Mobile-integration, command center operation are key components in early success.
Emergency physicians are often caught in a paradox: trying to maintain the viability of an existing healthcare system while simultaneously knowing that many patients could be equally or better served by care outside the four walls of the traditional emergency department. Several years ago, as emergency physicians at Dallas-based Evolution Health, we decided to take matters into our own hands, and for inspiration turned to an unlikely source — Netflix [1].
We understood that, in the streaming video space, Netflix used their flexibility to adapt to the sea change from physical to digital media while harnessing what they had learned about viewer preferences to develop highly successful proprietary content [2]. Similarly, we believed that emergency and EMS physicians were ideally suited not only to design patient-centered strategies that guide patients to appropriate sites of care but also to provide the day-to-day oversight of such programs. So far, our innovative program is showing promising results, both for target population — Medical Advantage (MA) patients — and our care providers.
The core of our program involved putting together a wide-ranging inter-professional, mobile-integrated health team (MIH), including physicians from appropriate specialties, nurse practitioners, paramedics, physician assistants, nurses, pharmacists, and social workers. But we wanted our team to be different from traditional case management or nurse advice programs, so we made sure to include licensed practitioners capable of rendering care and providing treatment 24/7/365. We believe that a sophisticated system of care is as beneficial to a high-utilizing MA population with chronic disease as it is for patients experiencing acute stroke, STEMI, cardiac arrest, or multi-system trauma. Although the interventions provided for this population were in the realm of tertiary and quaternary prevention, the principles that influence outcomes improvement and team-based care are no different than when caring for a STEMI patient.
Accessing ‘Headquarters’ Is Game-Changer
In addition to the integrated team approach, we were convinced that we needed to establish a headquarters operations, so we created a Medical Command Center (MCC) that patients could access at any time. All participants in the program are made aware of a toll-free phone number as well as the availability of a smart phone app to access the MCC. At the inception of our program, patients were risk stratified, with high-risk members receiving proactive, planned care management visits on an on-going basis. Participants are encouraged to reach out via phone or text with any unplanned care requests and to only use 911 for true emergency situations. Participants also received proactive outreach for any transitions of care, such as discharge from a hospital admission.
Don’t Ignore Patient Choice
Our program was also designed to provide meaningful patient choice 24/7. At any time, eligible members could contact the MCC — a virtual practice of medicine — which included nurses and pharmacists, capable of connecting appropriate resources needed to solve various medical situations. Prescriptions are refilled, and, in some cases, delivered at all hours of the day, while, in other cases, a nurse, paramedic or advanced practice provider completes a facilitated telemedicine virtual visit with the on-call emergency physician. The concept here is to provide a system whereby the right thing to do is also the easy thing to do — provide a single point of contact, triage appropriately, and utilize an inter-professional team with appropriate technological support to deal with medical needs.
Our goal is also to preserve existing PCP relationships while filling gaps in medical care. The MIH team regularly communicates with the PCP during business hours and often serves as an extension of the PCP on nights and weekends.
Here are two examples of how our program works in practice: A post-operative patient with slight redness around the wound contacted the MCC via the toll free number. Our proprietary Needs-Matched, Time Appropriate Resource Allocation (NMTARA) triage system assigned the patient to an urgent but non-emergent response. A nurse practitioner, a member of the integrated health team, was able to respond to home, prescribe antibiotics, and prevent an urgent care or emergency department visit.
Another case: A 78-year-old man with multiple, chronic medical conditions received proactive in-home visits from a nurse, who again, was part of our integrated health care team. The MCC was utilized for unexpected changes in symptoms during hours when the PCP office was closed. The patient transitioned from a curative to a palliative care plan and eventually elected hospice. Nearly all of his care occurred outside of the ED and hospital based settings.
From the inception of the program, we were committed not just to reporting anecdotally about particular cases but to actually measuring improvement. Sophisticated logistical support routed members of the MIH team in an efficient manner while allowing for robust data-gathering. The MIH team recorded all activities in a sophisticated logistics platform, allowing us to match supply and demand as well as task time analysis tied to geographic location. Our population intelligence team is in the process of analyzing the dose-response effect, which will allow us to assign discrete value to each of our interventions, planned or unplanned, virtual or in-person.
