Perspectives on EMS Value

10/7/2016

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Perspectives on EMS ValueViews from our Partners in Care

Your Panel…

John MezoGeneral ManagerVITAS Healthcare of Fort Worth

Trudi Stafford, PhD, RN, NEA‐BCPresident & CEOStafford & Associates, LLC

Stacy Elmer, Senior ConsultantCommunity Paramedicine Program LeadKaiser Permanente

Kate Jones, MSN, RN, CCMSVP, Public Policy and ResearchAmedisys Inc.

What We’re Gonna Do…

• Answer key questions…

– How has your perception of value in general changed in the past 2‐3 years?

– What have you looked for from EMS in the past?

– What will you be looking for from EMS in the future?

– What are the ways EMS agencies can demonstrate value to you?

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Txt to 817‐991‐4487

Quick Glance at Skilled Home Health Care (Medicare benefit)

Approximately 12,000 home health agencies

provide care to about 3.4 million Medicare beneficiaries

24% of Medicare home health users are 85years of age or older, 37% live alone, and 85%

have 3 or more chronic conditions

Kate Jones

CMS / Home Health Quality

• Home health star ratings

• Publicly reported on “Home Health Compare”

•medicare.gov/homehealthcompare

• Home health value based purchasing (HHVBP)

• innovation.cms.gov/initiatives/home‐health‐value‐based‐purchasing‐model

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2 Home Health Quality Measures of interest to the EMS sector

Acute Care Hospitalization Emergency Department Use without Hospitalization

Patients who have a Medicare claim for admission to an acute care hospital in the 60 days following the start of a home health stay

Patients who have a Medicare claim for outpatient emergency department use and no claims for acute care hospitalization in the 60 days following the start of the home health stay

Home Health Value‐Based Purchasing (HHVBP)

Opportunities

Explore more formal

arrangements between HHA

and EMS

Improve coordination between HHA

and EMS

Improve communication between HHA

and EMS

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Txt to 817‐991‐4487

Framing the Hospice Issue:

• Patients & families want the patient to pass comfortably at home

• Hospice wants the patient to pass peacefully at home

• Death is scary

• When death is near….

• 9‐1‐1 usually = Hospice Revocation

– Voluntary or involuntary

Economic Model

• Hospice benefit– Per diem from payer to agency– Agency pays hospice related care– LOS issues– Varies based on Dx

• MedPAC recommends increasing hospice benefit

• IHI recommends increase hospice enrollment

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J Clin Oncol. Oct 1, 2010; 28(28): 4371–4375

Hospice Revocation Avoidance

• Enroll patients “at risk” for revocation• Visit at home

– Counsel – instruct – 10 digit access– “Register” patient in CAD

• Co‐respond with a “9‐1‐1” call• Help family through process

– While awaiting hospice RN

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Notes:(1) Patients referred who are identified as at high risk for voluntary disenrollment, or

involuntary revocation.(2) Difference results from referrals outside the MedStar service area, or patients

who declined program enrollment.(3) Patients who either voluntary disenrolled, or had their hospice status revoked.

Hospice Program SummarySept. 2013 ‐ July 2016

# %Referrals (1) 321Enrolled (2) 225

Deceased 161 71.6%Active 27 12.0%

Improved 2 0.9%

Revoked (3) 37 16.4%

Activity:EMS Calls 93

Transports 53 57.0%Hospice Related 29 31.2%

Direct Admits 7 13.2%ED visits 46 86.8%

From: John Mezo [mailto:[email protected]] Sent: Tuesday, February 9, 2016 10:38 AMTo: Matt Zavadsky; Desiree PartainCc: Monica CushionSubject: Great call!

Hi Matt & Desi,Excellent call last night by MedStar! It's so good when everything works as planned.

Also, JCAHO recommended we submit the Hospice Revocation Avoidance program to them as a Joint Commission Leading Practice for Healthcare Providers.

Very cool,JM

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Trudi B. Stafford, PhD, RN, NEA-BC, Retired

Stafford & Associates, LLCPresident & Chief Executive Officer

Former Chief Nursing OfficerOchsner Medical Center, New Orleans, LA

Baylor All Saints Medical Center, Fort Worth, TXUniversity of Pittsburgh Medical Center - McCandless,

