AAA Annual 2012: Mobile Medicine Strategies

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A timely examination of Mobile Medicine Strategies and emerging innovative solutions to provide optimized patient care and efficient resource allocation.

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AAA Annual 2012: Mobile Medicine Strategies

  1. 1. Mobile Medicine Strategiesand Vision for all ProvidersDouglas R. Hooten, MBAExecutive DirectorMedStar Mobile HealthcareFort Worth, TXJonathan WashkoAVP – CEMS OperationsNorth Shore – LIJ Health SystemManhasset, NY
  2. 2. Emergenc y Medical Services?
  3. 3. Unscheduled Medical Services!
  4. 4. Current State ofRN Unscheduled Care T riag 9- e e 1- lanc Life Line 1 bu Am E/D’s re ic Ca Out of pi sod dEHospital Care d ule MD sche /D O Off Un ice Vi s its An Noncompliance sw Se erin rvi ces g SN F/L TA Urgent Care C
  5. 5. Current State of Unscheduled Care• 9-1-1 safety net access for non-emergent healthcare – 36.6% of 9-1-1 requests are non-emergent • Past 12 months Priority 3 calls (37,508/102,601)• Problems with uncontrolled and unmanaged access – Emergency department as the source of primary care
  6. 6. Current State of Unscheduled Care• Incentivized to use the highest cost transport to highest cost care setting – And it’s the easiest… – Same with hospital admissions
  7. 7. Current State of Unscheduled Care• Reasons people use emergency services – To see if they needed to – It’s what we’ve taught them to do – Because their doctors tell them to – It’s the only option• Many patients using ED have payer source…
  8. 8. Frequent Users of Emergency Departments:The Myths, the Data, and the Policy ImplicationsResultsFrequent users comprise 4.5% to 8% of all ED patients but account for21% to 28% of all visits. Most frequent ED users are white and insured;public insurance is overrepresented. Age is bimodal, with peaks in thegroup aged 25 to 44 years and older than 65 years. On average, thesepatients have higher acuity complaints and are at greater risk forhospitalization than occasional ED users. However, the opposite may betrue of the highest-frequency ED users. Frequent users are also heavyusers of other parts of the health care system. Only a minority offrequent ED users remain in this group long term. Why is this important? Annals of Emergency Medicine Volume 56, Issue 1 , Pages 42-48, July 2010
  9. 9. Our New World:
  10. 10. Our New World:• ACA tipped the 1st domino• New partnerships – ACOs • Aligned incentives/risk sharing • Bundled payments/episode of care – Pay for performance – Satisfaction-based reimbursement• EMS impacts 25% of health expenditures
  11. 11. Our New World:• Changing healthcare market – Current U.S. healthcare system built on quantity, not quality – Most likely payment bundled in some form of Accountable Care Organization• Greater emphasis will be placed on OUTCOMES – Quality measures• Likely that your current major payers will not be in the future
  12. 12. Our New World:• 5.6 million health care jobs will be created by 2020 - University of Georgetown• By 2015, 33% of hospital payments will be based on patient satisfaction (PPACA)• 50% of health expenditures occur in last 2 years of life• Today, 40 million people > 65 – 70 million in next 20 years• 2010 20,000 docs short – By 2025 = 140,000 to 214,000 short
  13. 13. Our New World:• Catalyst for Payment Reform (Yes, CPR) – Coalition of employers (Wal-Mart, Intel, GE for example) – Pushing for value oriented payments to providers (20% by 2020) – Aetna – Now paying the same for c-section or vaginal birth – eliminate incentive for c- section (H&HN) – $1,250 for screening colonoscopies – regardless of in or out of the hospital (H&HN)
  14. 14. Our New World:• AHRQ = 1% of patients accounting for 20% of healthcare expenditures (H&HN) – There are 4.6 million Medicare beneficiaries with CHF (AHRQ) – One CHF admission cost CMS $17,500 (AHRQ) – 30-day readmission rate for CHF = 24.7% (AHRQ) – 52% of CHF patients readmitted within 30 days did not see their doc between discharge and readmit (NEJM)• MedPAC = $12 billion CMS expenditures for PPR
  15. 15. Our New World: 10-year % change of MedStar’s overall call volumeEMD Code % Increase EMD Code % Decrease33-Interfacility 11.3% 01-Abd Pain 2.8%26-Sick Person 10.3% 30-Traum Inj. 3.7%17-Falls 5.9% 10-Chest Pain 7.9%31-Unc Per 5.2% 29-MVA 10.4%04-Assault 4.2% 06-Breath. Prob. 10.5%12-Convulsions 4.1%25-Psyc 3.8%
  16. 16. Our New World:
  17. 17. OPPORTUNITY!!
