This document summarizes mobile medicine strategies and a vision for providing unscheduled medical services for all providers. It discusses the current state of unscheduled care including overuse of emergency medical services for non-emergent issues. It then outlines a new world with opportunities for partnerships and new payment models emphasizing quality outcomes. Specific strategies proposed include nurse triage of 911 calls, community health programs, reducing heart failure readmissions, avoiding observation admissions, and reducing hospice revocations. Financial analyses are provided estimating cost savings from avoiding transports, ED visits, admissions and other services. Patient and provider satisfaction opportunities are also discussed.

2. Mobile Medicine Strategies
and Vision for all Providers
Douglas R. Hooten, MBA
Executive Director
MedStar Mobile Healthcare
Fort Worth, TX
Jonathan Washko
AVP – CEMS Operations
North Shore – LIJ Health System
Manhasset, NY

3. Emergenc
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Medical
Services?

4. Unscheduled
Medical
Services!

5. Current State of
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Unscheduled Care
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6. Current State of
Unscheduled Care
• 9-1-1 safety net access for non-emergent
healthcare
– 36.6% of 9-1-1 requests are non-emergent
• Past 12 months Priority 3 calls
(37,508/102,601)
• Problems with uncontrolled and
unmanaged access
– Emergency department as the source of
primary care

7. Current State of
Unscheduled Care
• Incentivized to use the highest cost
transport to highest cost care setting
– And it’s the easiest…
– Same with hospital admissions

8. Current State of
Unscheduled Care
• Reasons people use emergency services
– To see if they needed to
– It’s what we’ve taught them to do
– Because their doctors tell them to
– It’s the only option
• Many patients using ED have payer
source…

9. Frequent Users of Emergency Departments:
The Myths, the Data, and the Policy Implications
Results
Frequent users comprise 4.5% to 8% of all ED patients but account for
21% to 28% of all visits. Most frequent ED users are white and insured;
public insurance is overrepresented. Age is bimodal, with peaks in the
group aged 25 to 44 years and older than 65 years. On average, these
patients have higher acuity complaints and are at greater risk for
hospitalization than occasional ED users. However, the opposite may be
true of the highest-frequency ED users. Frequent users are also heavy
users of other parts of the health care system. Only a minority of
frequent ED users remain in this group long term.
Why is this important?
Annals of Emergency Medicine
Volume 56, Issue 1 , Pages 42-48, July 2010

10. Our New World:

11. Our New World:
• ACA tipped the 1st domino
• New partnerships
– ACOs
• Aligned incentives/risk sharing
• Bundled payments/episode of care
– Pay for performance
– Satisfaction-based reimbursement
• EMS impacts 25% of health expenditures

12. Our New World:
• Changing healthcare market
– Current U.S. healthcare system built on
quantity, not quality
– Most likely payment bundled in some form of
Accountable Care Organization
• Greater emphasis will be placed on
OUTCOMES
– Quality measures
• Likely that your current major payers will
not be in the future

13. Our New World:
• 5.6 million health care jobs will be created
by 2020 - University of Georgetown
• By 2015, 33% of hospital payments will be
based on patient satisfaction (PPACA)
• 50% of health expenditures occur in last 2
years of life
• Today, 40 million people > 65
– 70 million in next 20 years
• 2010 20,000 docs short
– By 2025 = 140,000 to 214,000 short

14. Our New World:
• Catalyst for Payment Reform (Yes, CPR)
– Coalition of employers (Wal-Mart, Intel, GE for
example)
– Pushing for value oriented payments to
providers (20% by 2020)
– Aetna – Now paying the same for c-section or
vaginal birth – eliminate incentive for c-
section (H&HN)
– $1,250 for screening colonoscopies –
regardless of in or out of the hospital (H&HN)

15. Our New World:
• AHRQ = 1% of patients accounting for 20%
of healthcare expenditures (H&HN)
– There are 4.6 million Medicare beneficiaries
with CHF (AHRQ)
– One CHF admission cost CMS $17,500 (AHRQ)
– 30-day readmission rate for CHF = 24.7%
(AHRQ)
– 52% of CHF patients readmitted within 30 days
did not see their doc between discharge and
readmit (NEJM)
• MedPAC = $12 billion CMS expenditures for
PPR

