laws, rules, and regulations as they pertain to the CP program.

References:

Becknell, J., Simon, L. (2016, December). Beyond EMS data collection: Envisioning an information-driven future for Emergency Medical Services (Report No. DOT HS 812 361). Washington, DC: National Highway Traffic Safety Administration.

Dept. of Health and Suman Services HRSA. (2012). Community paramedicine evaluation tool.

Hooten, D. (2017). Best practices in high value EMS. EMS World; accessed on line:




28

PROGRAM FINANCING and FISCAL EFFICIENCY

A new strategic mindset must be built around the IHI Quadruple Aims. In today’s environment, a ‘triad of

value’ drives the health care economy: increased access, increased quality and decreased cost. The pilot

must be able to demonstrate its value to a range of potential stakeholders and payers who may fund the

program, including hospitals, IPAs, hospice groups, post-acute care agencies, third-party payers, ACOs,

Medicare, and managed-care organizations.

The provision of MIH has direct and indirect costs and reimbursement is currently challenging. MIH

programs must achieve sustainable funding to be financially viable. In an environment of constant economic

flux, it is crucial to continuously strive for a solid financial foundation. Human, financial, and technical

resources are essential in conducting an MIH program; therefore, creative fund raising and capital support

will be imperative to meeting the pilot goals.

Principles such as regional service delivery, enhanced service delivery, and alternative payment models

will help improve fiscal efficiency (Hooten, 2017). Pro forma results were fed into a net present value (NPV) calculation to yield an assessment of the true economic value of the proposal. The NPV calculation incorporated the factors affecting economic return to provide a comprehensive set of metrics for gauging MIHs financial risk and return on investment.

The financial incentives in the Medicare Access and CHIP Reauthorization Act will accelerate the

transition to alternative payment models not only in the public sector, but also in the private sector. Value-

based insurance design will speed patients’ understanding of the variation in cost and quality of services

among providers. Providers need the infrastructure to monitor their quality and financial performance in

near-real time so they can afford to take on risk. “Health Care 2020: Transition to Value,” Healthcare

Financial Management Association, 2016

CMS requirements for transition care billing: Telephonic or e-mail contact within two days of

discharge; a review of discharge information and communication with relevant community partners; and

face-to-face contact between the patient and their primary care provider within seven days for simple cases

and 14 days for complex ones. If all of these are achieved, an organization can bill for transition care.

Desired state:

Discharge registry is transparent, user-friendly and open to all with a need to know

Discharge registry is interactive

Decreased need for duplication of entries

Patients are stratified by clinical risk.

GOAL:

Capture accurate data, leverage technology by automating as much as possible, and use economies of

scale to recoup more costs while maintaining patient safety.

Initial capitalization and operating costs were projected and a one-year budget was created.

Direct costs: (Need 2018 dollars – pro forma based on 2015 figures)

Salary(regular, OT, 7G rate) for visit, travel and documentation time

Vehicle costs; insurance; mileage (based on 10 miles per visit with a small SUV Type vehicle)

Equipment maintenance & supplies

Workman’s comp

Education and administrative costs

Total per visit costs: $125.00 Paid by NCH to agency

Total anticipated visit costs/yr: $ 60,000

Initial capitalization costs $ 55,000

NCH Staff admin/ed time: $ 5,000

Total pilot cost: $120,000 per year


29

Sources of pilot funding projected for go-live:

For Providers: Pilot Agencies will invoice NCH for initial capitalization costs plus $125 per visit. For NCH: Initial capitalization costs have been offset by $40,000 donated by philanthropy. Cost savings realized prior to go-live:

Agencies determined that they did not need to purchase new vehicles EMS System negotiated MIH-CP fields to be inserted into existing Image Trend software saving the

direct and indirect costs of purchasing and implementing CP version of their software ($17,000 saving.

We continue to negotiate with vendors for preferred pricing on all purchased goods. The Program’s final financial plan shall be presented to key stakeholders for their review.

Evolving MIH reimbursement landscape

October 2017: Anthem announced that it would begin paying EMS agencies for healthcare common

procedure coding system (HCPCS) code A0998: Ambulance response and treatment, without transport.

Some states (Arizona, Minnesota, Nevada, New Mexico) are now paying EMS to treat and refer select

patients to destinations besides emergency departments. Private insurers are also beginning to pay for such

services. Need to advocate for this in Ill. Anthem will reimburse EMS at 75% of the state average of the allowed payment for all ambulance trips.

This basis considers regional variations, such as the geographic practice cost index that Centers for Medicare and Medicaid Services (CMS) uses for the ambulance fee schedule. It costs more to provide EMS service in California vs. Mississippi, and this methodology accounts for those variations.

One of the most innovative payers in the country, Medicaid, has begun reimbursing for mobile integrated healthcare (MIH) services in states such as Minnesota, Nevada and Idaho. Any payer who recognizes the value of this type of model can reimburse for it.

MedStar is implementing a model with another commercial payer, and a managed Medicaid payer, to pay a capitated, per member, per month (PMPM) fixed rate for their members in their service area. The PMPM covers traditional ambulance and MIH services.

This allows them to use MIH strategies (9-1-1 nurse triage, community paramedicine and ambulance transport alternatives) to help navigate patients to the most appropriate healthcare resource based on their clinical need—not based on whether or not we transport them to an ED.

Additionally, a managed Medicare payer is working with them to implement a regional MIH program to manage high utilizer members in their network. That model will pay MedStar a monthly fee for each high utilizer enrolled in the program.

