Keeping AMPDS Delta and Charlie Level Patients Safely at

Home

The latest research findings from Northwell Health’s Integrated Care Model

March 29th, 20191

Agenda

1. Northwell’s Center for Emergency Medical Services

2. What is Advanced Illness Management?

3. Community Paramedicine Framework

• Workflow

4. Outcomes / Results

5. Patient/ Caregiver Satisfaction

6. Limitations to Growth

7. Connecting the Dots to ET3

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Center for Emergency Medical Services

• Established in 1993, CEMS provides air & ground BLS, ALS, SCT, CCT & 911 services

• Largest health system based ambulance services in NY Metropolitan area & one of the largest in the US

• Duly accredited by the Commission on Accreditation of Ambulance Services (CAAS) & the National/International Academics of Emergency Dispatch, Accredited Center of Excellence (ACE)

• 900+ Emergency Medical Technicians & Paramedics with over 140 available response units across New York City, Nassau & Suffolk

• Utilizes Medical Priority Dispatch System with Advanced Life Support

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Advanced Illness Management – House Calls Program

Northwell Health’s House Calls program is a value-driven, home-based primary care program that delivers care to homebound older adults in Queens, Nassau and Suffolk counties

Our Mission is to serve the highest need patients to achieve better care and health at a lower cost

Services provided include:

• Intensive home-based primary care by Interdisciplinary Care Team

• Physicians, NPs, nurses, social workers, medical coordinators

• 7-days/24 hours response and real time alerts of ER and hospital utilization

• Longitudinal care through illness trajectory

• Transitional care visits

Program Eligibility:

• Homebound (Medicare criteria)

• Medical necessity: multiple chronic medical conditions in an advanced state

• Generally over 65 years old

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Our geographic area has over 43,000 homebound frail

seniors.

Community Paramedicine Framework

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• 24/7, on-demand clinical response

• Utilizing paramedics as physician extenders with provider level clinical decision making

• Diagnostics and formulary

• “Out of the back of the ambulance” clinical design

• 3,751 responses to date*

• All responses triaged by EMDs prior to dispatch

*As of 2/28/2019

Community Paramedicine Program Evolution

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Integrated ECNS/ AMPDS Workflow

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Patient

• (Point of Crisis)

Dials Clinical Call Center*

• “Press 1”

Triage (Nurses in CCC go through the

ECNS/Low Code Algorithm)

Nurse Assessment Only

Phone Consult with OLMC

Appointment Scheduled for

Same or Next-Day

Community Paramedic Response

Ambulance Transport to ED

CP provides an urgent in-home response at all hours of the day and night through utilization

of the marginal capacity of CEMS and the Clinical Call Center

AcuityLow Risk High Risk

CP

Fo

rmu

lary

& D

iagn

ost

ic

Cap

abili

ty T

oo

lbo

x

Evaluation & Treatment of Clinical Exacerbations

Exacerbations that can be stabilized or treated include:

• Patient or caregiver for help: Paramedics can provide primary and secondary physical exams, including vital signs, blood glucose, EKGs and environmental assessment

• Heart failure exacerbation: Paramedics can provide intravenous diuretics

• Cardiac condition: Paramedics can provide 12-lead EKG diagnostics to help rule out myocardial infarction and can provide treatments for angina and arrhythmias

• Respiratory crisis: Paramedics can provide oxygen and/or nebulizers

• Pain management crisis: Paramedics can provide medication such as morphine and other pain relief medications

March 29th, 2019

Patient Characteristics

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Patient Characteristics Number (%)

Sex

Male 400 (35)

Female 759 (65)

Age

< 70 103 (9)

70-79 143 (12)

80-89 416 (36)

> 90 497 (43)

Chronic conditions

Hypertension 819 (71)

Dementia 580 (50)

Pressure and Chronic Ulcers 488 (42)

Hyperlipidemia 501 (43)

Depression 415 (36)

Heart Failure 405 (35)

Asthma / COPD 327 (28)

Rheumatoid Arthritis/

Osteoarthritis397 (34)

Atrial Fibrillation 344 (30)

Diabetes 309 (27)

Chronic Kidney Disease 297 (26)

