The “5 Rs” of Community Paramedicine and Mobile Integrated Healthcare

by Jonathon S. Feit, MBA, MA —Co-Founder & Chief Executive Officer, Beyond Lucid Technologies, Inc. — Jonathon.Feit [at] beyondlucid.com

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After the 2014 International Roundtable on Community Paramedicine (where I gave a talk about sustainability and measuring results), plus a day of sessions on Community Paramedicine and Mobile Integrated Health (CP/MIH) at the 2014 EMS World Expo, and additional content on the subject at the 2015 EMS Today conference, among other events —much ado has been made of the burgeoning opportunity to attain the IHI Triple Aim of better health, better care, and lower costs by “restructuring” emergency medical services to incorporate out-of-home care, alternate site transport, non-transport, readmission prevention, and even telemedicine.

Yet as an MBA (and Co-Founder / C.E.O. of the first EMS-facing technology firm that designed patient documentation software with CP/MIH in mind), I have personal and professional inclinations to advocate for sustainability and sound economic judgment in new ways of working that show early signs of success. Fire and EMS agencies nationwide have sought my team’s help to tightrope the new CP/MIH care model’s regulatory lines (which are still drawn with a dotted line in most places). Although the archetypical CP/MIH models highlighted frequently across the country — including REMSA, MedStar, UPMC, Mesa (Arizona), Eagle County (Colorado), and San Diego (among a dozen pilot projects recently approved in California)—offer an inspiring set of models, they are also regionally specialized and therefore challenging to replicate. In the long-term, most locales cannot get paid for CP/MIH (and they won’t be able to for a while), so below are my “5 Rs of Community Paramedicine and Mobile Integrated Health, advice to guide the efforts of agencies large and small that wish to engage this new, healthcare reform-focused care delivery model…even when their budgets to explore such a modern care model are razor-thin (if they exist at all):

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1. REASON

Agency leaders should ask themselves why they want to go down this road. Is it to improve clinical care, lower costs, or free up resources? Or — if we’re being honest — is it because CP/MIH seems like “the thing to do”? It’s a hot topic, and “the cool kids are doing it.” Are you afraid of being left out? Implementation isn’t easy: a fire chief in Texas once told me he had to “use all his political capital” to push through non-transport regulation pertaining to frequent transport patients. CP/MIH is at least as complex as frequent transports because its cost-benefit analysis is less obvious, as is the means by which to identify the patients — and providers — who will take part in the program, how patients will be tracked, and who holds command authority. (Add in union issues, and you have a recipe for extensive negotiations.)

2. RIGHTS

Speaking of extensive negotiations: Do you even have the legal permission to engage in CP/MIH? Consider what’s happening in California right now: the state has authorized “Community Paramedicine Pilot Projects,” including an educational program to be run by UCLA, with statistical oversight by the University of California San Francisco. Given its practical, innovative curriculum and a statewide training model, the program should be a shoe-in — but California tightly restricts ambulance operations, and nursing unions have complained about EMS agencies invading what has traditionally been ”their turf.” Does your state allow you to take patients somewhere other than a hospital? With other stakeholders in your network?

3. REVENUES

Revenue considerations are an interesting question-mark in the age of Accountable Care and the readmission prohibition. Hospitals weigh whether bringing patients in frequent visits is worth a penalty and possible non-reimbursement. (It’s a more complicated calculation than it sounds.) Ask yourself: is CP/MIH a line of business worth the economic loss that your agency will incur by engaging in non-transport activities? Have you considered “the other side of the ledger”? Matt Zavadsky’s presentations stand out among expert discussions on the cost savings promised by CP/MIH, but in his zeal to evangelize system savings, Matt rarely references the costs incurred by EMS agencies — like gasoline, supplies, and provider time — that cannot be reimbursed under CMS’s current payment scheme.

If you are to spend money on CP/MIH but not get paid back, you must find another way to justify the expense: Recast it within your organization as a way to build community engagement, or train crews to improve bedside manner with chronic patients. Perhaps you want to be your region’s early adopter, who gets credit for bringing to life the “EMS Agenda for the Future.” Whatever your metric, you’ll have to justify any foregone revenues.

4. REGION

How supportive is your regional ecosystem? Who will pay for your services? What if (as one agency brought to us) your CP/MIH proposal calls for taking patients away from local care providers? Will they cry foul, or support the idea of more professional patient care, despite a loss of revenues from incoming patients? Now the current CP/MIA models start becoming difficult to copy: Medstar’s relationships with Fort Worth’s hospitals is unique. REMSA received a federal CMS Innovation Challenge grant to build its system; Mesa Fire received funding, too. UPMC and Allegheny Health Network in Pittsburgh have a complex competitive relationship that exists in few other places. San Diego’s federally funded Beacon Community a regional data sharing incentive program. What does your region have at its disposal to incentivize and underwrite the costs of a CP/MIH program?

5. RECORDS

I’m admittedly biased by my Day Job, but a shortage of robust, sophisticated charting software is a flaw in the common conception of CP/MIH processes. It’s also a critical reason that almost every CP/MIH program — no matter how clinically well-designed — has stayed small. Unlike traditional incident-specific ePCRs, CP/MIH requires records that are longitudinal in nature, tracking patients over time. Quality Metrics pertaining to Accountable Care and post-discharge follow up to avoid readmissions demand modern tools for data management, aggregation and real-time, high quality statistics.

It has been interesting to watch the famous CP/MIH programs try to bend legacy technologies to meet their needs, yet none has so far succeeded because traditional electronic patient care record systems and hospital- or physician-oriented electronic health records systems do not collect enough data of the longitudinal sort that CP/MIH demands (here is a hint: NEMSIS v3 compliance should be considered a minimum requirement— don’t bother with older data sets because they won’t serve your interoperability needs when it comes to data aggregation, analysis and collaboration). The question is how quickly agencies will acknowledge CP/MIH’s unique data needs — and the associated need for smart technology to measure success.

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