Mobile Medicine Strategies and Vision for all Providers

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

3. Emergency Medical Services?

4. Unscheduled Medical Services!

5. Current State of Unscheduled Care RN Triage Ambulance Life Line 9-1-1 E/D’s Unscheduled Episodic Care Out of Hospital Care MD/DO Office Visits Noncompliance Answering Services SNF/LTAC Urgent Care

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 MedicineVolume 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 33-Interfacility 11.3% 26-Sick Person 10.3% 17-Falls 5.9% 31-Unc Per 5.2% 04-Assault 4.2% 12-Convulsions 4.1% 25-Psyc 3.8% EMD Code % Decrease 01-Abd Pain 2.8% 30-Traum Inj. 3.7% 10-Chest Pain 7.9% 29-MVA 10.4% 06-Breath. Prob. 10.5%

17. Our New World:

18. OPPORTUNITY!!

19. What we Can Offer… Patient Navigation

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?

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

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

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

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 • Whileawaiting 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

35. And the Grand Total Is…

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 integratedClinical 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 • IntegratedCommunity 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) • Referral to Post Acute Services (House Calls, Home Care) • 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 Escalation De-escalation

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