Pittsburgh, PAMemorial Hermann Southeast Hospital, Houston, TX

Defining Value

THE

Quality• Patient Outcomes

• Evidence-Based Practice

• Clinical Pathways

• Safety

• Reducing Hospital Acquired Conditions

• Fall Prevention

• CLABSI Prevention

• Patient Experience

• Perception of Value/Quality

• Patient Throughput

• NEDOCS

• EMS Turnaround Times

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Payment

• Value-Based Purchasing

• Hospital Acquired Conditions

• Readmission Reductions Program

Future of Healthcare• Healthcare Value Equation Refinement

• Technology

• Wearable

• Electronic Medical Records

• Point of Care Testing

• Evidence-based Practice

• Right role, right place, right time, right treatment

• Patient Experience

• Wellness

• Communication

• Transparency

"It's gotta go. Repeal and replace with something terrific."Donald Trump, candidate for the Republican presidential nomination, on the Affordable Care Act, in an interview with CNN

"Repeal of the ACA would let insurers write their own rules again, and wipe out coverage for 16 million Americans."Hillary Rodham Clinton, candidate for the Democratic presidential nomination, on Twitter

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The Value of Mobile Integrated Healthcare for Kaiser PermanenteStacy Elmer, MA, MPA, EMTEMS World ConferenceOctober 2016

Why Mobile Integrated Healthcare?

Growing aging population

Pressure to reduce health care costs

Increase in covered care

Nursing shortages

Physician shortages

Misaligned financial incentives

Cost of Care

Avoided ambulance rides & ED visits

Individual Care

Prevention & most appropriate care providers

Population Health

Connecting to primary care & social services

URGENT

CARE

Alternative Destination Transport

Frequent 911/ED Utilizers

Treat & Release/ Refer

Post-Discharge Follow Up

Alternative Destination Mental Health

Hospice Support

Triple Aim Impact

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Why Systems Matter

HOSPITALS

CLINICS & SPECIALTY CAREFACILITIES

DOCTORS

NURSESPARAMEDICS

& OTHER CARE PROVIDERS

PHARMACIES

PAYERS/HEALTH INSURANCECOMPANIES

DATA

PATIENTS

Why Systems Matter

Why Systems Matter

HOSPITALS

CLINICS & SPECIALTY CAREFACILITIES

DOCTORS

NURSESPARAMEDICS

& OTHER CARE PROVIDERS

PHARMACIES

PAYERS/HEALTH INSURANCECOMPANIES

DATA

PATIENTS

PAYER/HEALTH INSURANCE COMPANY

NURSES & OTHER CAREPROVIDERS

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Why Systems Matter

Why Systems Matter to MIH Programs

HOSPITALS

CLINICS

DOCTORS

OTHER CARE PROVIDERS

PAYERS/HEALTH INSURANCE COMPANIES

Decreases overcrowding

Revenue loss

Why Systems Matter to MIH Programs

Creates cost savings to the system

Diminishes overcrowding in EDs & urgent care

Increases opportunities for improved patient care

HOSPITALS

CLINICS

DOCTORS

OTHER CARE PROVIDERS

PAYERS/HEALTH INSURANCE COMPANIES

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Kaiser and Mobile Integrated Healthcare

911 Response‐Based Models

• Alternative Destination Transport

• Treat & Release/Refer

• Pre‐scheduled visits

Kaiser and Mobile Integrated Healthcare

Kaiser Based EMS Models • Post‐discharge follow‐up

• Management of chronic conditions

• Mental & behavioral health

The First Value Proposition

• Kaiser + other payers

• Kaiser only

$$$

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High utilizers of 911

ED high utilizers

ED high cost utilizers

Outside medical expenses

The Second Value Proposition

Held MCAT meeting

MCAT formed ED High Utilizers Workgroup

Pulled Pan CityED data

Visualized the data

Chart review super high utilizers

KP MIH Pilot Process

2. ED High Utilizers Workgroup – Meeting 2

Reviewed data analysis

Narrowed down subgroups to target

3. Chart Review Party!!!!


Identified the problem

Socialized the data analysis process – introduced Tableau


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5. Utilize video ethnography capability to talk with members in the identified subgroups about their ED utilization

KP Now

Health Leads

Phone Call Back

KP On Call


Review chart review outcomes

Finalize subgroups to target

Map current KP assets and interventions available to address subgroups problems – identify gaps in the continuum for these members


Review video ethnography

Empathy map members in targeted subgroups

Identify quality improvement needs in existing assets

Develop options for solutions to address gaps


7. Validate proposed solutions with members

8. Convene ED High Utilizers Workgroup – Meeting 5

Review member input

Design plan for operationalizing solutions

9. Present proposal to MCAT

10. Present proposal to SCAL leadership

11. Implement pilot program


Data as We Typically Know It

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Data as We Can Know It

ED Disposition (group) ED Disposition

HOME HOME

ADMIT TO INPATIENT, ADMIT TO OBS, ADMIT TOOR and 2 more

ADMIT TO INPATIENT

ADMIT TO OBS

ADMIT TO OR

TRANSFER TO L&D

TRANSFER FOR CARDIAC CATH (DC/Transfer toanother type of Health Care Institution not