Stroke / Transient Ischemic Attack 178 (15)

Cancer 119 (10)

Osteoporosis 102 (9)

Number of activity of daily living

dependencies (ADLs) * Number (%)

0 90 (8)

1 - 2 91 (8)

3 - 4 116 (10)

5 - 6 829 (72)

Advance care planning

Advance Care Planning 1076 (93)

Do Not Resuscitate (DNR) order 798 (69)

Do Not Hospitalize (DNH) order 457 (39)

Insurance status

Medicaid primary 29 (3)

Medicare primary 768 (66)

Private 356 (31)

ADLs = bathing, toileting, walking, transferring, feeding, dressing

1/2014-12/2017; n=1159

AMPDS Analysis

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Common CP Results in AIM Program

• Average response time: 24.7 minutes

• Average time on scene: 73.4 minutes

• Most common reasons for dispatch:• Card 06, Breathing Problems: 28.2%

• Card 26, Sick Person: 26.5%

• Card 17, Falls: 13.1%

• Most common dispatch acuities:• CHARLIE, 40.1%

• DELTA, 25.5%

• Assessment vs. Treatment• 54% Assessment Only

• 28% Assess & Treat

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15.52%

11.86%

8.49%

7.74%

3.32%

2.48%2.27% 2.14%

1.01%0.59% 0.59%

0.25%0.00%

2.00%

4.00%

6.00%

8.00%

10.00%

12.00%

14.00%

16.00%

PER

CEN

TAG

E O

F A

DM

INIS

TRA

TIO

N

1/2014-12/2017; n=1159

How Was a Low Transport Rate Achieved?

• Among CHARLIE & DELTA level responses only 21% resulted on transport

• Of those not transported or pronounced at the time of the CP response• 4.9% transported within 24 hours

• 2.0% transported between 24 – 48 hours

• How & Why?• Fast response times = meaningful clinical response

• Diagnostics and formulary

• Physician oversight of OLMC is PCP from the AIM Program

• All medical records available for review/ decision making

• Extended CP training

• Follow-up care from AIM program

• Defined patient goals of care in >90% of cases

• TRUST & TEAMWORK between CPs and PCPs

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Patient/ Caregiver Satisfaction

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1/2014-12/2017; n=633

Implications

• First study to link EMS triage codes (AMPDS) with CP transport rates within an AIM program

• CP program can provide a safe and effective option for responding to and treating frail older adults in their home

• Avoiding transport to the ED and likely hospitalization

• Once in the ED, due to medical complexity, frailty and uncertain availability of ambulatory follow up, older adults experiencing a change in condition are highly likely to be admitted

• In 90% of cases, patients/ caregivers reported that they would have either called 911 or gone directly to the emergency room had CP not been available

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Limitations for Model Growth

• In-home care provided by paramedics and other EMS responders that does not culminate in hospital transport is not traditionally reimbursed

• Variability amongst local and state regulations on EMS services by state and county

• Regulatory heterogeneity makes standardization of best practices difficult

• AIM programs may not have relationships with EMS agencies

• Incentives for partnerships misaligned in current fee-for-service reimbursement models

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Connecting the Dots to ET3

“You aren’t doing Community Paramedicine, you are doing Telemedicine Assisted EMS!”

A wise FDNY representative at the GNYHA Community Paramedicine Event in 2014

Our IAH model is ET3 Treat & Stay NOT CP - but for ALL patient acuity levels

Our lessons learned can be applied to all future ET3 participants

We are the top Performing IAH program in the country on all categories

Right now it appears our IAH program will not be eligible for ET3 participation

More research to come soon on ET3 related issues

Telemedicine with video vs. voice only – what’s the clinical impact

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March 29th, 201918

Thank You

Jonathan WashkoAVP, OperationsCenter for EMS | SkyHealth | CTCNorthwell Healthjwashko@northwell.edu

Karen Abrashkin, MDMedical Director, House Calls ProgramMedical Director, Clinical Call CenterNorthwell Healthkabrashkin@northwell.edu

Alyeah E. RamjitAdmin Manager, MIH/CP ProgramNorthwell Healtharamjit@northwell.edu