Session Code A25, B25

1. I Am Worried. Can you Send Someone to See My Mom? Kristofer Smith, MD, VPJonathan Washko, AVPAsantewaa Poku, Clinical Data AnalystElizabeth Quellhorst, Administrative Manager Session Code A25, B25 Presenters have nothing to disclose 1

2. Session Objectives • Identify the key operational strategies necessary to build programs to keep high-risk frail elderly from going to the emergency room • Review lessons learned from a collaboration between an advanced illness management program and a community paramedicine program aimed at reducing admission rates for the high-risk frail elderly in the community • Understand how to ensure the financial viability of clinical collaboratives focused on high-risk patients by taking advantage of health care reform and/or partnering with insurance companies

3. Problem Statement • Seniors with multiple chronic conditions in an advanced state with functional impairment have frequent deteriorations in health status which requires meaningful 24x7 clinical responses. • These high risk, high cost populations have extreme difficulty getting to traditional outpatient services and therefore rely heavily on emergency department and hospital care. • Interrupting this cycle through at home clinical support programs could alleviate suffering, improve quality and decrease cost.

5. Advanced Illness Management – House Calls Program Background • Complex medical management for more than 1,000 patients in Queens, Nassau, and Suffolk counties with multiple chronic conditions and functional impairment • Interdisciplinary care teams, which include physicians, nurse practitioners, social workers, and medical coordinators deliver primary and palliative care in the patient’s home in an effort to: • Understand wishes of the patient and family (advance care planning) • Maintain or improve functional status • Reduce unnecessary utilization or unwanted care • Increase days at home • Allow for death with dignity at home • Care for the whole person: social work and care coordination

6. Advanced Illness Management – House Calls Program Background Nassau, Suffolk and Queens counties * November 2014 Census

7. Advanced Illness Management – House Calls Program Background House Calls Stats* * November 2014 Census

8. Program Background • Established in 1993, providing air and ground BLS, ALS, SCT, CCT and 911 services • 600+ Emergency Medical Technicians and Paramedics • Largest health system based ambulance service in New York Metropolitan area and one of the largest in the United States • Duly accredited by the Commission on Accreditation of Ambulance Services (CAAS) and the National/International Academics of Emergency Dispatch, Accredited Center of Excellence (ACE)

9. Program Background • Over 110 available response units across New York City, Nassau, and Suffolk • More than 135,000 requests for service per year • 24x7x365 Fault tolerant services • Advanced Medical Priority Dispatch System with Dispatch Lift Support • Clinician answers every call utilizing call prioritization & triage system • All ALS system operates under a High Performance EMS operations model • Reliable, clinically appropriate response time

10. Unique, Innovative & Integrated Solution • RN based Clinical Call Center for Care Navigation • Comprehensive Mobile Integrated Healthcare / Community Paramedicine Program • Telemedicine • Centralized Command and Control System • Integrated into EMS System as a Clinical Safety Net • Advanced Analytics • Integrated Quality Assurance / Improvement

11. Clinical Call Center Care Navigation Services • Staffed by specialty trained RNs • Triage of caller with a change in clinical condition • Leverages LowCode integrated telephonic triage system to determine: • Intervention timeliness (immediate or delayed) • Locus of care (face to face or remote) • Clinical documentation Integration • Follow-up care • EMS integration as a safety net

12. Comprehensive Mobile Integrated Healthcare Community Paramedicine Program • MIH Framework • Regulatory Approach • Specialized Training • Specialized Equipment • EMS Operations • Command and Control • High Performance EMS • Marginal vs. Specialized Approach • Clinical • Telemedicine, On Line Medical Control • Formulary, Diagnostics & Treatment Modalities • Death at Home with Dignity

13. Integrating Telemedicine • In 2014, the Verizon Foundation awarded a grant to the North Shore-LIJ Health System • LG G2 wireless devices and lines of service were provided as in-kind support to allow for secure video conferencing (WebEx) between the paramedic, OLMC MD, and patient/family during Community Paramedicine responses • Launched in September 2014, integration of telemedicine allows for more accurate assessment and enhanced “physician extender” ability.

14. Comprehensive Mobile Integrated Healthcare Community Paramedicine Program • Year One Program Results • Operational Metrics • Clinical Metrics • Outcome Metrics • Quality of Care & Patient Safety Metrics • Financial Metrics

15. Operational Metrics Over 60% of the calls occurred during House Calls non-business hours

16. Operational Metrics

17. Clinical Metrics EMD Coding by Category

18. Clinical Metrics EMD Problem/ Nature Transport Avoidance

19. Clinical Metrics EMD Problem/ Nature by Non-Transport Type

20. Clinical Metrics Emergency Medical Dispatch Priority Codes

21. Clinical Metrics Transport Avoidance by EMD Priority Code

22. Clinical Metrics EMD Priority Code by Non-Transport Type

23. Clinical Metrics Administered Treatment by Disposition

24. Clinical Metrics Administered Medication by Disposition

25. Clinical Metrics Follow-Up Planning

26. Outcome Metrics • Admission Rate of Transported Patients

27. Quality of Care & Patient Safety • Avoidable Transports by Presenting Problem

28. Quality of Care & Patient Safety • RCA to avoid future Transports 34 (38.6%) of the 88 CP transports were potentially avoidable

