NORTH MEMORIAL HEALTH CARE Primary Care Community Paramedicine

1. NORTH MEMORIAL HEALTH CAREPrimary Care Community Paramedicine Peter Carlson CMPA Health workforce innovations Sept 12-13, 2016

2. NORTH MEMORIAL HEALTH CARE • 18 clinics (specific to NMHC) • 5 additional clinic systems in ACO • Level 1 trauma services • Multi-state ambulance system • Air care division • BLS services • ALS services • Critical Care ground • 2 hospitals • Maple Grove hospital (Maple Grove) 100 bed • North Memorial hospital (Robbinsdale) Metro area 350 bed

3. The People: Paramedics • Expands Role not Scope of Practice • Scope of practice: • Set by state • Defined by relationship with Medical Director • Medications, wound care, education, advanced care planning, suturing… • What they are not: • Home care replacement • Any service replacement • Long term solution for most customers

4. Co-piloting care I become faint and nauseous during even very minor medical procedures, such as making an appointment by phone.- Dave Barry

5. NMHC CP launch • Specific application to NMHC primary care patients (payor blinded) • Launched October 2012, 1.0 FTE/6 medics • Current state 4.0 FTE 11 medics=ave 95 visits weekly • Integrated into Primary Care network NMHC • Focused Team based care delivery model • EHR access within first 2 months of program (EPIC) • EPIC ambulatory hyperspace build • Geographical hubs created for efficiency • Scheduled via EPIC

6. Daily schedule view

7. CP application by site Percentage of FTE

8. 2014 referral source ✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆

9. The Who-NMHC’s IHP population • IHP/NMHC CP potential • <2016 = apr 4,500 lives • 2016 = over 20,000 lives • One of six systems to enter ground floor (yr 1=2013) • Top three conditions NMHC IHP population • Depression=32.2 % • Hypertension= 23.4% • Persistent asthma= 20.1%

10. Our approach to care delivery by grouping • Care transitions • Improved experience • Readmission focus • Increased primary care access • Chronic disease management • Increased primary care access • In home disease monitoring • Community engagement • Attribution • Capture • Leakage • Increased primary care access

11. Care Transitions gap • Patients not qualifying for in home services (not homebound) • Patients refusing TCU/LTC • Patients not accessing primary care in timely fashion • Approached using Coleman model • Goal of follow up within 48 hours of discharge • Graduate patient within 30 days • Alternative access created (911) • Aligned with North Memorial/Broadway Family Medicine • Or no primary care established • Poor primary care relationship established (out of system) • Bariatric surgery example

12. Meet the Colleen Nadeau: VP Clinical Operations MGH and Executive Sponsor Kris Henderson: Director of Acute Care Sheryl Vugteveen: Manager of Med/Surg Mike Choi: Manager of Clinical Effectiveness Deborah Warhol: Senior Case Manager Julie Borchert: Social Worker Emilie Hedlund: Manager Outpatient Care Coordination Peter Carlson: Community Paramedic Manager Cherry Kiser: Community Paramedic Scheduler John Riley: Community Paramedic Faith Zwirchitz: Director of Nursing and Professional Practice Andria Ruehl: PCF ICC Jo Knight: PCF ICC Mary Ellen Cook: Case Manager RN Andrea Dorado: Clinical Social Worker Julie Heitzman: Case Manager RN Sandy Bremer: Assistant Clinical Manager, ICU Deb Scheid: Patient Flow Coordinator Megan Matack: Pharmacy Manager Sarah R Johnson: Director of Clinical Support Services Robby Moss: Pharmacist Maura Hamilton: Administrative Fellow