References:

Carlson, C. (2014). Planning for mobile integrated health care? – What do the people with the checkbook

think is important? Accessed on line: http://www.carlsonmed.com/1/post/2014/07/planning-for-mobile-

integrated-health-care-what-do-the-people-with-the-checkbook-think-is-important.html

Hooten, D. (2017). Best practices in high value EMS. EMS World; accessed on line:


Robbins, V.D. (2017). EMS 3.0 document to guide operations in value-based healthcare systems. Accessed on line: http://www.jems.com/articles/print/volume-42/issue-1/departments-columns/management-focus/ems-3-0-document-to-guide-operations-in-value-based-healthcare-systems.html

http://www.carlsonmed.com/1/post/2014/07/planning-for-mobile-integrated-health-care-what-do-the-people-with-the-checkbook-think-is-important.html

http://www.carlsonmed.com/1/post/2014/07/planning-for-mobile-integrated-health-care-what-do-the-people-with-the-checkbook-think-is-important.html


http://www.jems.com/articles/print/volume-42/issue-1/departments-columns/management-focus/ems-3-0-document-to-guide-operations-in-value-based-healthcare-systems.html




30

COMMUNICATIONS and MARKETING

All stakeholders shall be kept informed of our progress, barriers, and successes.

A Communications Checklist provides common concerns among stakeholders, and communications strategies to address stakeholder interests.

The Business plan describes how the program impacts or extends the existing hospital/agency brands, as well as proposes appropriate promotional strategies for:

Targeted consumer campaigns

Physician-directed marketing

Internal awareness-building efforts

External awareness-building efforts

Program champions solicit ideas and input from marketing staff during the plan development to outline

likely market response upon plan implementation and develop the marketing campaign.

Marketing strategy defined:

Written media: Create a brand image for the pilot. Create communication messaging to be distributed on the EMSS and NCH websites/ intranet, through e-mails to stakeholders, and via print media to potential patients and community stakeholders.

The dashboard of milestones and achievement will be updated at least monthly for a snapshot of our progress.

Verbal reports: Updates will be provided at relevant System and hospital meetings.

Next steps: Ongoing tasks:

□ Solicit input □ Obtain resources □ Create tools □ Revise policies and documents □ Generate buy in; activate champions □ Monitor compliance; collect, analyze and report out on feedback

NCH

Create budget for FY 19

Educate C3s and Hub on program/processes

Work with QMI to determine data collection & reporting processes

Work with marketing/communications to create messaging

Hold stakeholder meetings to gain support

Facilitate contract approval by NCH and all pilot agencies

Explore possible Image Trend bridge integration with EPIC; explore EPIC access by CPs

Identify telemedicine opportunities based on stakeholder expectations.

NWC EMSS

Complete protocols & written documents

Complete CP curriculum and educational materials; seek input from Sherman program

Conduct MIH CP education & testing (40 hours)

Competency, & credential CPs

Work with Community Service dept. to obtain social services resource documents

Continue work w/ Patrick Sennett to modify ImageTrend software to customize for CPs

Provide Image Trend access for MIH patients to C3s

Finalize performance measures from National MIH QMI model in collaboration with NCH

Develop go-live plan

Agencies

Recruit, select, MIH CPs

Identify response vehicle; brand for MIH, stock vehicle/equipment

Create call schedules

Communicate with all agency & community stakeholders


31

APPENDIX A

32

33

NCH/NWC EMSS MOBILE INTEGRATED HEALTHCARE PILOT

Residence Safety Assessment Form

Patient name: Address:

Caregiver/POA: Date

Living Room YES NO N/A

Floor is free from any clutter that would create tripping hazards All cords are either behind furniture or secured in a manner that prevents trip hazards Phone is readily accessible and/or patient has way to alert family/caregiver or 911 Emergency numbers are printed near all phones in house

Kitchen Items/equipment needed for food storage/cooking are clean, in working order, and within easy reach Step stool is present, is sturdy and has handrail

Bathroom(s) / toileting supplies

Tub and shower have non-slip surface Tub/shower and toilet have grab bar Pathway from the bedroom to the bathroom is free from clutter and well lit for ease of movement at night Portable commodes / urinals are within patient reach; safe use demonstrated w/o fall hazard

Bedroom or sleeping location

Free from clutter that would create tripping hazards Location (bed/chair) where pt sleeps is physically accessible with or without assistance / fall risk Light is near bed/chair and easy to turn on Phone is next to bed/chair and/or patient has way to alert family /caregiver/911

General

Smoke detectors in all areas of the house (each floor) and tested CO detectors on each floor of the house and tested Pt/caregiver has phone contact # for PCP; public utilities/services if help is needed Pt ID/emerg contacts/medical info/POLST form available where EMS/police will easily find All heaters are away from any type of flammable material All assistive devices readily accessible; adjusted to pt/good working condition; safe use demonstrated All medications are properly stored and labeled to avoid confusion on dosage, time to take, and avoidance of missed doses

Equipment

Scale is in working condition and is in an easily accessible location Home health monitor set up and working Patient/caregiver can demonstrate how to use the home health monitor Blood glucose monitor is working Patient/caregiver can demonstrate how to use the blood glucose monitor The patient has a working inhaler and/or nebulizer Patient/caregiver can demonstrate how to use the inhaler and/or nebulizer Patient has an incentive spirometer and can demonstrate its use Oxygen tank/source is safely secured close to pt and does not pose a trip hazard O2 tubing is less than 50 feet long and does not pose a trip hazard Oxygen is at sufficient level Patient/caregiver can demonstrate safe use of oxygen equipment Patient/caregiver knows whom to call if the oxygen is low Patient has personal alarm system worn on person; and appropriate alerts are programmed in

Comments:

With your consent, EMS has done a Safety Assessment of your home. The items checked “NO” may put you and/or those living with you at risk. You are urged to correct these at once for your own safety. This inspection does not identify future conditions such as a failure of utilities, equipment, or human behaviors which could result in an injury

NAME/ Signature MIH-CP conducting assessment.

