Arizona Treat & Refer Program: Enhancing Health Continuum

Medical Care & ProtocolARIZONA TREAT AND REFER PROGRAM: A monitored, community specific, and clinically grounded effort to enhance the healthcare continuum for Arizonans

Definition of Treat & Refer • Purpose of Treat & Refer • Requirements of Treat & Refer • Initial Medical Care/Assessment • Documentation • Protocols TREAT & REFER

Treat & Refer Defined “A healthcare event with an individual that has accessed 911 or a similar public emergency dispatch number, but whose illness or injury does not require an ambulance transport to an emergency department based on the clinical information available at the time.” http://www.azdhs.gov/preparedness/emergency-medical-services-trauma-system/#community-paramedicine-treat-refer-ems-agency

Purpose Recognize EMS agencies that… • Demonstrate optimal patient safety and quality of care • Match treatment, transport, and care destination options to the needs of the patient • Opportunity to seek cost recovery for service (AHCCCS) The treat and refer program allows for great flexibility in the variety of diseases and conditions addressed. http://www.azdhs.gov/preparedness/emergency-medical-services-trauma-system/#community-paramedicine-treat-refer-ems-agency

TRIPLE AIM • Improving the patient experience of care (including quality and satisfaction) • Improving the health of populations; and • Reducing the per capita cost of health care.

EMS Costs • Ambulance Transport • ED visit 3. Consumable costs Buckeye Valley Transport $1123.10 /$1123.10 /$14.32 http://www.azdhs.gov/documents/preparedness/emergency-medical-services-trauma-system/ambulance/ground/rates/ground-ambulance-rates-may-2016.pdf

Motivational Interviewing • ASKING PERMISSION • Rationale: • Communicates respect patients • Patients are more likely to discuss when asked, rather than being lectured or told to change • Examples of Asking Permission • “Do you mind if we talk about [insert behavior]?” • “Can we talk a bit about your [insert behavior]?” • “I noticed on your medical history that you have hypertension, do mind if we talk about how • different lifestyles affect hypertension?”(Specific lifestyle concerns such as diet, exercise, and alcohol use can be substituted for the word “lifestyles” in this sentence. http://www.nova.edu/gsc/forms/mi_rationale_techniques.pdf

Motivational Interviewing ELICITING/EVOKING CHANGE TALK • Rationale: “Change talk tends to be associated with successful outcomes.“ • Has patients give voice to the need or reasons for changing • Change talk consists of responses evoked from patients Questions to Elicit/Evoke Change Talk • “What would you like to see different about your current situation?” • “What makes you think you need to change?” • “What will happen if you don’t change?” http://www.nova.edu/gsc/forms/mi_rationale_techniques.pdf

Motivational Interviewing OPENED-ENDED QUESTIONS • Rationale: Open-ended questions allows for a richer, deeper conversation that flows and builds empathy • Too many back-to-back closed-or dead-ended questions can feel like an interrogation • (e. g., “How often do you use cocaine?”“How many years have you had an alcohol problem?” “How many times have you been arrested?”). Examples of Open-Ended Questions • “Tell me what you like about your [insert risky/problem behavior].” • “What makes you think it might be time for a change?” • “What brought you here today?” • “What happens when you behave that way?” http://www.nova.edu/gsc/forms/mi_rationale_techniques.pdf

MOTIVATIONAL INTERVIEWING REFLECTIVE LISTENING • Rationale: Involves listening carefully and then making a reasonable guess about what they are saying • It is like forming a hypothesis, paraphrasing comments back (e.g., “It sounds like you are not ready to quit smoking cigarettes.”). EXAMPLES OF REFLECTIVE LISTENING: • “It sounds like....” • “What I hear you saying...” • “So on the one hand it sounds like .... • “And, yet on the other hand....” • “It seems as if....” • “I get The sense that....” http://www.nova.edu/gsc/forms/mi_rationale_techniques.pdf

Treat & Refer Documentation Required • The interaction must include the following: • Documentation of an appropriate clinical and/or social evaluation; • A treatment/referral plan for accessing social behavioral, and/or healthcare services addressing the patient’s immediate needs; • Evidence of efforts to follow-up with the patient to ascertain adherence with the treatment plan; and Documentation of efforts to assess customer satisfaction with the T&R visit.

