Indiana Community Paramedicine: Measuring Impact for Sustainability October 12, 2017 Claudine Samanic, PhD CDC Epidemiology Assignee Indiana State Department of Health Division of Chronic Disease, Primary Care & Rural Health

MIH/CP Evolution MIH/CP programs represent a shift in Fire/EMS approach to care No longer just transport – emergency response models now take patient-centered approach to delivery of healthcare: Based on community needs Out-of-hospital environment Coordination with local heath and social service partners “Newish” transitional care models Tertiary prevention in public health

MIH/CP Program Impact Financial and operational metrics show success: Reduced unnecessary ambulance transports Reduced ED visits Reduced hospital readmissions All equal ↓ $$$ What about long-term impact and sustainability? How to ensure MIH/CP programs become standard practice in current healthcare climate?

MIH/CP Payment Models (N=99) Source: National Association of Emergency Medical Technicians. Mobile Integrated Healthcare and Community Paramedicine (MIH-CP), 2014. Accessed at https://www.naemt.org/docs/default-source/MIH-CP/naemt-mih-cp-report.pdf.

MIH/CP Funding Sources Source: National Association of Emergency Medical Technicians. Mobile Integrated Healthcare and Community Paramedicine (MIH-CP), 2014. Accessed at https://www.naemt.org/docs/default-source/MIH-CP/naemt-mih-cp-report.pdf.

MIH/CP Program Sustainability? Source: National Association of Emergency Medical Technicians. Mobile Integrated Healthcare and Community Paramedicine (MIH-CP), 2014. Accessed at https://www.naemt.org/docs/default-source/MIH-CP/naemt-mih-cp-report.pdf.

MIH/CP Sustainability “It will no longer be enough to simply monitor financial and operational implications, we must show our impact on patient-specific health outcomes that influence the population health status while subsequently proving that our delivery mechanism(s) enhance the patient experience and reduce total cost.” Outcome measures should comprise state/region- specific metrics combined with: The National MIH/CP Outcome Measures Project CMS Quality Measures IHI Triple Aim Measures Relevant, validated patient-centered health outcome evaluation tools Source: George TA. Arizona MIH-CP Data Crosswalk Project. 2016. Accessed at http://vitalysthealth.org/wp-content/uploads/2016/11/20160907_CrosswalkProjectPackage_FINAL.pdf

What’s being measured now?

MIH/CP Impact “All measured trends demonstrated favorable results for patients participating in the MIH program when compared against a matched cohort: 19% decrease in ED visits per member per month (PMPM) cost, 21% decrease in ED utilization, 37% decrease in inpatient PMPM cost, 40% decrease inpatient utilization….”1 “…patients in the intervention group were less likely to attend an ED (RR 0.72, 95%CI= 0.68 to 0.75) or require hospital admission within 28 days (0.87, 0.81 to 0.94) and experienced a shorter total episode time (235 v 278 minutes, 95%CI for difference − 60 minutes to −25 minutes). Patients in the intervention group were more likely to report being highly satisfied with their healthcare episode (RR 1.16, 1.09 to 1.23)….”2 1. Castillo DJ, et al. Mobile integrated healthcare: preliminary experience and impact analysis with a Medicare advantage population. JHEOR 2016;4(2):172-87. 2. Mason S, et al. Effectiveness of paramedic practitioners in attending 999 calls from elderly people in the community: cluster randomised controlled trial. BMJ 2007;335:919

MIH/CP Impact “The following are highlights of the CP Program as of June 30, 2015: Enrolled 75 patients accounting for 773 visits Decreased ER utilization 58.7% Decreased IP utilization 60.0% Decreased 30-day readmission rate 41.2% 85% of diabetic patients showing improved health outcomes 69.9% of hypertension patients showing improved health outcomes” Source: Bennet KJ et al. Community paramedicine applied in a rural community. J Rural Health. 2017;00:1-9.

EMD Problem/ Nature Transport Avoidance Clinical Metrics EMD Problem/ Nature Transport Avoidance Source: http://www.naemt.org/docs/default-source/community-paramedicine/mih-cp-toolkit/cp-presentation---north-shore-lij.pptx?sfvrsn=2

MedStar Mobile Healthcare – High Utilizer Program http://www.medstar911.org/Websites/medstar911/files/Content/1089414/MedStar_High_Utilizer_Economic_Outcomes_Through_July_2017.pdf

MedStar Mobile Healthcare - Patient Self-Assessment of Health Status http://www.medstar911.org/Websites/medstar911/files/Content/1089414/MedStar_MIH_Patient_Self_Assessment_of_Health_Status_Scores_Through_July_2017.pdf

MIH/CP Patient Outcomes Source: Bennet KJ et al. Community paramedicine applied in a rural community. J Rural Health. 2017;00:1-9.

Improvements in clinical measures COPD: COPD patients had significantly fewer ED admissions in past 6 months than before enrollment for SOB episodes (91.6% decrease) Source: Bennet KJ et al. Community paramedicine applied in a rural community. J Rural Health. 2017;00:1-9.

MIH/CP Program Measures - Summary Fit within population health framework, value- based payment models, and have quantifiable outcomes: Impact on patient outcomes Impact on patient satisfaction Impact on quality of care Impact on cost

Medicare: The Big Fish “…..Using 2005–09 Medicare claims data….we estimated that 12.9–16.2% of Medicare-covered EMS transports involved conditions that were probably non-emergent or primary care treatable. Among beneficiaries not admitted to the hospital, about 34.5% had a low-acuity diagnosis that might have been managed outside the ED. Annual Medicare EMS and ED payments for these patients were approximately $1 billion per year. If Medicare had the flexibility to reimburse EMS for managing selected 911 calls in ways other than transport to an ED, we estimate that the federal government could save $283–$560 million or more per year, while improving the continuity of patient care. If private insurance companies followed suit, overall societal savings could be twice as large.” Source: Alpert A, et al. Giving EMS flexibility in transporting low-acuity patients could generate substantial Medicare savings. HEALTH AFFAIRS 32, NO. 12 (2013): 2142–2148.

Challenges to data collection

Challenges Defining common clinical metrics for various patient enrollment conditions that are: Not overly burdensome to collect Can be collected by all Can be analyzed in meaningful way Demonstrate patient outcome across range of potential conditions (heart failure, diabetes, COPD, asthma) Can output from EHRs and CP notes into manageable data

Indiana MIH/CP Program Statewide Survey To better understand Indiana MIH/CP landscape Collaboration: Indiana State Department of Health, Indiana University, and Qsource, Indiana’s Medicare Quality Innovation Network-Quality Improvement Organization Survey programs to inventory: Target populations served Methods of identification/enrollment/enrollment period Services offered Funding sources Outcome measures/metrics currently collected Other items identified today

Thank you! Questions?