34

NCH/NWC EMSS MOBILE INTEGRATED HEALTHCARE PILOT

Patient/Residence Safety Assessment

WAIVER, RELEASE AND HOLD HARMLESS AGREEMENT

In consideration of the voluntary performance of a Residence Safety Assessment of my

home located at , I, on behalf of myself,

hereby waive any claim or cause of action of any nature that I have, or in the future may

have, against any and all individual or organizational participants in the Residence

Safety Assessment including but not limited to Northwest Community Healthcare and

the (EMS provider agency),

and it’s officers, agents or employees, which claim or cause of action grows out of or

results following the said Residence Safety Assessment; and I further hereby agree to

release and hold harmless any and all organizational and individual participants

including the aforesaid EMS provider in the Residence Safety Assessment from and

against all damages of any kind, to persons or property, growing out of or resulting from

a Residence Safety Assessment.

I acknowledge having read, understood, and agreed to the above waiver, and release. ______________________________________________________________________ Patient (print name) Signature Date ______________________________________________________________________ POA (Power of Attorney) (print name) Signature Date ______________________________________________________________________ Witness (print name) Signature Date


35

Minimum Qualifications:

Currently licensed as a PM/PHRN in good standing in the NWC EMSS meeting all requirements.

Two years active duty as a licensed paramedic or PHRN meeting preceptor-eligibility criteria.

Has had direct patient care in at least 6 of the last 12 months. (If they have not provided direct patient care during that time, submit how they have maintained full knowledge and competency of EMS principles and skills.)

Demonstrated competency in all three domains of learning that ensures the delivery of safe, timely, efficient, effective, equitable, compassionate and person-centered care to serve the health care needs of the MIH population. Competencies of note: conceptual; technical, integrative, adaptive, social, and emotional.

No sustained findings of merit with respect to EMS professionalism or practice in the paramedic’s file at

the EMS Agency or with the EMS System in the past twelve months suggesting high risk behavior

(cannot be on an active disciplinary process or probation status) per Policy G-1.

Additional requirements:

Completion of the MIH CP Education program and approval to function as a CP by the EMS MD.

Uncompromised character; strong professional identity; ethical standards; scholarly concern for improvement; and motivation for continued learning.

Demonstrated critical thinker traits: Routinely applies intellectual standards to the elements of

reasoning in order to demonstrate intellectual traits.

o Intellectual standards: Uses discerning judgment based on standards and/or makes objective

judgments by determining both merits and faults. Ability to think and act with clarity, precision,

accuracy, relevance, depth, breadth, logicalness, significance, completeness, and fairness.

o Elements of reasoning: Purposes, questions, inferences, concepts, points of view,

implications, information, and assumptions

o Intellectual traits: intellectual humility; autonomy, integrity, courage, perseverance, empathy,

and confidence in reason and fairmindedness.

Demonstrated basic skills of thought – ability to clarify questions; gather relevant data; and reason to

logical or valid conclusions; identify key assumptions; trace significant implications; and enter without

distortion into alternative points of view.

Demonstrated emotional intelligence: Strong ability to perceive emotion, understand emotion,

manage emotion, and use emotions to facilitate thinking.

Demonstrated strong interpersonal and communication skills (written and verbal).

Demonstrated skill in patient advocacy: Defend patient’s rights, place patient’s needs first unless

safety threat; and protect confidentiality

Schedule Information:

During the pilot, the majority of MIH CP on call and visit times will be based on a M-F work week from 0900 - 1700.

Based on compelling need, some CPs may be asked to complete a visit during evening and/or possibly weekend hours.

Submit applications to: by the close of business on

The completed application can be emailed to .

Alternatively they may be sent via interoffice mail or hand delivered to .

Applicants will interview with a review committee at a time to be announced at a later date. The committee will

make recommendations on the final selection of applicants to Chiefs Anderson, May, and Valentino and Dr.

Jordan.

Northwest Community EMS System (NWC EMSS) MIH-CP PROGRAM

MIH-CP Qualifications and requirements

36

NWC EMSS MIH-Community Paramedic (CP) APPLICATION

Name (PRINT): Employer:

Phone #: Date of original PM/PHRN licensure:

e-mail address: Date of NWC EMSS entry:

Additional licensures/certifications (Submit current card/license if applicable)

CPR instructor Community/health educator RN

ACLS, ITLS, PHTLS Preceptor for EMT or PM classes Critical care paramedic

PALS/PEPP Peer Educator (list level): Flight paramedic

Other (list):

Highest level of academic preparation

Paramedic certificate Associate degree: List field of study:

Bachelor’s degree: List credential:

Master’s degree: List credential:

Doctorate: List credential:

MIH CP applicant: Please give a brief description of why you would like to serve as a CP. May attach as a letter/memo to this

application if preferred.

This information is accurate to the best of my knowledge: Signature MIH CP candidate

Provider EMSC - please verify and rate

Qualifications Verification

Currently licensed as a Paramedic/PHRN in good standing in the NWC EMSS meeting all System requirements.

Two years active duty as a licensed paramedic or PHRN meeting preceptor-eligibility criteria.

Has had direct patient care in at least 6 of the last 12 months. (If they have not provided direct patient care during that time, submit how they have maintained full knowledge and competency of EMS principles and skills.)

No sustained complaints relative to patient care or ethical violations suggesting high risk behavior in past year per Policy G-1

Rating key 3 Exceptional/superior: Clearly outstanding consistently exceed standards 2 Proficient: Strong performer that consistently meets standards 1 Marginal/deficient: Opportunity; performs inconsistently or below benchmarks

Rating of recommended competencies: Rating

Medical knowledge: Knowledge base and ability to apply knowledge and work within SOPs & MIH policies when caring for patients.