16. Our New World:
10-year % change of MedStar’s overall call volume
EMD Code % Increase EMD Code % Decrease
33-Interfacility 11.3% 01-Abd Pain 2.8%
26-Sick Person 10.3% 30-Traum Inj. 3.7%
17-Falls 5.9% 10-Chest Pain 7.9%
31-Unc Per 5.2% 29-MVA 10.4%
04-Assault 4.2% 06-Breath. Prob. 10.5%
12-Convulsions 4.1%
25-Psyc 3.8%

17. Our New World:

18. OPPORTUNITY!!

19. What we Can Offer…

20. Nurse Triage
• Take low-acuity 9-1-1 calls out of the
system
– 37.1% of referred patients to alternate
dispositions
– Help unclog EDs
• Improve throughput
• Improve patient:revenue ratio
• Improved Press Ganey scores?
• Physician/Hospital call services
• Telemedicine/patient monitoring
– Rx compliance/reminders
• Connect with payer databases?

21. Expenditure Savings Analysis
Based on Medicare Rates
July 1 - Sept 30, 2012 9-1-1 Nurse Triage
Base Avoided Savings
Ambulance Charge $ 1,668 125 $ 208,500
Ambulance Payment $ 421 125 $ 52,625
ED Charges (ACSC) $ 904 125 $ 113,000
ED Payment (ACSC) $ 774 125 $ 96,750
ED Bed Hours (ACSC) 6 125 750
Observation Admission Charge $ 5,400
Observation Admission Payment $ 2,160
Admission Charge $ 23,838
Admission Payment $ 14,899
Hospice Revocation Charge $ 23,838
Hospice Revocation Payment $ 19,071
Charge Avoidance $ 321,500
Payment Avoidance $ 149,375
Per Patient Enrolled 9-1-1 Nurse Triage
Charge Avoidance $ 2,572
Payment Avoidance $ 1,195

22. Community Health
Program
• “EMS Loyalty Program”
– Proactive home visits
– Educated on health care and alternate
resources
– Enrolled in available programs = PCMH
– Flagged in computer-aided dispatch system
• Co-response on 9-1-1 calls
• Ambulance and CHP medic
• Non-Compliant enrollees moved to
“system abuser” status
– No home visits
– Transport may be denied by Medical Director
in consult with on-scene CHP medic

23. Community Health
Program
• 31 patients with 12 month data pre and
post enrollment as of Sept. 30, 2012…
– During enrollment
• 52.2% reduction in 9-1-1 use to the
emergency department
– Post Graduation
• 76.3% reduction in 9-1-1 use to the
emergency department

24. Expenditure Savings Analysis
Based on Medicare Rates
July 1 - Sept 30, 2012 CHP (1)
Base Avoided Savings
Ambulance Charge $ 1,668 104 $ 173,472
Ambulance Payment $ 421 104 $ 43,784
ED Charges (ACSC) $ 904 104 $ 94,016
ED Payment (ACSC) $ 774 104 $ 80,496
ED Bed Hours (ACSC) 6 104 624
Charge Avoidance $ 267,488
Payment Avoidance $ 124,280
Per Patient Enrolled CHP (1)
Charge Avoidance $ 2,572
Payment Avoidance $ 1,195

25. CHF Readmission
Reduction
• At-Risk for readmission
– Referred by cardiac case managers
– Routine home visits
• In-home education!
• Overall assessment, vital signs, weights,
‘environment’ check, baseline 12L ECG, diet
compliance, med compliance
• Feedback to primary care physician (PCP)
– Non-emergency access number for episodic
care
– Decompensating?
• Refer to PCP early
• In-home diuresis

28. CHF Readmission
Reduction
• For patients with 12 month data pre and
post enrollment (23 patients)
– 44 admissions prevented (46.8%)
• 94 admissions pre-enrollment and 50 post-
enrollment
– Ambulance transports to ED avoided as of
Sept. 30, 2012:
• 44.1% reduction during enrollment
• 55.9% reduction post graduation

29. Expenditure Savings Analysis
Based on Medicare Rates
July 1 - Sept 30, 2012 CHF (1)
Base Avoided Savings
Ambulance Charge $ 1,668 32 $ 53,376
Ambulance Payment $ 421 32 $ 13,472
ED Charges (ACSC) $ 904 32 $ 28,928
ED Payment (ACSC) $ 774 32 $ 24,768
ED Bed Hours (ACSC) 6 32 192
Admission Charge $ 23,838 32 $ 762,829
Admission Payment $ 14,899 32 $ 476,768
Charge Avoidance $ 845,133
Payment Avoidance $ 515,008
Per Patient Enrolled CHF
Charge Avoidance $ 26,410
Payment Avoidance $ 16,094