So, what did we find out? First, the NMTARA process at the MCC safely and effectively triaged patients, with no one experiencing mortality at 30 days after the call who had not been referred to the hospital. Additionally, only 8% (95% CI 5-11% n=339) of the initial tranche of unplanned care requests were referred to 911 for transportation. [3].
Patient Satisfaction Sky-High
Patients were extraordinarily well satisfied with the program, with more than 95% affirming they would recommend this MIH program to a friend or family member. Notably, for those participating in our program, emergency department utilization decreased by 21% and by 40% for inpatient medical utilization. A cost analysis comparing the actual costs of the entire MA population against expected costs indicated an annualized savings of over $23 million [4].
Overutilization Debate Rages On
ED utilization can be analyzed from different perspectives. Some endorse EMTALA and other guarantees of access as an essential component of the healthcare safety net [5]. Indeed, there is substantial debate about the actual versus perceived magnitude of “overutilization,” as well as the effectiveness of emergency department “diversion” programs [6]. Others believe that the burden of ED utilization can be improved by better health system processes.
There is also a growing body of literature indicating there is a substantial percentage of patients who are not best served by utilizing the EMS and ED, and that notable cost reduction is possible via safely designed alternative systems [7,8,9]. Health plans have utilized increased co-payments to discourage ED visits as well as aligned at-risk providers and case management organizations in efforts to decrease avoidable emergency department utilization [10,11].
Bottom line: Based on our experience, we think an MIH practice extensively designed and led by emergency and EMS physicians can be safe, satisfying to patients, and effective in reducing preventable emergency department utilization. The use of virtual capabilities, such as facilitated telemedicine, can extend the reach of emergency physicians while a robust inter-professional team provides the clinical reassurance that patients will receive appropriate care.
REFERENCES
- Beck E et al. Mobile Integrated Healthcare Practice: A Healthcare Delivery Strategy to Improve Access, Outcomes, and Value. http://media.cygnus.com/files/base/EMS/whitepaper/2015/02/Medtronic_MIH Whitepaper.pdf (accessed April 5, 2017)
- Nocera J. Can NetFlix Survive in the New World it Created? New York Times, June 15, 2016
- Sague JC et al. Needs Matched Time Appropriate Resource Allocation: A Novel Triage and Dispatch Program for Mobile Integrated Healthcare. Prehospital Emerg Care 2017;21(1):117 [abstract]
- Castillo DJ et al. Mobile Integrated Healthcare: Preliminary Experience and Impact Analysis with a Medicare Advantage Population. J of Health Economics and Outcomes Research. 2016;4(2) 172-87.
- Meyer H. Why Patients Still Need EMTALA. Modern Healthcare March 26, 2016.
- Raven MC et al. The Effectiveness of Emergency Department Reduction Programs: A Systemic Review. Annals of Emergency Medicine 2016;68(4):467-483
- Munjal K and Carr B. Realigning Reimbursement Policy and Financial Incentives to Support Patient-Centered Out-of-Hospital Care. JAMA 2013;309(7):667-8
- Alport A et al. Giving EMS Flexibility in Transporting Low Acuity Patients Could Generate Substantial Medicare Savings. Health Affairs 2013;32(12):2142-48.
- Robert Wood Johnson Foundation Quality Field Notes: Emergency Department Overuse Issue Brief. September 2013 (1): 1-3. http://www.rwjf.org/content/dam/farm/reports/issue_briefs/2013/rwjf407773 (accessed April 3, 2017)
- Selby JV, Fireman BH & Swain BE Effect of a Copayment on Use of the Emergency Department in a Health Maintenance Organization. NEJM 1996;334:635-42.
- Sabik LM & Gandhi SO. Copayments and Emergency Department Use Among Adult Medicaid Enrollees. Health Econ. 2016;25(5):529-42.