  18. 18. What we Can Offer…
  19. 19. Nurse Triage• Take low-acuity 9-1-1 calls out of the system – 37.1% of referred patients to alternate dispositions – Help unclog EDs • Improve throughput • Improve patient:revenue ratio • Improved Press Ganey scores?• Physician/Hospital call services• Telemedicine/patient monitoring – Rx compliance/reminders• Connect with payer databases?
  20. 20. Expenditure Savings AnalysisBased on Medicare RatesJuly 1 - Sept 30, 2012 9-1-1 Nurse Triage Base Avoided SavingsAmbulance Charge $ 1,668 125 $ 208,500Ambulance Payment $ 421 125 $ 52,625ED Charges (ACSC) $ 904 125 $ 113,000ED Payment (ACSC) $ 774 125 $ 96,750ED Bed Hours (ACSC) 6 125 750Observation Admission Charge $ 5,400Observation Admission Payment $ 2,160Admission Charge $ 23,838Admission Payment $ 14,899Hospice Revocation Charge $ 23,838Hospice Revocation Payment $ 19,071Charge Avoidance $ 321,500Payment Avoidance $ 149,375Per Patient Enrolled 9-1-1 Nurse Triage Charge Avoidance $ 2,572 Payment Avoidance $ 1,195
  21. 21. Community Health Program• “EMS Loyalty Program” – Proactive home visits – Educated on health care and alternate resources – Enrolled in available programs = PCMH – Flagged in computer-aided dispatch system • Co-response on 9-1-1 calls • Ambulance and CHP medic• Non-Compliant enrollees moved to “system abuser” status – No home visits – Transport may be denied by Medical Director in consult with on-scene CHP medic
  22. 22. Community Health Program• 31 patients with 12 month data pre and post enrollment as of Sept. 30, 2012… – During enrollment • 52.2% reduction in 9-1-1 use to the emergency department – Post Graduation • 76.3% reduction in 9-1-1 use to the emergency department
  23. 23. Expenditure Savings AnalysisBased on Medicare RatesJuly 1 - Sept 30, 2012 CHP (1) Base Avoided SavingsAmbulance Charge $ 1,668 104 $ 173,472Ambulance Payment $ 421 104 $ 43,784ED Charges (ACSC) $ 904 104 $ 94,016ED Payment (ACSC) $ 774 104 $ 80,496ED Bed Hours (ACSC) 6 104 624Charge Avoidance $ 267,488Payment Avoidance $ 124,280Per Patient Enrolled CHP (1) Charge Avoidance $ 2,572 Payment Avoidance $ 1,195
  24. 24. CHF Readmission Reduction• At-Risk for readmission – Referred by cardiac case managers – Routine home visits • In-home education! • Overall assessment, vital signs, weights, ‘environment’ check, baseline 12L ECG, diet compliance, med compliance • Feedback to primary care physician (PCP) – Non-emergency access number for episodic care – Decompensating? • Refer to PCP early • In-home diuresis
  25. 25. CHF Readmission Reduction• For patients with 12 month data pre and post enrollment (23 patients) – 44 admissions prevented (46.8%) • 94 admissions pre-enrollment and 50 post- enrollment – Ambulance transports to ED avoided as of Sept. 30, 2012: • 44.1% reduction during enrollment • 55.9% reduction post graduation
  26. 26. Expenditure Savings AnalysisBased on Medicare RatesJuly 1 - Sept 30, 2012 CHF (1) Base Avoided SavingsAmbulance Charge $ 1,668 32 $ 53,376Ambulance Payment $ 421 32 $ 13,472ED Charges (ACSC) $ 904 32 $ 28,928ED Payment (ACSC) $ 774 32 $ 24,768ED Bed Hours (ACSC) 6 32 192Admission Charge $ 23,838 32 $ 762,829Admission Payment $ 14,899 32 $ 476,768Charge Avoidance $ 845,133Payment Avoidance $ 515,008Per Patient Enrolled CHF Charge Avoidance $ 26,410 Payment Avoidance $ 16,094
  27. 27. Observation Admission Avoidance• Partnership with ACO – ED Physician (Case Manager) identifies eligible patient • Refer to MedStar Community Health Program • Non-emergency contact number for episodic care given to patient – In-home care coordination with referring physician – Assure attendance at PCP follow-up next business day – Initiated September 1, 2012 • 8 patients enrolled • No patient’s revisited prior to PCP follow-up
