1. Reducing Readmits Using Patient Navigation! “ Welcome to the Real World ”

2. About MedStar… Governmental authority serving Ft. Worth and 14 Cities o 880,000 residents o Exclusive provider for all emergency and non emergency EMS 110,000 responses annually 375 employees Medical Control from 14 member physician medical board o Physician Medical Directors from all emergency departments in service area + Tarrant County Medical Society

3. Global Issues Today, 40 million people > 65 o 70 million in next 20 years 2010 20,000 docs short o By 2025 = 140,000 to 214,000 short By 2015, 33% of hospital payments will be based on patient satisfaction (PPACA) EMS controls 25% of downstream health expenditures 50% of health expenditures occur in last 2 years of life

4. Global Issues Catalyst for Payment Reform (Yes, CPR) o Coalition of employers (Walmart, Intel, GE for example) o Pushing for value oriented payments to providers (20% by 2020) o Aetna – Now paying the same for c-section or vaginal birth – eliminate incentive for c-section (H&HN) o $1,250 for screening colonoscopies – regardless of in or out of the hospital (H&HN)

5. Global Issues AHRQ = 1% of patients accounting for 1/5 of healthcare expenditures (H&HN) o There are 4.6 million Medicare beneficiaries with CHF (AHRQ) o One CHF admission cost CMS $17,500 (AHRQ) o 30-day readmission rate for CHF = 24.7% (AHRQ) o 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

6. Emergency Medical Services?

7. Unscheduled Medical Services!

8. Current State of Unscheduled Care 9-1-1 safety net access for non-urgent healthcare o 32.8% of 9-1-1 requests are non-emergent/non-urgent May 2012 Priority 3 calls Problems with uncontrolled and unmanaged access o Emergency department the source of primary care

9. Current State of Unscheduled Care Incentivized to use the highest cost transport to highest cost care setting o And it’s the easiest… o Same with hospital admissions

10. Current State of Unscheduled Care Reasons people use emergency services o To see if they needed to o It’s what we’ve taught them to do o Because their doctors tell them to o It’s the only option Many patients using ED have payer source…

11. Frequent Users of Emergency Departments: The Myths, the Data, and the Policy Implications Results Frequent users comprise 4.5% to 8% of all ED patients but account for 21% to 28% of all visits. Most frequent ED users are white and insured; public insurance is overrepresented. Age is bimodal, with peaks in the group aged 25 to 44 years and older than 65 years. On average, these patients have higher acuity complaints and are at greater risk for hospitalization than occasional ED users. However, the opposite may be true of the highest- frequency ED users. Frequent users are also heavy users of other parts of the health care system. Only a minority of frequent ED users remain in this group long term. Annals of Emergency Medicine Volume 56, Issue 1, Pages 42-48, July 2010 Volume 56, Issue 1 Why is this important?

12. New EMS Role! Right Resource Right Time Right Patient Right Outcome

14. Programmatic Solutions Community Health Program o “EMS Loyalty Program” members enrolled Proactive home visits o Educated on health care and alternate resources o Enrolled in available programs o Flagged in computer-aided dispatch system Co-response on 9-1-1 calls Ambulance and CHP medic o 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

15. CHP Program Outcomes For patients with 12 month data pre and post enrollment as of August 31, 2012… o During enrollment 52.2% reduction in 9-1-1 use to the emergency department o Post Graduation 76.3% reduction in 9-1-1 use to the emergency department

16. Programmatic Solutions CHF Program o At-Risk for readmission As referred by cardiac case managers o Routine home visits In-home education! Overall assessment, vital signs, weights, ‘environment’ check, baseline 12L ECG Feedback to primary care physician (PCP) o Non-emergency access number for episodic care o Decompensating? Refer to PCP early In-home diuresis

17. Initial Assessment of Health Status

18. Patient/Provider Satisfaction

19. CHF Program Outcomes Admissions avoided: o Patient-specific data provided by local hospitals For patients with 12 month data pre and post enrollment (23 patients) o 44 admissions prevented (46.8%) 94 admissions pre-enrollment and 50 post-enrollment o Ambulance transports to ED avoided as of August 31, 2012: 44.1% reduction during enrollment 55.9% reduction post graduation

20. CHF Program: Economic Results Congestive Heart Failure Average charge and cost for an inpatient stay for Congestive Heart Failure. Discharge Dates between 10/01/2010 and 09/30/2011 X Y Z Health Network The following ICD9 Codes were used to identify Congestive Heart Failure: HEART FAILURE428.* Average Charge - $56,919.87 56,919.87 Cost 18,214.36 44 Admissions Prevented: 44 X $57,000 (Average Charge) = $2,500,000 in Savings

21. Programmatic Solutions Hospice revocation avoidance o Enroll patients “at risk” for revocation o Visit at home Counsel – instruct – 10 digit access o “Register” patient in CAD Co-respond with a “9-1-1” call Help family through process awaiting hospice RN

22. Hospice Program Outcomes 12 patients enrolled 1 family called 9-1-1 o Intervened prior to transport o Still transported based on nature of illness 9 patients successful in the end 3 still enrolled

23. CHF Medicare Specific Savings Fort Worth Hospitals o 12 Medicare patients with one 1 year pre and post enrollment data Payments for EMS Transports  126 fewer ambulance trips  $66,241 CMS payment savings Hospital Admits  6 fewer in-patient admissions (-33.3%) 9% increase in outpatient visits  $111,726 in savings $177,967 Total payment savings o $14,831 Medicare cost savings per patient

24. What about November 2012?

25. Observation Challenge Study: Hospital 23 Hour Observation Stays Increase 34 Percent In 2 Years “Using Medicare enrollment and claims data nationwide, we documented a rising trend in the prevalence and duration of hospital observation services in the fee-for-service Medicare population during 2007–09… … the ratio of observation stays to inpatient admissions increased 34 percent, from an average of 86.9 observation stay events per 1,000 inpatient admissions per month in 2007 to 116.6 in 2009.” Feng, Wright, and Mor: Sharp Rise In Medicare Enrollees Being Held In Hospitals For Observation Raises Concerns About Causes And Consequences Health Aff June 2012 31:61251-1259Health Aff June 2012 31:61251-1259

26. Programmatic Solutions ’23 hour observation’ Avoidance o Partnership with IPA/ACO o ED Physician identifies eligible patient Refer to MedStar Community Health Program Non-emergency contact number for episodic care given to patient o In-home care coordination with referring physician o Assure attendance at PCP follow-up next business day o Initiated August 1, 2012 5 patients enrolled No return ED visits prior to PCP appointment

28. Additional Resources http://www.medstar911.org/community-health-program http://www.communityparamedic.org/ http://www.ircp.info/ http://www.hrsa.gov/ruralhealth/pdf/paramedicevaltool.pdf http://www.wecadems.com/cp.html http://www.dhhs.ne.gov/Documents/CommunityParamedicineReport.pdf http://www.dhhs.ne.gov/Documents/CommunityParamedicineReport.pdf http://www.nytimes.com/2011/09/19/us/community-paramedics- seek-to-prevent-emergencies-too.html http://www.nytimes.com/2011/09/19/us/community-paramedics- seek-to-prevent-emergencies-too.html

29. Opportunities in Your System?