30. Observation Admission
Avoidance
• Partnership with ACO
– ED Physician (Case Manager) identifies eligible
patient
• Refer to MedStar Community Health Program
• Non-emergency contact number for episodic
care given to patient
– In-home care coordination with referring physician
– Assure attendance at PCP follow-up next business
day
– Initiated September 1, 2012
• 8 patients enrolled
• No patient’s revisited prior to PCP follow-up

31. Expenditure Savings Analysis
Based on Medicare Rates
July 1 - Sept 30, 2012 Obs Avoidance
Base Avoided Savings
Observation Admission Charge $ 5,400 8 $ 43,200
Observation Admission
Payment $ 2,160 8 $ 17,280
Charge Avoidance $ 43,200
Payment Avoidance $ 17,280
Per Patient Enrolled Obs Avoidance
Charge Avoidance $ 5,400
Payment Avoidance $ 2,160

32. Hospice Revocation
Avoidance
• Enroll patients “at risk” for revocation
• Visit at home
– Counsel – instruct – 10 digit access
– “Register” patient in CAD
• Co-respond with a “9-1-1” call
• Help family through process
– While awaiting hospice RN

33. Hospice Revocation
Avoidance
• 18 patients enrolled
• 13 patients successful in the end
• 1 family called 9-1-1
– Intervened prior to transport
– Still transported based on nature of illness
• Direct admit – no ED visit
• 6 currently enrolled

34. Expenditure Savings Analysis
Based on Medicare Rates
July 1 - Sept 30, 2012 Hospice Rev Avoidance
Base Avoided Savings
Ambulance Charge $ 1,668 9 $ 15,012
Ambulance Payment $ 421 9 $ 3,789
ED Charges (ACSC) $ 904 9 $ 8,136
ED Payment (ACSC) $ 774 9 $ 6,966
ED Bed Hours (ACSC) 6 9 54
Hospice Revocation Charge $ 23,838 9 $ 214,546
Hospice Revocation Payment $ 19,071 9 $ 171,636
Charge Avoidance $ 237,694
Payment Avoidance $ 182,391
Hospice Rev
Per Patient Enrolled Avoidance
Charge Avoidance $ 26,410
Payment Avoidance $ 20,266

35. And the Grand Total Is…
Expenditure Savings Analysis
Based on Medicare Rates
July 1 - Sept 30, 2012
Patient Navigation Savings:
Charge Avoidance $ 1,393,544
Payment Avoidance $ 838,959

36. Patient/Provider
Satisfaction

37. Patient Assessment of
Health Status

38. Future Opportunities…
• Delivery System Reform Incentive
Payments
– 1115a waiver - Regional Health Partnership
• Hospital-based
– New process for Upper Payment Limit
payments to Critical Access Hospitals
– Paid for programs that:
• Improve Care
• Improve Health
• Reduce Cost
– How can EMS change the landscape of
healthcare?
$4 million $11 million $26 million

40. Director of Primary
Care and Clinical
Partnerships

41. Statements to be Banned
• “We’ve always done it that way!”
• “There’s no money to be made in that…”
• “It’s what the community expects…”
• “We’re an ambulance service…”
• “We don’t have the money.”
• “There are regulatory ‘issues’…”

42. The Clinical Call Center
At
The Center for Emergency Medical Services
North Shore-LIJ Health System

43. Background
• Patient interviews reveal need for 24x7
response to a change in clinical condition
• Provider surveys reveal inadequate coverage
to meet patient demands and lack of access to
patient information
• Because of the lack of 24x7 intelligent clinical
services, patients are directed to or rely upon
ED based care
• Complex patients are admitted at high rates
regardless of whether there is potential
clinical benefit

44. Emerging Innovative Solutions
• Centralized, system integrated Clinical Call Center
that provides 24x7 access to algorithmically
driven: Clinical Decision Support, Locus of Care
Navigation & Off-hours Call services
 E.g. Transitions of care, D/C follow up, CHF readmission
abatement management, locus of care navigation,
Clinically intelligent MD call services
• Integrated Community Paramedic programs
 911/Emergency de-escalation to appropriate locus of
care, on demand - on site clinical decision support &
treatment, in-home risk assessment & abatement, PERS
integration