History taking skills: Ability to obtain a thorough & accurate history needed to assess the patient’s health status

Physical exam skills: Ability to perform a thorough competent exam appropriate to the patient’s care plan and needs

Affective domain: Social and emotional intelligence; professional attributes of integrity, empathy, self-motivation, appearance; self-confidence; time management; teamwork and diplomacy; attitude; patient advocacy, respect; careful delivery of service

Communication skills (written and verbal)

Clinical reasoning skills: Ability to problem solve and reach accurate conclusions using appropriate reasoning skills.

Patient coaching/teaching skills: Ability to competently coach patient to achieve DC plan.

Written documentation: Ability to complete reports and other supplementary documents that reflect the clinical encounter in an factual, accurate, complete and timely manner.

Intellectual curiosity: Independent study of SOPs, clinical literature, standards and guidelines reflecting effort to improve knowledge and competencies.

PRINT name/Signature PEMSC Date

37

MOBILE INTEGRATED HEALTHCARE CURRICULUM DRAFT

The Mobile Integrated Healthcare CP is a Paramedic who in coordination with NCH fills the gaps between

community, healthcare systems and the patient. The MIH-CP will identify and assist individuals to overcome

barriers to receiving healthcare focusing on wellness and evaluation of specific disease processes. The MIH-CP

will receive standardized education approved by IDPH.

Module 1: Fundamentals of the healthcare system and the MIH Program Plan 8 hrs

Objectives:

Upon completion of the class and independent reading, each participant will independently do the following within their scope of practice with a least an 80% degree of accuracy and no critical errors:

1. Discuss the current healthcare trends and challenges in the United States and external forces impacting

MIH planning and the drivers for innovation and change.

2. Explain the attributes of person-centered, value-based care

3. Describe how an MIH program can strengthen interdisciplinary integration and collaboration in providing

person-centered care.

4. Compare and contrast MIH models currently in operation at the national and state level.

5. Identify the legislative and regulatory authority to pilot MIH programs in Illinois.

6. Explain the purpose and evolution of the NCH/NWC EMSS MIH-CP pilot.

7. State the mission, vision, and values for the NCH/NWC EMSS CP program.

8. Cross-walk the MIH program with the NCH mission, strategic goals and objectives

9. Identify the pilot goals, stakeholders and measures of success.

10. Discuss the community needs assessment / market analysis findings supporting the selection of the

target patient population to enroll in the MIH pilot.

11. Sequence the pilot design and workflow including identification of eligible patients, risk stratification for

readmissions, enrolling patients, communication between NCH and pilot agencies, scheduling the visits,

and CP performance expectations before, during and after the visits.

12. Compare and contrast the operations management to be provided by NCH and the pilot provider agencies.

13. Identify the source of medical direction for MIH-CPs.

14. Describe a CPs scope of practice and specific roles and responsibilities within an integrated value-

based care coordination model.

15. Explain the qualifications and requirements; methods of onboarding, educating, and credentialing an

MIH-CP in the NWC EMSS.

16. Explain the MIH-CP staffing plan and hours of operation.

Module 1 Content

I. Current healthcare trends and challenges

A. Features of the current US healthcare system

B. Biggest challenges for healthcare

C. Healthcare industry trends to follow

D. Healthcare top investment areas over the next three years

E. Current healthcare priorities - forces impacting MIH planning in person-centered care models

II. Need for quality, coordinated, humanistic, and value-based care

A. Need to ensure efficient and safe patient care transitions

B. CMS Hospital Readmission Reduction Program (HRRP) and assessed penalties

C. Lack of care coordination services for large majority of elderly

D. Current data on care transitions

E. Independent predictors of 30 day revisit or readmission

F. Strategies associated with decreased readmission rates

III. Current Models of Community Paramedicine / Mobile Integrated Healthcare Programs

A. National Models: Minnesota, North Dakota, Missouri, Maine, Washington, Idaho, Nevada,

Arkansas, California, Ohio, Pennsylvania, Virginia

B. Illinois State Wide MIH Initiatives


38

1. Genesis in planning: Desire to meet IHI Triple Aims for Healthcare (2008)

2. Programs currently in place

C. Local Model

1. Filling gaps in a value-based economy

2. Safe, seamless, personal care

3. NCH/NWC EMSS pilot six guiding principles

4. Principles of transformative innovation underpinning MIH pilot

5. Extension of NCH Clinical Care Coordination Model

IV. MIH-CP Legislative and Regulatory authority in Illinois

A. House joint resolution HJ0037

B. State approval – MIH concept in general

C. NCH/NWC EMSS pilot plan approval

V. Partnership agreements

VI. Pilot goals

A. Safe transitions and value-based care in the home environment

B. Enhance the NCH Coordinated Care delivery model by establishing partnerships with MIH CPs

C. Meet the outcome points from the IHI Triple Aim Initiative to optimize health system performance:

1. Improve the patient experience of care including quality and satisfaction as

evidenced by an increase in patient experience scores that are based on US IOM Quality

Chasm key dimensions: safe, effective (evidence-based practice), timely, and efficient

care.

2. Improve the health of target populations and clinical outcomes via early patient

engagement; enhanced understanding/compliance with DC care plans; exploring and

overcoming challenges to compliance; identification of therapy failures; closing care gaps,

providing effective health coaching, and improving patient quality of life evidenced by a

reduction in avoidable hospital and unscheduled ED readmissions by 10% in target

patients. Increase engagement with PCPs; support/generate NCH primary care

appointments.

3. Reduce costs evidenced by a reduction in CMS penalties in target populations by 5%.

D. Enhance patient safety and reduce home falls and fires via safety/wellness checks; fall abatement

strategies, installation of working CO and fire detectors, and community education.

