1. Right Care Initiative Best Practices: Pre-hospital Initiatives Specialty Care Systems Community Paramedicine
Howard Backer, MD, MPH, FACEP
Director, California Emergency Medical Services Authority

2. Specialty Care Systems
Clinical systems of care
Time sensitive
Integrated protocols across pre-hospital, hospital, rehabilitation
Performance Improvement relies on data from entire system
Driven by patient outcomes

5. Reperfusion therapy for patients with STEMI

6. Division of Responsibility for Specialty Care Systems
EMSA:
Oversight, regulation, guidelines for planning and development, system plan approval, Q/A and PI plan
EMS scope of practice
LEMSA:
Local system design and implementation
Designation of facilities
Medical protocols and oversight

7. Division of Responsibility for Specialty Care Systems
EMS providers
Assure resources for pre-hospital response
Assure appropriate training and care
Report disciplinary issues
Facilities
Resources and personnel
Clinical care
Quality assure and improvement
Verification

8. Clinical recommendations
Specialty care organizations
Heart /Stroke Association
Quality Standards organizations
Joint Commission
Professional organizations

9. STEMI System Prehospital patients who call 9-1-1
Direct care begins when EMS at patient’s side
obtain a prehospital ECG,
make the diagnosis,
activate the system, and
Decision to transport patient to a PCI-capable or non–PCI-capable hospital.
Rate of false activations (≈ 15%) and is outweighed by earlier treatment times

10. 2018 Acute Ischemic Stroke Treatment Guidelines (corrected): EMS
Public education to call for stroke
9-1-1 dispatch should prioritize stroke
Educational stroke programs for healthcare personnel prehospital and in hospital
Use of stroke assessment system recommended
Begin management in field
Provide notification to receiving hospital

11. 2018 Acute Ischemic Stroke Treatment Guidelines (corrected): EMS
develop triage protocols to ensure that patients with a suspected stroke are rapidly identified and assessed using a validated instrument for stroke screening
Develop Regional Systems of Care
Transport patients with positive screen rapidly to facility that can administer IV alteplase
If several choices, unclear if advantage to bypassing closest to go to thrombectomy capable center

12. Common Sections in Regulations
Definitions
System requirements
Plan approval
Personnel and early recognition
Levels and requirements for medical centers
Data, Quality, Evaluation

13. Specialty Care System Levels
Trauma
STEMI
Stroke
Pediatric (EMSC)
Level I
STEMI Receiving Center
(PCI center)
Comprehensive Stroke Center
Level 1
Level II
Level 2
Thrombectomy-capable
Level III
STEMI Referring Hospital
Primary Stroke Center
Level 3
Level IV
Acute Stroke Ready Hospital
Level 4
Change pediatric trauma column to EMSC

14. Areas of Controversy for Regulations
Stroke—pace of change in science of treatment
Degree of alignment with other guidelines
New mandates for facilities
State vs local authorities
Required data elements

15. Community Paramedicine Pilot Program Summary and Two Year Evaluation
University of California, San Francisco
Philip R. Lee Institute for Health Policy Studies and Healthforce Center
Janet Coffman, MPP, PhD Lead Evaluator
California Emergency Medical Services Authority
Howard Backer, MD, MPH, FACEP
PI for HWPP #173
Lou Meyer
Project Manager
11/7/2018

16. Working Definition of Community Paramedicine
A locally determined community-based, collaborative model of care that leverages the skills of paramedics and EMS systems to address care gaps identified through a community-specific health care needs assessment.
New models of community-based health care that bridge primary care and emergency care
Utilizes paramedics outside their traditional emergency response and transport roles
People utilize EDs more often because of a lack of access to other providers as opposed to the seriousness of their complaints
Pre-hospital EMS system is uniquely positioned to care for 911 patients and assist less emergent patients with transport to the most appropriate care setting based on medical and social needs… reducing the cost of care and ED burden

17. Why Paramedics? Trusted and accepted by the public
In most communities--inner city and rural
Work in home and community-based settings
Licensed personnel that operate under medical control as part of a system of care
Trained to make health status assessments, recognize and manage life-threatening conditions outside of the hospital
Always available (24 / 7 / 365)
Pre-hospital EMS system is uniquely positioned to care for 911 patients and assist less emergent patients with transport to the most appropriate care setting based on medical and social needs… reducing the cost of care and ED burden

18. Community Paramedicine Concepts
Post hospital discharge short-term follow-up
Frequent EMS user case management
Directly Observed Therapy for tuberculosis: public health department collaboration
Hospice support
Alternate destination to mental health crisis center
Alternate destination to sobering center
Alternate destination to urgent care center (Cancelled)

19. Methods
Evaluation period 24 to 28 months except for alternate destination to sobering center (depending on project start time between June 2015-October 2015)
Outcomes assessed across three domains
Safety
Effectiveness
Potential savings accrued by other parts of the health care system