45. What Others Are Experiencing
Sisters of Mercy – St. Louis, Missouri
• Hospital Based Program
 Centralized 24x7x365 clinical call center
 CHF & COPD patient populations
 Inbound & outbound call management
 Locus of care navigation model
• Results
 10% decline in readmission rates and
remain stable despite the increasing clinical
complexity of admitted patients
 Customer Satisfaction = 91% | Physician
Satisfaction = 89%

46. What Others Are Experiencing
Cleveland Clinic – Cleveland, OH
• 24x7 Integrated centralized appointment call center
 Same day service program, custom algorithms by service
line, best in class high performance operational model
• 24x7 Community service based RN advice line
 Community benefit based program, risk adverse
escalation to 911/EMS model, locus of care navigation
• D/C follow up program (lower level clinicians)
 Customer service focused, new transitional care concept
• Results
 Significant increased outpatient capture ROI
 Customer Satisfaction >90% | Error Rate <0.5%

47. What Others Are Experiencing
Medstar - Fort Worth, TX
• EMS Based Program
 Multiple health systems and insurance companies
contracting with single EMS provider to eliminate
readmissions for:
• CHF | Asthma | Hospice | System Abuse Management
• Safety Net | Transitional Care
• 12 Month Pilot Results Highlights…
 40% Emergency calls referred to alternate dispositions (non-
ED)
 46.8% reduction in CHF readmissions
 $14,831 cost reduction per patient to CMS
 9% increase in outpatient visits

48. Our Solution – The Clinical Call Center at CEMS
Synergistic Combination of Best Practices
• Consolidated – Service Integrated 24x7 Clinical Call Center
 Paramedic & RN algorithmically based clinical decision support for:
• Inbound & outbound caller programs (transitions of care, readmission
abatement, locus of care navigation, 911/EMS escalation and de-
escalation capabilities)
• Clinically intelligent MD call services for off-hours
• Integration of CEMS as Community Paramedic Provider
 24x7 On-demand, on-site clinical decision support services for
appropriate locus of care navigation, in-home off-hours treatment
& transport to alternative destinations
 In home risk assessment, abatement and provider communication
 Chronic disease management & readmission abatement
collaborations
 PERS program Integration

49. Our Solution – The Clinical Call Center
Locus of Care Navigation Model
 Empowers patient navigation “GPS” to the…
 Right - Type of Care
 Right - Clinically Appropriate & Customer Acceptable Timeframe
 Right - Place
 Right - Quality
 Right - Cost
• A “Locus” could include (based on patient’s clinical situation):
 Self treatment with call center based follow up
 Referral to same day or next day appointment with MD (Scheduling Call
Center Integration)
De-escalation
 Referral to Post Acute Services (House Calls, Home Care)
Escalation
 Referral to urgent care or other doc-in-the-box (Walgreens, Wal-
Mart)
 Referral to Community Paramedic with treatment or transport
options to all Locus treatment destinations
 Referral to Emergency Department

50. What About the Impact on FFS Service Lines?
• Service Volumes & Down Stream Revenues
 Service volumes will shift away from traditional FFS
pathways
 (e.g. ED -> In-patient)
 FFS revenues negatively impacted if FFS reimbursement
 Cost avoidance if Capitated / Managed Care reimbursement
 Services volumes will shift into Primary, Post Acute &
Pre-hospital pathways
 FFS revenues positively impacted if FFS reimbursement available
 Cost avoidance if Capitated / Managed Care reimbursement
• Girder framework that “bridges the FFS chasm”
 Allows the bridge to be built one capitated contract
“plank” at a time
 Continue to direct FFS populations to traditional
approach
 Point Managed Care populations to new approach

51. Populations Served for - 1 R.N., 24x7 Coverage
Hypothetical Model
Case
Clinical Call Center Number of Calls per Day Population Served
Mix
Inbound Clinical Triage
and Locus of Care
35% 18 2455 / Year
Transition of Care
(4 Calls / 30 days)
37% 21 160 / Month
Daily Diuretic
Management 29% 35 35 / Month
(30 Calls / 30 Days)