E. Decrease dependency on the 9-1-1 system; encourage appropriate use of EMS in the target population evidenced by a reduction in calls to EMS for non-emergency causes to < 5 per year.

VII. How we propose to accomplish those goals

VIII. Pilot stakeholders and executive steering committee

IX. Measures of success

X. Feasibility and risk assessment

XI. Mission, vision, and values for the NCH/NWC EMSS CP program.

XII. Alignment with the NCH mission, strategic goals and objectives

XIII. Community needs assessment and market analysis findings

A. Projected need for MIH-CPs

B. Pilot agency selection

C. Market volume determination

D. Baseline data on targeted conditions

XIV. Pilot design and work flow

A. Patient eligibility for inclusion in pilot

B. Target patient populations


39

C. Timing and number of anticipated visits based on readmission risk calculation

D. Risk of readmission risk prediction model

E. Clinical Care Coordinator (C3 on hospital unit) duties

F. HUB C3 duties

G. MIH-CP duties prior to enrollment visit

H. MIH-CP duties during visits

I. MICH-CP acuity rating of patient status and actions to be taken

J. MIH CP communication/documentation duties after each visit

K. Primary Care Practitioner – engagement, communication linkages, further orders

L. HUB C3 after each MIH-CP visit and determinations by PCP

XV. Operations management (hospital and agency)

A. Management structure and reporting relationships

B. Supplies and equipment

1. Vehicles

2. Supplies/equipment brought to home

XVI. Medical direction for MIH-CPs – NWC EMSS EMS MD

XVII. MIH-CP scope of practice

A. Extension of current paramedic license

B. Shift from episodic emergency care to longitudinal monitoring and adjustment of chronic care

discharge plans

C. Services provided in general

XVIII. CP Education

A. Comprehensive initial curriculum developed by North Central EMS Institute in St. Cloud

Minnesota. Programs since offered at Inver Hills Community College and Hennepin Technical

College.

B.

XIX. MIH-CP Credentialing

XX. MIH-CP staffing plan and hours of operation

XXI. Clinical Care

A. Service level commitments

B. Just culture and mindfulness: 7 dimensions of wellness

C. Three categories of clinical services

1. Assessment and evaluation

a. Scene safety assessment

b. Review hospital DC plan and health targets

c. General patient assessment

d. Medication reconciliation and compliance

e. Assess if needed medical resources are available in home

f. Psychosocial needs assessment

2. Disease specific patient understanding and compliance with DC instructions: Ability to

do self-care

3. Prevention and patient education

a. Understanding and compliance with healthy choices

b. Ability to perform ADLs

c. Home safety check; fall analysis, and risk abatement

D. Post-visit follow-up and communication with PCP


40

XXII. Patient education and injury prevention

XXIII. Documentation and integration with hospital EHRs

A. Technology safeguards

B. Physical safeguards

C. Administrative safeguards

D. Pilot processes

XXIV. Quality management and data collection

A. Questions to be answered by QI

B. 2018 Safety Resolutions adapted for EMS

C. Data collection and reporting affirmations

D. MIH benchmarks and metrics

1. Process metrics

2. Outcome metrics

3. Experience of care and patient satisfaction metrics

4. Cost of care metrics

5. Others: Quality of care and patient safety metrics

E. HRSA benchmarks

1. 100: Assessment

2. 200: Policy development

3. 300 Assurance

XXV. Program Financing and fiscal efficiency

A. Desired state

B. Budgetary goals

C. Sources of funding

D. Evolving MIH reimbursement landscape

XXVI. Communications and marketing

Module 2: Shift in focus from acute to chronic care management

a. Difference in acute vs. chronic care management

Module 3

I. Resource Mapping – what is it?

a. Identification of community based resources (customized for community)

b. Accessing community resources, developing relationships

Module 4 Performing the Home/Equipment Safety check

Module 5 Special Home Equipment

Module 6 Pharmacology Review and Medication Reconciliation

Module 7

I. Assessment Guidelines

a. Heart Failure

b. COPD

c. S/P Major joint replacement

d. Status post MI

e. Pneumonia

II Rating acuity and taking appropriate action

Module 8 Scenarios and role modeling; Post Test – Written and practical

Committee-of-the-Whole Meeting – September 18, 2018 FY 2019 Proposed Budget Attachments:

• FY 2019 Proposed Budget Planning Calendar • 2018 Proposed Property Tax Levy for the FY 2019 Proposed Budget (draft is similar to

the handouts at the July 17th COW Meeting) The FY 2019 Proposed Budget will be released at the September 18th Committee-of-the-Whole Meeting. The City’s FY 2019 Proposed Budget will be available on the City’s website at www.cityrm.org under the Finance tab after the September 18th COW Meeting. A copy of the FY 2019 Proposed Budget will also available at the Rolling Meadows Library at 3110 Martin Lane, Rolling Meadows, IL 60008. Tonight is the distribution of the FY 2019 Proposed Budget. Some items are still in draft form in terms of the formatting as it is a new document from the City’s ERP system. Recall that the former budget document took a year or two before it was developed in the final form. There are some new charts and ways to look at the data in this new budget document. For each Fund, there is a Summary Page, an account number page which lists all of the accounts for the fund and then there is a detail line item page for all Funds. Given that the City has a new ERP Financials and Budget system there are new updates that are being integrated as we go along. For now, the “overall look” of the proposed budget document will be different from prior years and from what the FY 2019 Adopted Budget will look like. Again, understand that there will be some updates during the FY 2019 Proposed Budget process as Staff continues to finalize the new budget document for the City in the ERP. The City Manager and Finance Director will be scheduling initial, one-on-one budget meetings with City Council members. The Public Hearing for the City Tax Levy and the Library Tax Levy will take place at the October 9th City Council Meeting. The Public Hearing for the City’s Budget and the Library’s Budget will take place at the October 23rd City Council Meeting. There are no discussion items for this evening – only the distribution of the FY 2019 Proposed Budget.

http://www.cityrm.org/

CITY OF ROLLING MEADOWSFY 2019 BUDGET PLANNING CALENDAR

DATE DAY ACTIVITY

February & March --- Capital Improvement Projects - Inputted by Departments.