20. Cumulative Patients Enrolled by Concept through September 2017*
11/7/2018
Cumulative Patients Enrolled by Concept through September 2017*
Concept
# Enrolled
Post-Discharge Short-term Follow-Up
1,401
Frequent EMS Users
103
Directly Observed Therapy for Tuberculosis 42
Hospice
270
Alternate Destination – Mental Health
251
Alternate Destination –Sobering Center
400
Alternate Destination – Urgent Care
48§
All Projects
2,515
* 24 to 28 months for individual projects, depending on start date except for alternate destination to sobering center
§ Pilot projects for alternate destination urgent care cancelled

21. Enrolled Patients’ Payer Types – Through September 2017
11/7/2018
Enrolled Patients’ Payer Types – Through September 2017

23. Post-Discharge Short-term Follow-Up
Decreased hospital readmissions within 30 days for at least one diagnosis at all sites
CPs identified 229 patients (16%) who misunderstood how to take their medications or had duplicate medications and were at risk for adverse effects.
All five post-discharge projects achieved potential cost savings for payers, primarily Medicare and Medi-Cal.

24. Project Impact on 30 Day Hospital Readmission Rate
11/7/2018
Project Impact on 30 Day Hospital Readmission Rate
Decreased hospital readmissions within 30 days for at least one diagnosis at all sites
CPs identified 229 patients (16%) who misunderstood how to take their medications or had duplicate medications and were at risk for adverse effects.
All five post-discharge projects achieved potential cost savings for payers, primarily Medicare and Medi-Cal.
*All projects except Butte CHF and Alameda COPD showed statistically significant reduction in the readmission rate for enrolled patients relative to the partner hospitals’ historical readmission rates (p value < 0.05). Alameda COPD had no statistically significant difference. Butte CHF had a higher readmission rate than the historical rate.

25. Frequent EMS Users
Reductions in numbers of 911 calls, ambulance transports, and ED visits among enrolled patients.
Assisted patients in obtaining housing and other non- emergency services that met the physical, psychological, and social needs that led to their frequent EMS use
EMS collaboration with many other community organizations

26. Reduction in Emergency Services: Frequent 911 Users
Note: 24 months of operation for San Diego, 28 months for Alameda

27. Directly Observed Therapy for Tuberculosis
Dispensed appropriate doses of tuberculosis (TB) medications and monitored side effects and symptoms that could necessitate a change in treatment regimen
CPs achieved better compliance (99.9%) than community health workers (93.3%) and provided care to patients that CHW could not reach
Demonstrates capability for collaborative work with public health

28. Hospice Support
Provided hospice patients and their families with psychosocial support and administered medications in consultation with a hospice nurse, until nurse could arrive
In accordance with patient wishes, reduced rates of ambulance transports to an ED
Potential savings for Medicare and other payers by reducing unnecessary ambulance transports, ED visits, and hospitalizations

29. Percent of 911 Calls for Hospice Patients Resulting in Transport to ED
11/7/2018
Percent of 911 Calls for Hospice Patients Resulting in Transport to ED
(26 months data; N=270 hospice patient calls to 911 )
Provided hospice patients and their families with psychosocial support and administered medications in consultation with a hospice nurse, until nurse could arrive
In accordance with patient wishes, reduced rates of ambulance transports to an ED
Potential savings for Medicare and other payers by reducing unnecessary ambulance transports, ED visits, and hospitalizations
1/23/2017

30. Alternate Destination – Mental Health
Performed medical screening of patients to determine whether they could be safely transported directly to a mental health crisis center
96% of patients enrolled were evaluated at the mental health crisis center without the delay of a preliminary ED visit.
Over study period (24 months), 4% of patients required subsequent transfer to the ED (9 patients)
Potential savings for payers, primarily Medi-Cal, due to reduced ED visits and subsequent transfer to mental health center
Strongly supported by law enforcement because reduces the amount of time required for mental health calls

31. Alternate Destination—Mental Health

32. Alternate Destination-Sobering
Performed medical screening of patients to determine whether they could be safely transported directly to a sobering center
Enrolled and transported 400 patients in first 8 months.
Ten patients (2.5%) were transferred to an ED within six hours of admission to the sobering center due to medical complaints
9/10 complaints developed after admission to sobering center
7 subsequently treated and released, 2 transferred for psych eval, 1 left ED without being seen
Potential savings for payers, primarily Medi-Cal, due to reduced ED visits

33. Alternate Destination – Urgent Care
Insufficient data to make firm conclusions about this model
No patients experienced an adverse outcome, although two patients were transferred to an ED following admission to an urgent care center
Nine patients were rerouted to an ED because the urgent care center declined to accept
Projects closed: Multiple barriers to this model in California, although successful in other states

34. Conclusion
Specially trained paramedics can provide services beyond their traditional and current statutory scope of practice in California
Projects have improved patients’ well-being
No adverse outcomes for patients
No other health professionals displaced
In most cases, yielded savings for health plans and hospitals