DC TO KFH, DC TO LAW ENFORCEMENT, DC TONON KFH and 7 more

DC TO NON KFH

DC TO KFH

DC/TRANS TO BEHAVIORAL HEALTH

DC/TRANSFER TO SNF

DC TO LAW ENFORCEMENT

DC/TRANSFER TO ICF

DC/TRANSFER TO HOME W/HOSPICE CARE

DC/TRANSFER TO IP REHAB FACILITY

DC/TRANSFER TO HOME UNDER CARE OF HOMEHEALTH

DC/TRANSFER TO SHELTER

LEFT AGAINST MEDICAL ADVICE (AMA) & LEFTWITHOUT BEING SEEN (LWBS)

LEFT AGAINST MEDICAL ADVICE (AMA)

LEFT WITHOUT BEING SEEN (LWBS)

ELOPED POST MSE, MD ELOPED, RN ELOPED RN ELOPED

MD ELOPED

ELOPED POST MSE

EXPIRED EXPIRED

Pt Zip

0.00

0.01

0.02

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0.04

0.05

0.06

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0.11

0.12

Valley Village, N Hollywood, North Hollywood, Sherman Village, Studio City

Sun Valley, La Tuna Canyon, Shadow Hills, Rancho La Tuna Canyon

Canyon Country, Santa Clarita, Fair Oaks Ranch, Canyon Cntry

Sylmar, Kagel Canyon, Lake View Terrace, Lake View Ter

Pacoima, Arleta, Hansen Hills, Lakeview Terrace

North Hollywood, N Hollywood, Valley Glen

Studio City, N Hollywood, North Hollywood

Van Nuys, Sherman Oaks, Valley Glen

Newhall, Friendly Valley, Santa Clarita

North Hills, Northridge, Sepulveda

North Hollywood, N Hollywood

Granada Hills, San Fernando

Sherman Oaks, Van Nuys

Panorama City, Van Nuys

Van Nuys, Lake Balboa

Valencia, Santa Clarita

Van Nuys, Valley Glen

San Fernando

Frazier Park

Tujunga

AverageAverageAverage

Understanding ED High Utilizers

We started with all ED encounters that occurred at the Panorama City Medical Center from July 2014 – June 2015 (one calendar year).62,152 encounters

Kept only the ED encounters attributable to patients who live in the Panorama City Service Area.

Before 62,152 encounters After 51,348 encounters


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Kept only the ED encounters attributable to patients who live in the San Fernando Valley subregion of the Panorama City Service Area.



Age (group)0-17

18-35

36-55

56+

Kept only the ED encounters attributable to patients who live in the San Fernando Valley subregion of the Panorama City Service Area who are age 18 or older.



Age

0

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Age

0

100

200

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Kept only the ED encounters attributable to patients who live in the San Fernando Valley subregion of the Panorama City Service Area who are age 18 or older and are KP members.



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Age

0

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Age

0

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Kept only the ED encounters attributable to patients who live in the San Fernando Valley subregion of the Panorama City Service Area who are age 18 or older, are KP members, and were either discharged to home or otherwise left without being admitted.



Among these 20,501 encounters, these are the top discharge diagnosis categories, stratified by whether or not the individual arrived in an ambulance.


Among these 20,501 encounters, these are the top discharge diagnosis categories, stratified by whether or not the encounter is from a “high utilizer”.


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Unique Patients # Encounters

1‐time utilizers 9,759 9,759

Low Utilizers (2‐5 times) 4,155 8,524

Moderate‐to‐High Utilizers (6‐21 times) 362 2,993

Super High Utilizers (22+ times) 10 225

Among the target subset (San Fernando Valley, Panorama City Members, Age 18+)


Dead ends ‐ older patients would have longer ED stays since they were more complex, but that didn’t turn out to be a huge effect. Younger adult patients had much shorter lengths of stays. What conclusion to draw of this? It was uncertain.


Nice to know ‐ we looked at race/ethnicity of ED utilizers by age, and noted that it reflects the changing demographic of Panorama City’s membership – younger patients are more likely to be Hispanic, older patients are more likely to be White.


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Cost Analysis – Predicted High Utilizers

8.9% of ED encounters were due to Predicted High Utilizers.

1 out of every 20 of this subgroup is predicted to be a member who might spend close to $60,000 per year (compared to the average member yearly cost of $5,300).


The Second Value Proposition

Know the

problem you are trying to

solve

DATA SHARING

DATA INTEGRATION

DATA IS THE KEY

Closing Thought

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[email protected]

THANK YOU!

Txt to 817‐991‐4487

Documents

Perspectives on EMS Value