March --- CIP Meetings & Review with City Manager & Finance Director.

February to July --- Ad-Hoc Capital Improvements Committee Meetings.

April to July --- Input Budget Entries, Review Budget Entries, Hold Departmental Meetings, Review and Editsby City Manager and Finance Director.

June 19, 2018 Tuesday June Committee of the Whole Meeting.FY 2017 Audit Presentation & FY 2017 Year-End Fund Balances Presentation.FY 2017 Citizens' Annual Financial Report Presentation.Budget Parameters Discussion.

August 10, 2018 Friday CIP Released to the City Council & Public with the August 14, 2018 City Council MeetingAgenda Packet.

August 21, 2018 Tuesday CIP presented to the City Council at the Committee-of-the-Whole Meeting for discussion &Revenues, Chargebacks, and Fund Balances.

September 18, 2018 Tuesday FY 2019 Proposed Budget - Released to the Public and City Council

September 18, 2018 Tuesday Committee-of-the-Whole Meeting: City Levy/Budget Discussion.

September 2018 Wednesday Public Hearings for Tax Levy (10/9/18) & Budget (10/23/18) published in newspaper.

October 9, 2018 Tuesday City Council Meeting - Public Hearing - Tax Levy (i.e., Truth In Taxation)(City & Library).City Council Meeting - Some Budget Ordinances - 1st Reading.

October 16, 2018 Tuesday Committee-of-the-Whole Meeting - City & Library Levy/Budget Discussion.

October 23, 2018 Tuesday City Council Meeting - Public Hearing - City Budget & Library Budget.City Council Meeting - Some Budget Ordinances - 2nd Reading.

October 23, 2018 Tuesday City Council Meeting - 2nd Reading of some Ordinances & 1st Reading of some Ordinances.

November 13, 2018 Tuesday City Council Meeting - Approve City & Library Levy (1st Readings), and 1st and2nd Reading of some Ordinances.

November 20, 2018 Tuesday Committee-of-the-Whole Meeting - City Budget (If Needed)

November 27, 2018 Tuesday City Council Meeting - Approve City & Library Levy (2nd Readings), Adopt City Budget & Accept Library Budget; and 2nd Reading of some Ordinances.

Note:The City Manager and the Finance Director will hold one-on-one meetings with the Mayor and City Council to review the FY 2019 Proposed Budget from September through October.

Property Tax Levy Draft for the FY 2019 Proposed Budget A similar Property Tax Levy draft was discussed with the City Council at the July 17, 2018 COW meeting and during the one-on-one meetings with the City Council. Here is a summary of the items and what has changed from last year’s Property Tax Levy to this year’s Proposed Property Tax Levy:

• Police Protection and Fire Protection (Property Taxes to fund Police & Fire Operations – no increase.

• Police Pension Fund Tax Levy decreased by $93,779 due to improved investment returns.

This still stays with Council direction on contribution limit.

• Fire Pension Fund Tax Levy decreased by $93,563 due to improved investment returns. This still stays with Council direction on contribution limit.

• IMRF Pension Fund Tax Levy decreased by $50,000 due to improved investment returns.

• Public Works Operations Tax Levy increased by $2,998 as a minor incremental change. Please remember that this amount was lowered a few years ago.

• The Proposed Infrastructure Bond is the annual payment amount (for two fire stations at $13 million and $4 million for capital infrastructure improvements including utilities improvements for a term of twenty years). This scenario was discussed at the May and July COW Meetings and the one-on-one meetings with the City Council. This is not a final number – only a working scenario. This $1,222,274 increase in the tax levy would bring the overall tax levy increase to 4.7% with a typical homeowner’s increase of ranging from $20 to $75 for this upcoming tax year. [NOTE: prior annual debt service ranged from $1.2 to $1.3 million per year paid from the Property Tax Levy.] It is important to note that the City has not yet issued these bonds and therefore

these property tax levy monies would be restricted in the General Fund until the bonds are issued.

• The Annual Street Program Property Tax Levy increased by $100,000 from $900,000 to

$1.0 million to fund improvements to the City’s roadways. This has been discussed at past discussions.

• The City’s 2002A (2012 Refunded) Bond was paid in full in FY 2017 and there is

a decrease in the debt service portion by $430,500 for the Property Tax Levy.

Property Tax Levy Year-Over-Year Change is $657,430 or by 4.7%.

Average Increase to a Homeowner for this Tax Year is $20 to $75.

Proposed Dollar Percent2016 2017 2018 Change from Change

Tax Levy Tax Levy Tax Levy From 17 Levy From 17 LevyGeneral Fund

Police Protection 1,629,836$ 1,850,000$ 1,850,000$ 0 0.0%Fire Protection 1,629,836 1,850,000 1,850,000 0 0.0%Police Pension 3,220,749 3,493,779 3,400,000 (93,779) -2.7%Fire Pension 3,541,622 3,793,563 3,700,000 (93,563) -2.5%IMRF Pension 875,000 850,000 800,000 (50,000) -5.9%Public Works Operations 43,801 187,002 190,000 2,998 1.6%Proposed Infrastructure Bond 0 0 1,222,274 1,222,274 100.0%

Sub Total General 10,940,844 12,024,344 13,012,274 987,930 8.2%

Local Road FundAnnual Street Program 550,000 900,000 1,000,000 100,000 11.1%

E911 FundE911 Service 601,500 651,500 651,500 0 0.0%

Debt Service Purpose2002A Bond (matures FY 2018) 441,000 430,500 0 (430,500) -100.0%2005 Bond (matures FY 2017) 832,000 0 0 0 0.0%