29. Quality of Care & Patient Safety • Physician Survey Responses Did the information provided by the Community Paramedicine evaluation change your medical management? • “Patient had large laceration on foot and it would not have been washed and dressed properly (with a pressure dressing) if the Community Paramedic was not there.” • “The negative neurological exam helped remove possibility of CVA.” • “I was not going to prescribe antibiotics until the evaluation by CP medics revealed abnormality of skin.” • “The patient complained of being short of breath but her normal oxygen saturation provided reassurance that she could be treated at home.” • "I was going to order an x-ray, which would have meant waiting 5+ hours for results. But one leg was actually found to be rotated and shorter than the other, so immediate transport was arranged, avoiding hours of suffering." • Death pronouncement • Reassurance for overwhelmed or distressed caregiver • Public assist

30. Quality of Care & Patient Safety • Physician Survey Responses If the Community Paramedicine evaluation had not been available, would you have advised the patient to go to the ER? • “I definitely was going to send the patient to the ER if Community Paramedicine had not been available.” • “The Community Paramedics’ evaluation gave me more confidence in my plan. I would have recommended that the patient go to ER based on the symptoms described by the patient’s daughter.” • “I originally was going to have the patient stay home, but then found that she was somnolent and hypoxic so I sent her to the hospital for further evaluation.”

31. Quality of Care & Patient Safety • Physician Survey Responses Did video monitoring enhance your evaluation of the patient during the Community Paramedicine response? • “It showed the intensity of the bleeding from the patient’s trach.” • “I was able to see urine and that the Foley was draining despite what the patient stated.” • "Video conferencing allowed me to see my patient pre-Lasix. Since she is my patient, I was able to see that she was more lethargic than usual, despite the paramedic's report that she looked 'fine.' I could see her change from baseline status. She appeared more energetic after the Lasix was given, and she was able to stay at home." • "I was able to see on video conference that the patient was flat in bed, and recommended he be raised HOB to help with cough. I decided not to prescribe Albuterol."

32. Quality of Care & Patient Safety • Patient Satisfaction Survey Results • 78 surveys were mailed to the patient home following a Community Paramedicine (CP) response from 9/17/14 to 11/6/14. • Surveys were not mailed to patients who passed away. • Patients who had multiple CP responses within a 1-3 day window received one survey. • 21 surveys were completed (27% response rate) • 3 (14%) were completed by the patient • 18 (85%) were completed by a family caregiver

33. Quality of Care & Patient Safety • Patient Satisfaction Survey Results

34. Quality of Care & Patient Safety • Patient Satisfaction Survey Results If the Community Paramedicine Program did not exist, what would you have done during your medical emergency? • “Could not have asked for more. Could not be more grateful for be in the House Calls Program.” • “I (the caregiver) was completely satisfied with the doctor and Paramedics in the prompt care my father received, from the time the doctor called me with the results of his blood work, to his care by paramedics, to his trip to the ER.” • “I was very impressed with the program. I am an RN and I truly appreciate the level of professionalism and caring that was shown to my father. Bernard (our paramedic) made my father feel at home immediately. This is a wonderful program.” • “I'm very well pleased with the House Call services for my daughter who is disabled. This is a blessing for me and my daughter. I would have had to take her to the LIJ Emergency as I did in June 2014. I was there with my daughter from 6pm until 2am. It was very hard for her because she is in a wheelchair.” From mail survey: 9/17/14 – 11/6/14

35. Financial Metrics • Costs based on use of existing CEMS infrastructure • Calculated using fixed and variable costs per visit • Approximately $200 per visit @ 1.25 hours which includes: • Vehicle, maintenance and fuel • Salaries, wages and benefits • Medications, supplies and equipment • Dispatch services and specialized software • Integrated call services • Other general expenses

36. Comprehensive Mobile Integrated Healthcare Community Paramedicine Program • Program successes to date • 24x7 on-demand Community Paramedic response effectively and efficiently fills care gaps in the home • Significant decrease in transports to the ED yielding subsequent down stream charge avoidance • High patient satisfaction levels • Zero adverse clinical outcomes • Low cost of services compared to acute care setting • Opportunities exist to lower transport rate even further

37. Comprehensive Mobile Integrated Healthcare Community Paramedicine Program • Program challenges to date • Physician understanding and adoption of EMS capability and scope into workflow • Scope of practice / formulary limitations • State regulatory hurdles & limitations • Payer source (internally funded R&D project) • Data integration amongst disparate systems

38. Marketplace Challenges Government Payment Reductions Payer Mix Shift to Gov’t Payers & Exchanges Readmission Penalties Downgrades/Denials-RAC/MAC Increased Consumerism and Price Transparency Inpatient Volume & Case Mix Declines Increased Provider Competition 38

39. Health System Strategy Strategy Strategy

40. Risk Based Contracts

41. Margin Impact SourceAdvisory Board. The Essentials of Risk Based Contracting

42. Questions?