13. Charting visual for care transitions Symptoms/Diagnosis Do you have any new symptoms or problems that have occurred since Our last visit? {YES +++ /NO DEFAULT NO:13103} Review symptoms if any or delete this Has anyone called you to notify you of any test results? {YES:16607} Medications Have you been able to obtain and take all of the medications from your After Visit Summary medication list? {YES +++ /NO DEFAULT NO:13103} Review medications for discrepancies/ Develop a plan to resolve discrepancies Use of Med box / pill minder / other (How?) Refills needed? Or barriers to filling medications Do you have any questions about your medications? {YES +++ /NO DEFAULT NO:13103} Follow Up Appointments Do you have a follow up appointment with a physician? {YES +++ /NO DEFAULT NO:13103} Were all your questions answered? {YES +++ /NO DEFAULT NO:13103} If PCP visit still upcoming, has Pt written down questions for PCP follow up

14. Impact on compliance

15. Impact on compliance

16. Impact on compliance

17. 701.1 644 459.8

18. Chronic disease management • Infused in all approaches • Heavy emphasis on education • Specialty track for staff • Team integration • Huddles • Care conferences • Asthma project (partners) • MDH • Primary care • CDC • City of MPLS

19. Pediatric Asthma risk view

21. assessment

22. Documentation example: ped’s asthma • Let's Talk Triggers • Known Triggers include: {ASTHMA PRECIPITATING FACTORS:408} • Obvious allergens in the home: {Asthma allergens:19070} • 10 steps for making your home asthma-friendly (with handout) • Does anyone smoke in the home? Yes, no • Do you have dust-mite covers for mattresses? Yes, no • Have you heard the air-quality report during the weather report? Yes, no • Has someone dusted this month? Yes, no • Are there pets in the house? {YES:11706} • Have you seen cockroaches in the house? Yes, no • Do you need to use pesticide sprays in the house? Yes, no • Have you noticed mold anywhere? Yes, no • Are you able to ventilate the bathrooms and kitchen? Yes, no • Do you have @HIS@ Asthma Action Plan posted in the home? Yes, no

23. Community Engagement: Turning Point • Chem dep center; all male • Staffed 8-12 Mon-Thur • Future telehealth hub/RPM station • Rule 25 for all clients • MA billable • Controlled duration of 90 days=care plan creation • FQHC historical access point • limited to pre treatment physical • High ED utilization

24. Vail place clubhouse • Safe & productive environment for members living with SPMI • CP on site twice a month performing health screenings/primary care discussions • Members can receive primary anywhere in the metro • Vail staff on site at NMHC; 2E • Education sessions on site; CPR/AED & first aid • High engagement from CP staff

25. 2016 referral source ✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆✆

26. Clinic/site 2016

27. Payor breakdown 2015 ✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚

28. Payor breakdown 2016 ✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚✚

29. Struggles/opportunities • Quantifying impact and associated savings (FFS - VBP) • Data access • Dedicated M&R is a challenge • Actionable data mining • Building documentation (extractible data) • EHR interoperability • Program growth; specific roles • Lab processes • Capitol purchasing • Vehicles, POC, tech growth, etc..

30. Is it working? -utilization

31. MN Community Paramedicine and Partners

32. Patient Story #1; Avoiding amputation Before After • Non-healing diabetic wounds • Told amputation necessary • Spending out of pocket for TCU>100 days three consecutive years • Finding transport three times a week for wound care • Amputation off the schedule>10 months • No hospitalization/TCU since CP services started • Wound care offered in home at fraction of cost • Wounds drastically improved

33. Patient Story #2;“Community Access Point” After Before • CPs helped develop plan to respond to seizures that involved linking back in to CP on call (lanyard patient wears includes direct line to program) • CPs attended appointments across multiple sites of care in order to enhance communication and develop shared care plan • Patient is back at work • Seizure disorder resulting in unnecessary 911 calls, trips to the emergency department (over 100 times per year) • Lack of coordination between health systems • Lack of social/caregiver support to help in managing condition

34. questions Peter Carlson, CMPA Community Paramedic Manager Peter.Carlson@Northmemorial.com O: 763-581-5177 C: 763-226-8931 Peter Tanghe, MD Community Paramedic Medical Director Peter.tanghe@NorthMemorial.com O: 763-226-6517 C: 612-298-7420