Sub Total Debt Service 1,273,000 430,500 0 (430,500) -100.0%

Total City 13,365,344$ 14,006,344$ 14,663,774$ 657,430$ 4.7%

** DRAFT FOR DISCUSSION ONLY

**Estimated

Property Tax Bill

City Share = Approximately

$0.1663 cents of each Tax Dollar

Estimated Property Tax

Annual Increase to Household

2,500$ 400$ 19$ 3,000 479 234,000 639 305,000 799 386,000 959 457,000 1,164 558,000 1,278 609,000 1,438 68

10,000 1,598 75

Additional Notes:1) IMRF Levy has been lowered due to better investment returns from IMRF.2) The Police & Fire Pension tax levy amounts are rounded slightly above the amout as prepared by the actuary.3) The Annual Street Program Tax Levy has been increased by $100,000 to $1.0 million.4) The 911 Tax Levy remains the same at $651,500.5) The Debt Service for the 2002A and 2005 Bonds have been paid in full.6) A line item for "Proposed Infrastructure Bond" has been added as a placeholder. The amount is subject to change as this is only a draft for discussion purposes.There are future items for City Council approval for the bond issuance. Per the Bond Counsel, the City cannot levy a Property Tax that designates it as"Debt Service" until a Bond Ordinance is adopted by the City Council.

(Percentage is approximatley 16.63% from the City's FY 2017 Audit.)

** DRAFT ** SUBJECT TO CHANGE **** DRAFT ** PROPERTY TAX LEVY FOR FY 2019 PROPOSED BUDGET ** DRAFT **

Property tax estimate increase by household - based on total dollar of property tax bill paid:

The above estimate represents the tax increase to a typical household's tax bill. The estimate is formulated from theprior year's City percentage of the tax bill. The City's portion of a property tax bill was approximately 16.63% for the 2016 Property Tax Levy.

Committee-of-the-Whole Agenda – September 18, 2018 Roadway Infrastructure Program Update

A) 2019 Proposed Resurfacing Project The proposed FY2019 Budget includes $900,000 for construction, and $100,000 for project engineering (design, surveying, and observation). The information provided is to present the street segments identified for resurfacing as part of the proposed 2019 Resurfacing Program. This information is being presented to provide City Council with a preview of the request for engineering field survey and design services for the 2019 program, which is scheduled to be presented at the September 25th City Council Meeting. As part of this year (and every year’s) evaluation of the road maintenance program, Staff utilizes GIS in conjunction with inspection data, geographic locations, and future capital projects to properly plan the Capital Program to avoid conflicts and minimize impacts on neighborhoods. To maximize funding and provide a consistent level of service and roadway performance, long-term maintenance planning is imperative. The focus and objective is always to avoid costly reconstruction on roadways that could be rehabilitated to extend their useful life. To achieve this, long-term planning is needed to ensure that the City can financially plan years ahead of time for roadway rehabilitation needs. Roadway segments will be added to the 5–year planning schedule when they reach a specific road rating (6), thereby allowing them to be rehabilitated when they are at a specific road rating (4 or 5). This type of critical planning and funding commitment provides for the highest level of cost-benefit returns to the City and its residents. Staff has reviewed comprehensively the Five-Year Capital Improvement Plan, short and long range utility projects, the long-range resurfacing plan, and the pavement rating evaluation performed in 2017. Based on this systematic review, Staff recommends the streets listed below for resurfacing in FY2019. These streets are classified as a high priority (consistent with lowest rated roadways) for resurfacing due to their current condition, poor curb and gutter conditions, and drainage problems. Efforts have been made to group the roadways geographically to minimize neighborhood impacts and rehabilitate road segments using a systematic and comprehensive approach. Below are the engineering preliminary estimate of costs for the 2019 project for each street proposed.

Location - Primary Rating Limits Miles Estimated Cost

Wren Lane 4.5 Grouse to Hawk .30 $240,000 Wren Court 4.75 All .05 $ 30,000 Hawk Lane 4.5 Meadow to Dove .59 $415,000 Oriole Lane 4.75 Grouse to Hawk .27 $190,000 Kingfisher Lane 4.75 Owl to East Frontage .18 $125,000

Class D Patching Various 2,500 sy $50,000

Total: $1,050,000 Location – Alternate

Rating Limits Miles Estimated Cost

Quail Lane 5.0 Dove to Wren .17 $90,000 Quail Court 4.75 All .05 $30,000

Total: $120,000

The estimates above are rounded to the nearest thousand. The project has been over-designed to accommodate a full program. If bid results do not come in favorable or on-budget, staff will recommend to the Council the removal of a road segment to allow the project to move forward at the budgeted amount.

As part of the road resurfacing project, storm sewer improvements will be incorporated into the project. As part of standard procedures, Staff will televise all storm sewers within the project limits to ensure damaged pipes were incorporated into the project. The estimate provided is based on typical road improvements and may change pending the subsurface investigation and the need for possible additional storm sewer improvements on the targeted streets. Staff has added 5% contingency to the total cost to account for quantity deviation and unknowns discovered during the design of the project. Below is the proposed schedule of activities to ensure the City secures the best pricing possible and completes the project before the end of summer, 2019.