  28. 28. Expenditure Savings AnalysisBased on Medicare RatesJuly 1 - Sept 30, 2012 Obs Avoidance Base Avoided SavingsObservation Admission Charge $ 5,400 8 $ 43,200Observation AdmissionPayment $ 2,160 8 $ 17,280Charge Avoidance $ 43,200Payment Avoidance $ 17,280Per Patient Enrolled Obs Avoidance Charge Avoidance $ 5,400 Payment Avoidance $ 2,160
  29. 29. 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
  30. 30. Hospice Revocation Avoidance• 18 patients enrolled• 13 patients successful in the end• 1 family called 9-1-1 – Intervened prior to transport – Still transported based on nature of illness • Direct admit – no ED visit• 6 currently enrolled
  31. 31. Expenditure Savings AnalysisBased on Medicare RatesJuly 1 - Sept 30, 2012 Hospice Rev Avoidance Base Avoided SavingsAmbulance Charge $ 1,668 9 $ 15,012Ambulance Payment $ 421 9 $ 3,789ED Charges (ACSC) $ 904 9 $ 8,136ED Payment (ACSC) $ 774 9 $ 6,966ED Bed Hours (ACSC) 6 9 54Hospice Revocation Charge $ 23,838 9 $ 214,546Hospice Revocation Payment $ 19,071 9 $ 171,636Charge Avoidance $ 237,694Payment Avoidance $ 182,391 Hospice RevPer Patient Enrolled Avoidance Charge Avoidance $ 26,410 Payment Avoidance $ 20,266
  32. 32. And the Grand Total Is…Expenditure Savings AnalysisBased on Medicare RatesJuly 1 - Sept 30, 2012Patient Navigation Savings: Charge Avoidance $ 1,393,544 Payment Avoidance $ 838,959
  33. 33. Patient/Provider Satisfaction
  34. 34. Patient Assessment of Health Status
  35. 35. Future Opportunities…• Delivery System Reform Incentive Payments – 1115a waiver - Regional Health Partnership • Hospital-based – New process for Upper Payment Limit payments to Critical Access Hospitals – Paid for programs that: • Improve Care • Improve Health • Reduce Cost – How can EMS change the landscape of healthcare?$4 million $11 million $26 million
  36. 36. Director of Primary Care and Clinical Partnerships
  37. 37. Statements to be Banned• “We’ve always done it that way!”• “There’s no money to be made in that…”• “It’s what the community expects…”• “We’re an ambulance service…”• “We don’t have the money.”• “There are regulatory ‘issues’…”
  38. 38. The Clinical Call CenterAtThe Center for Emergency Medical ServicesNorth Shore-LIJ Health System
  39. 39. Background• Patient interviews reveal need for 24x7 response to a change in clinical condition• Provider surveys reveal inadequate coverage to meet patient demands and lack of access to patient information• Because of the lack of 24x7 intelligent clinical services, patients are directed to or rely upon ED based care• Complex patients are admitted at high rates regardless of whether there is potential clinical benefit
  40. 40. Emerging Innovative Solutions• Centralized, system integrated Clinical Call Center that provides 24x7 access to algorithmically driven: Clinical Decision Support, Locus of Care Navigation & Off-hours Call services  E.g. Transitions of care, D/C follow up, CHF readmission abatement management, locus of care navigation, Clinically intelligent MD call services• Integrated Community Paramedic programs  911/Emergency de-escalation to appropriate locus of care, on demand - on site clinical decision support & treatment, in-home risk assessment & abatement, PERS integration
  41. 41. What Others Are ExperiencingSisters of Mercy – St. Louis, Missouri • Hospital Based Program  Centralized 24x7x365 clinical call center  CHF & COPD patient populations  Inbound & outbound call management  Locus of care navigation model • Results  10% decline in readmission rates and remain stable despite the increasing clinical complexity of admitted patients  Customer Satisfaction = 91% | Physician Satisfaction = 89%
