The Mobile Integrated Healthcare Challenge
by Alan Perry
I recently embarked on a journey to explore what has come to be known as Mobile Integrated Healthcare Practice (MIHP). The concept was outlined in the NIH book EMS agenda for the future but not named or structurally defined at that time. The concept has been under development by a number of hospital and pre-hospital systems for several years with some success. With the passage of the Affordable Care Act and the formation of Accountable Care Organizations (ACO’s), additional monetary incentives have been created, and the concept has gained significant momentum and support. I have, for several years, realized that the future of EMS rested in the improvement of the relationship and integration between healthcare providers and systems across the continuum of patient care. An article I wrote in early 2012, EMS Manifesto describes my vision then as it does now. I am very excited to see the concept taking shape, of course this type of concept will have application in very different ways depending on patient population, the type of EMS and hospital systems that are involved, and the input and participation of local and state governments.
The goals of Mobile Integrated Healthcare
The general goals of Mobile Integrated Healthcare are: to reduce healthcare costs, decrease inappropriate system use, prevent hospital re admissions and improve hospice results through appropriate use of healthcare resources including the whole spectrum of healthcare. The “triple aim” as described by the Institute for Healthcare Improvement (IHI) , improving the healthcare experience, improving health and reducing costs are met as well as the defined goals of Accountable Care Organizations (ACO’s), delivering high quality care and reducing costs. Patients should receive the care needed in the most appropriate way, improving health and the quality of the experience. For providers it should produce greater job satisfaction, greater flexibility in providing care and more options for professional development. For EMS services this should mean a reduction in non-emergency calls, frequent users, permit cost recovery for alternative service delivery such as treat and release, or transport to alternative treatment centers. For hospitals it should reduce inappropriate ER visits, reduce re admissions and free up resources for true emergencies. With cooperation, the entire system should work more smoothly, costs will be reduced and quality of care improved.
Who will play a part in Mobile Integrated Healthcare?
Patients, healthcare providers, EMS & fire chiefs, physicians, administrators, politicians, EMS agencies, regional EMS councils, hospitals, ACO’s, public health, social services, mental health, state EMS offices, insurers, Medicaid, Medicare and the public will all have to contribute, collaborate and cooperate to develop a Mobile Integrated Healthcare Practice (MIHP) that accomplishes the goals described as well as addressing local needs. I suspect that the diversity of the stakeholders will play a large role in the ability of any locality to reach an agreement and develop a meaningful program. ACO’s that fall under one organizational umbrella will have a much easier time developing and implementing a MIHP provided they have all, or a majority of the required components to make it work. In the TEMS region of Virginia there are several independent hospital systems, volunteer, public and fire-based EMS systems, various private ambulance and home health organizations, local and state government entities that provide components of the system we will need to build.
Some potential obstacles
Politics, power, money, ignorance and apathy frequently prevent progress. The primary stakeholders in MIHP will be the EMS systems, hospitals and insurers. Our region has several EMS systems that are very diverse in their basic structure. We also have multiple hospital systems in the region that have differing organizational goals and strategies. Success will require funding through insurers both public and private who have been slow to adopt and pay for alternative treatment. Our biggest challenge will be reaching agreements that will allow us all to work together cooperatively. If we all start thinking about this now we can get through the first two stages of grief, denial and bargaining, and move on to acceptance, eventually reaching a point where we are anticipating the benefits of our success.
Success stories in Mobile Integrated Healthcare Practice
MedStar-Fort Worth, Texas http://www.medstar911.org/community-health-program Public utility model EMS system providing service to a large metropolitan and suburban area.
North Memorial Hospital, Robinsdale, Minnesota http://www.northmemorial.com/community-paramedic-program#.Ueqo_o1wre4 Hospital based ambulance service
Western Eagle County, Colorado http://wecadems.com/cp.html Public utility model EMS only agency providing rural EMS services
I was unable to identify a fire based EMS provider involved with MIHP when I wrote this
How should our local system proceed?
I will not represent myself as knowing enough about every aspect of this subject to try to write an implementation guide for my city, Tidewater or the State of Virginia. To my knowledge there is not a universally applicable model or implementation guide that will work for every system. We must find our own way together, with every stakeholders input, to find the application that works best for our patient population, healthcare facilities, emergency services and healthcare providers. There are some general first steps and considerations needed to begin putting it together. The majority of functional MIHP programs are hospital based or public utility model EMS systems, neither of those models is universally applicable to the current system in the Tidewater EMS council. It seems that a regional approach is the most practical for a number of reasons; even though we have multiple hospitals and EMS agencies, the practices and protocols required can be effectively utilized within the region as a whole, if all parties can agree on the basic concepts. The operational medical directors (OMD’s) already communicate at this level and can help facilitate discussion with the hospital administrations, the participation with existing ACO’s should be considered or the formation of one. The regional council can facilitate the involvement of VAOEMS and possible development of our program as a state-wide model. The support of EMS and fire chiefs is needed to promote participation and the eventual training of providers. The providers who will be on the front line should have a strong presence in any discussion. Once this core group of committed parties is in place and comes forth with a working proposal the other concerned parties; Insurers, Medicare/Medicaid, Public health, Social services, mental health, etc. can be consulted for refinements and by-in to the program.
The tidewater region has unique challenges to the implementation of MIHP but most practitioners are aware of the variations and they are accommodated on a daily basis. The need for a program such as MIHP has been acknowledged for several years with no action being taken. Changes in healthcare law, specifically the affordable care act, provide sources for funding such programs with collaboration across healthcare disciplines. A regional EMS council such as TEMS is uniquely suited to bring together the stakeholders and develop a plan for this region that will allow us to address long standing problems and recognized inefficiencies in the delivery of health care both in and out of the hospital. Our sacred oath as healthcare providers is to do no harm, by that we must infer that we do what is best for the patient, in this case correcting the known problems in our delivery model. By doing so, we will improve the quality of the experience, the health of the patient, and the sustainability of our system.
Institute for Healthcare Improvement website http://www.ihi.org/Pages/default.aspx
Accountable Care Organizations, Centers for Medicare and Medicaid Services website http://innovation.cms.gov/initiatives/ACO/
NAEMT website, Community Paramedicine http://www.naemt.org/about_ems/CommunityParamedicine.aspx
Community Paramedic website http://www.communityparamedic.org/