Capital Planning Process Estimate Costs for Street Program Engineering Proposal Present Program to City Council Engineering Services Contract to Council Field Investigation, Surveying and Core Samples Design Engineering, IDOT Docs. IDOT Review and Approval Advertising Bid Opening Contract Award – City Council Action Begin Construction

April to July (Completed) July (Completed) September September 18th Comm. of the Whole September 25th City Council September through October October through November November through January January or February (IDOT review dependent) February or March March or April April or May

B) Local Road Fund – FY2019 Proposed Other Capital Projects In addition to the resurfacing project proposed for FY2019, there are numerous other capital improvement projects intended to improve the City’s roadway infrastructure system. These projects are listed below. The status of the bolded projects are those projects which may be of Council interest or have been in the planning stages over the course of 2018, and are further described below. This list reflects those projects proposed in the Capital Improvement Plan identified in the Local Road Fund. Included in this list is the Annual Road Reconstruction Project, which is representative of a program resulting from conversations with the City Council in 2015/2016, and again in 2017 following the results of the pavement rating index (PRI), regarding road funding and capital planning efforts. The reconstruction program is intended to eliminate as much as 90% of the pozzolanic (pozz) based roads over the next ten (10) to fifteen (15) years, or as funding permits. Again, these are all projects identified in the Capital Plan, but have not yet been approved by City Council as part of the FY2019 Budget. PROJECT PRIORITIZATION LIST Annual Street Resurfacing Project Kirchoff Road Resurfacing Project Annual Street Reconstruction Project Annual Sidewalk and Curb Replacement Program Euclid Path Project (Grant Funding – City Share) Barker Avenue Bridge Project (Grant Funding – City Share) Kirchoff Median Replacement Project Bridge Inspections / Repairs Arbor Drive Resurfacing Project (Grant Funding) Algonquin & New Wilke Intersection Project (Engineering) Roadway Resurfacing Engineering, Weber Drive Roadway Extension Ring Road Engineering Only ADA Plan Improvements City Entry Marker Project

$1,100,000* $500,000 $825,000 $180,000 $70,000 $150,000 $200,000 $50,000 $400,000 $90,000** $25,000 $25,000 $25,000 $30,000

COST ESTIMATE TOTAL: $3,670,000 Less Arbor Grant (-$400,000) $3,270,000 * Combination of $500,000 (Local Road Fund) and $600,000 (MFT Fund). ** Capital Plan shows as $175,000. Staff has secured commitment for shared funding (50%) from the Village of

Arlington Heights in 2019, to complete the Phase I engineering.

1) Kirchoff Road Resurfacing, Proposed ($500,000) On November 9, 2018, the Kirchoff Road Resurfacing Project will be publicly let by the Illinois Department of Transportation. Provided the expected favorable pricing is received, the start date is expected to occur sometime in spring of 2019. It is estimated at this time that the overall project cost will be between $2,000,000 and $2,500,000, of which the City would be responsible for 20% (~$450,000).

2) Road Reconstruction Program, Proposed ($825,000) As a result of past Council discussions centering on the need to bring the road system pavement rating to a higher service level, staff developed a 10-Year Reconstruction Program. As has been discussed previously, the institution of a reconstruction program will have positive effects on the overall system rating as road segments are reconstructed. Below are the proposed reconstruction locations for 2019. If funding requires reduction due to other priorities or limited revenues, staff can reduce the scope of work to allow a portion of the proposed project to be completed.

The reconstruction proposed for FY2019, pending funding availability, is inclusive of:

• Remaining section of Highland Drive $300,000 • Kevin Lane, Jessica Court, and Michael Court. $345,000

Subtotal $645,000 • Resurface Prairie Lane $180,000

TOTAL $825,000

3) Euclid Bike Path Grant Project, Proposed ($70,000) This project received contract award by IDOT, to A Lamp Construction. Actual construction is to begin by late September, 2018, with substantial completion by November 30, 2018. Local agency costs are 10% ($70,000), as the Village of Arlington Heights is also paying 10% of costs.

4) Barker Avenue Bridge Reconstruction Project, Grant Project ($150,000) This project is proceeding through the IDOT approval process as required. The necessary land acquisition is also nearing completion and is scheduled for public letting at the end of 2018 / beginning of 2019. This project is expected to begin in June of 2019 with a completion date by the time school begins at the end of August.

5) Kirchoff Median Replacement Project, ($200,000) This project is included in the Kirchoff Road Resurfacing Project. As it is included in the plans proposed for the resurfacing project, the project will be publicly let on November 9th. It is the anticipation of staff that the combining of both projects will result in more favorable pricing and the qualifying portions of this work will be covered by Federal grant funding.

6) Arbor Drive Resurfacing Project, Grant Project ($400,000) Following Council approval, Staff submitted for a Community Development Block Grant with Cook County. The City has yet to be notified of the status of the application. However, based on previous year’s results, staff has little confidence that this project will be selected for funding. Staff will be proceeding with water main replacements in the area and will perform patching in lieu of resurfacing until those roadway segments can be incorporated into the five-year plan. Staff will continue to pursue this grant opportunity, unless directed by the Council otherwise.

7) Algonquin / New Wilke Intersection Improvements, ($90,000) Staff met with members of the Village of Arlington Heights to secure 50% funding for the Phase I engineering, required as part of the Illinois Department of Transportation project process. Additionally, staff met with the new Transportation Program Associate for the Northwest Municipal Conference to discuss where the project aligned with the City’s Capital Plan to ensure proper funding years. We also discussed the City’s continued efforts to seek additional funding from the Invest-In-Cook Grant opportunity.

8) Weber Road Resurfacing, ($25,000) Staff met with members of the Village of Arlington Heights and the new Transportation Program Associate for the Northwest Council of Mayors to discuss the funding for this project. This section of roadway was inadvertently dropped from the FAU Route status maintained by the Illinois Department of Transportation, despite being programmed for the funding. Staff is working with the NWMC to reinstate the roadway designation. Proposed costs are for preliminary engineering, which are not grant eligible.

Documents

AGENDA COMMITTEE OF THE WHOLE September 18, 2018 – …