  42. 42. What Others Are ExperiencingCleveland Clinic – Cleveland, OH • 24x7 Integrated centralized appointment call center  Same day service program, custom algorithms by service line, best in class high performance operational model • 24x7 Community service based RN advice line  Community benefit based program, risk adverse escalation to 911/EMS model, locus of care navigation • D/C follow up program (lower level clinicians)  Customer service focused, new transitional care concept • Results  Significant increased outpatient capture ROI  Customer Satisfaction >90% | Error Rate <0.5%
  43. 43. What Others Are ExperiencingMedstar - Fort Worth, TX• EMS Based Program  Multiple health systems and insurance companies contracting with single EMS provider to eliminate readmissions for: • CHF | Asthma | Hospice | System Abuse Management • Safety Net | Transitional Care• 12 Month Pilot Results Highlights…  40% Emergency calls referred to alternate dispositions (non- ED)  46.8% reduction in CHF readmissions  $14,831 cost reduction per patient to CMS  9% increase in outpatient visits
  44. 44. Our Solution – The Clinical Call Center at CEMSSynergistic Combination of Best Practices• Consolidated – Service Integrated 24x7 Clinical Call Center  Paramedic & RN algorithmically based clinical decision support for: • Inbound & outbound caller programs (transitions of care, readmission abatement, locus of care navigation, 911/EMS escalation and de- escalation capabilities) • Clinically intelligent MD call services for off-hours• Integration of CEMS as Community Paramedic Provider  24x7 On-demand, on-site clinical decision support services for appropriate locus of care navigation, in-home off-hours treatment & transport to alternative destinations  In home risk assessment, abatement and provider communication  Chronic disease management & readmission abatement collaborations  PERS program Integration
  45. 45. Our Solution – The Clinical Call Center Locus of Care Navigation Model  Empowers patient navigation “GPS” to the…  Right - Type of Care  Right - Clinically Appropriate & Customer Acceptable Timeframe  Right - Place  Right - Quality  Right - Cost • A “Locus” could include (based on patient’s clinical situation):  Self treatment with call center based follow up  Referral to same day or next day appointment with MD (Scheduling Call Center Integration) De-escalation  Referral to Post Acute Services (House Calls, Home Care)Escalation  Referral to urgent care or other doc-in-the-box (Walgreens, Wal- Mart)  Referral to Community Paramedic with treatment or transport options to all Locus treatment destinations  Referral to Emergency Department
  46. 46. What About the Impact on FFS Service Lines? • Service Volumes & Down Stream Revenues  Service volumes will shift away from traditional FFS pathways  (e.g. ED -> In-patient)  FFS revenues negatively impacted if FFS reimbursement  Cost avoidance if Capitated / Managed Care reimbursement  Services volumes will shift into Primary, Post Acute & Pre-hospital pathways  FFS revenues positively impacted if FFS reimbursement available  Cost avoidance if Capitated / Managed Care reimbursement • Girder framework that “bridges the FFS chasm”  Allows the bridge to be built one capitated contract “plank” at a time  Continue to direct FFS populations to traditional approach  Point Managed Care populations to new approach
  47. 47. Populations Served for - 1 R.N., 24x7 CoverageHypothetical Model Case Clinical Call Center Number of Calls per Day Population Served Mix Inbound Clinical Triage and Locus of Care 35% 18 2455 / Year Transition of Care (4 Calls / 30 days) 37% 21 160 / Month Daily Diuretic Management 29% 35 35 / Month (30 Calls / 30 Days)

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