Treat & Refer Documentation • Gather patient name, birth date, and contact details • Detailed assessment to include vitals, ECG, and physical • Assessment of patient’s surroundings, housing, and needs • Detailed documentation of everything in EPCR system • Custom Elements & Values: NEW Custom Elements & Values REQUIRED for Treat & Refer calls • Added Values: • Incident/Patient Disposition (eDisposition.12): • it4212.123 ‘Treat & Refer’ • (or ‘CP Patient Treated, Released per Protocol - Referred to Other Health Care Facility’) • This is the Disposition that should be used for all calls deemed “Treat & Refer”

Treatment/Referral Plan • A treatment/referral plan for accessing social behavioral, and/or healthcare services addressing the patient’s immediate needs; • Appropriate treatment that matches the patients needs • Referral to appropriate service with transportation plan • Detailed documentation of patient response to treatment and referral destination of choice in EPCR system • Type of Destination (eDisposition.21): • it4221.103 ‘Behavioral In-Patient’ • it4221.102 ‘Behavioral Out-Patient’, • it4221.101 ‘Dialysis Center’ • it4221.100 ‘Hospice’ • These values were added as choices in addition to the standard NEMSIS values already available. If you already have these custom values in your system, please make sure your vendor maps them to these codes when sending data to AZ-PIERS

Patient Follow-Up Requirements • Evidence of efforts to follow-up with the patient to ascertain adherence with the treatment plan; and • Follow up may be attempted by phone, email, or mail • Health Information Exchange (AZ-HEC) portal or alerts • Referral to community paramedic program for home visit • Community Health Follow up Outcome (itOutcome.023): • itOutcome.023.100 ‘Follow Up Successful’ • itOutcome.023.101 ‘No method to contact patient’, • itOutcome.023.102 ‘No Follow up attempted’ • itOutcome.023.103 ‘Follow up attempted, not able to contact’ • 7701001 Not Applicable • 7701003 Not Recorded • All Treat & Refer calls must have this variable filled in and submitted to AZ-PIERS. Initial submission need not contain a completed question, and could be sent on re-upload of the ePCR, but review for completeness after data submission deadline will require completeness.

Patient Follow-Up • Documentation of efforts to assess customer satisfaction with the T&R visit. • Customer satisfaction survey (text, phone, email, mail) • EPCR outcome documentation

Treat and Refer off-line protocols are created tohelp assist patients in receiving an appropriate level of care. • These off-line protocols do not pertain to patients currently in a health care facility with a higher level of care. I.e. Urgent Care, Clinic, Physician Office, etc. • Transportation decisions for these patients require communication with the Provider and if the Paramedic’s conclusion differs from the on scene Provider, the Paramedic must call for a high risk refusal to the base hospital. Treat & Refer Protocols

Treat & Refer Protocols

TREAT & REFER PROTOCOLS

What is congestive heart failure (CHF)? • Heart failure describes the inability or failure of the heart to adequately meet the needs of organs and tissues for oxygen and nutrients. This decrease in cardiac output, the amount of blood that the heart pumps, is not adequate to circulate the blood returning to the heart from the body and lungs, causing fluid (mainly water) to leak from capillary blood vessels. This leads to the symptoms that may include shortness of breath, weakness, nausea/vomiting, and swelling. A thorough assessment of the lungs/breath sounds is required. A person in an exacerbation of CHF may require urgent or emergent medical treatment and therefore is beyond the scope of treat & refer. Treat & Refer Protocols http://www.medicinenet.com/congestive_heart_failure_chf_overview/page2.htm

TREAT & REFER PROTOCOLS

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Arizona Treat & Refer Program: Enhancing Health Continuum