Lessons Learned
BY JESSE ROMAN
There's a well-known saying in EMS circles that if you've seen one EMS service, you've only seen one EMS service.
“Even more to that point, if you've seen one mobile health care medicine program, you've seen only one because the neighboring district may have something completely different,” said Jeff Siegler, a doctor and the medical director of three EMS systems in the St. Louis area.
The fact that MIH has a different flavor everywhere is more of a feature than a flaw, according to experts—if you’re taking a cookie-cutter approach to MIH, they say, you’re probably doing it wrong.
“Every community is different,” said Matt Zavadsky, president of the National Association of EMTs and an executive at MedStar Mobile Healthcare in Fort Worth, Texas. “What is driving high hospital readmissions in your community—is it heart failure? Diabetes? Mental health? What is driving high ER visits? What are the resources available? The answers to those questions are going to be different in every community. That’s why you have to do a gap analysis.”
The gap analysis process, used to figure out where EMS systems can get the most bang for their efforts, is central to the recommendations in the new NFPA 451, Guide for Community Health Care Programs, which Zavadsky and Siegler both contributed to as technical committee members. The goal of the document, they say, is to provide a roadmap for EMS leaders to quickly get up to speed and create MIH programs that are sound from the outset and built to last.
While MIH has brought tremendous value to many communities and EMS systems, the complexity of the health care system and the sheer number of stakeholders means there are pitfalls that are easy to fall into. EMS agencies that fail to answer crucial questions, or don’t include key health care partners in decisions, can end up expending a lot of effort for little return.
The value of NFPA 451, Zavadsky said, is what he affectionately refers to as “scar avoidance.”
“I can show you the scars that (MedStar) has from things that didn't work out real well,” he said. “That's why the NFPA 451 project is so beneficial—you've got a resource now that any agency or practitioner can go to. If you’ve been asked to do a mobile integrated health care program, which most agencies will, here’s how you do that. Here's the guide.”
Since both Zavadsky and Siegler have been involved in building and operating MIH programs, NFPA Journal asked them to list a handful of key lessons they’ve learned over the years, along with mistakes they’ve made and unexpected challenges they’ve faced or could see happening as MIH expands further.
BUILD WITH PURPOSE
Zavadsky: Before you start a specific MIH program, you always have to ask yourself the questions: “Am I going to make a difference?” and “Is this something that we can bend the curve on?” You need to be really honest and really objective.
For instance, if someone asks you to do an MIH program that addresses the excessive emergency department use for patients who are on renal dialysis, look at the trips to the emergency room that that population has had. If most trips result in the patient being admitted to the hospital because they were in acute renal failure, you're going to have a hard time bending that curve. Just because you can do something doesn’t mean you should.
COLLABORATE WITH STAKEHOLDERS
Z: Don't duplicate things that are already available in the community; instead, you need to find the gaps that you can fill.
We built our program in collaboration, not in competition, with the rest of the health care system. We did a gap analysis with our stakeholders—the hospitals, the payers, the United Way, and others. We held forums and asked them, “What are the gaps in the health care system where our patients, your patients, are falling through the cracks, and what role could we have as an EMS organization to help fill those gaps?” We built our programs based on our community partners’ responses to those questions.
Working collaboratively with your local community will ensure your program is not only successful, but also economically sustainable. If people view it as valuable, they're usually willing to fund it.
GET THE ECONOMICS AND
PRICE STRUCTURE RIGHT
Z: When we first started doing integrated health care programs, we did activity-based costing. For example, if we found that it was going to cost us $65 per visit to have a community paramedic go to somebody's house, when the client would ask us how much our services cost we would tell them $70. But what we learned is that the value we bring is way more than $70. The value to the payer is the avoidance of two $2,500 ambulance ride payments for a round-trip visit to the ER.
Now when we do our economic modeling, we don't start by asking what it will cost us—we start by asking, “What are we going to save the health care system?” We say to our clients, “You tell us how much you want to pay, and we'll figure out if we can do it.” Every time we've done that, we’ve found out that the payer is willing to pay much more than we would have charged.
BEWARE OF GROWING TOO FAST
Siegler: The growing pains that we've seen from our colleagues throughout the country and even in the Canada is that some of them are victims of their own success. They're doing so well that more patients get enrolled into their MIH programs and then they can't keep up because they don't have enough employees to manage the case load.
Z: The key is starting it small, testing some patients, showing that it works or in some cases that it didn't work, and refining it so it will work and then rolling out the program.
COOPERATE WHEN CROSSING
JURISDICTIONS
S: Depending on the state, you may not legally be able to go into a neighboring district to treat patients without that district’s permission. That could be an issue if a patient left your hospital, but is getting discharged back to another district. The hospital expects the patient to be enrolled in its MIH program, but maybe the EMS agency in the neighboring district views this MIH program as a threat to its funding source—they were expecting to get paid for transporting this patient a hundred times a year.
Sometimes you have to bring those neighboring districts to the table and say to them, “What is in the best interest of the patient? To continually transport them to the hospital and take up a bed, or to prevent them from getting transported in the first place by making them healthier?” And I don't know of anyone who has said no to that. In theory, though, if they have state regulations that allow them to say, “You shall not pass beyond these borders,” then there’s not much you can do.
EMBRACE THE CHANGE
S: Some medics fell in love with EMS by watching television shows, or got hooked by the excitement of the lights and the sirens. The whole point of the MIH concept is to prevent the lights, sirens, and excitement. It's a new version of health care that a lot of providers weren't initially going into EMS to do. I tell people that, while it may not be as exciting, it's more rewarding. Our MIH patients and families thank us more often than other patients for helping them get better. When you see that, it does give you a warm and fuzzy feeling.
JESSE ROMAN is associate editor at NFPA Journal. Top photo: Getty