Free Clinics and Community Paramedicine Community Paramedic Programs

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Free Clinics and Community Paramedicine

Free Clinics and Community Paramedicine

Community Paramedic Programs • Designed to utilize existing well trained medical staff (Paramedics) who

Community Paramedic Programs • Designed to utilize existing well trained medical staff (Paramedics) who are already in the field, to work with the healthcare community, and operate as a safety net for the medically vulnerable, and patients who have become disconnected from their primary care providers. • Programs Goals • Provide better care while working with the whole healthcare community • Assist patients with chronic conditions in better monitoring, more education and better tracking of their disease • Help provide better health – by using community based organizations and resources, reconnecting patients with their primary care providers and help by being a safety net by identifying diseases and infections before it becomes a crisis in someone recently discharged from the hospital • Lower healthcare costs, decreased unnecessary 911 calls/emergency room visits and decrease hospital readmissions

Pilot Program at Froedtert Health CMH & SJH Program started August, 2017 with West

Pilot Program at Froedtert Health CMH & SJH Program started August, 2017 with West Bend Fire Department and Lisbon Fire Department

Project Description Pilot program length is one year Program will provide home visits for

Project Description Pilot program length is one year Program will provide home visits for high risk patient populations within 48 -72 hours post hospital discharge (insured and uninsured) Menomonee Falls, West Bend and Lisbon Fire Departments Target high risk populations Heart failure COPD Diabetes Pneumonia Other patients who were screened as high risk for a readmission based on national criteria Also included in the Post-Acute Care Strategic Plan for implementation in years 1 -3 Funding: Community Memorial Foundation provided a $40, 000 grant and St Joseph’s Hospital foundation provided $17, 000 for the one year pilot

Pilot Goals 1. Is to reduce readmission rates, increase timely access to care for

Pilot Goals 1. Is to reduce readmission rates, increase timely access to care for individuals living with these chronic conditions and navigate patients in need of community resources 2. Aligns with the Froedtert + Medical College of Wisconsin’s Strategic Plan - Population Health Initiative by reaching the underserved population with accessible, affordable health services

Social Determinants of Population Health Robert Wood Johnson Foundation: Helping patients to overcome socioeconomic

Social Determinants of Population Health Robert Wood Johnson Foundation: Helping patients to overcome socioeconomic barriers to better health by spending more on community improvements can reduce downstream medical costs The World Health Organization defines social determinants as "the conditions in which people are born, grow, work, live, and age, plus the wider set of forces and systems shaping the conditions of daily life" Economic and social policies, political systems, and social norms Populational health management programs can address small pieces of the puzzle and change many lives for the better

What are some of our communities' socioeconomic disadvantages?

What are some of our communities' socioeconomic disadvantages?

Population Health Management "treatment of chronic diseases and avoidance of acute disorders for targeted

Population Health Management "treatment of chronic diseases and avoidance of acute disorders for targeted populations. " tools for managing these targeted populations included § outcomes measurement and management § wellness/preventive programs § care management programs § cost management Creating a coordinated, accessible, and comprehensive safety net for patients with complex needs or rising risks is an essential component of successful population health management.

The Importance of Developing Community Partners for Population Health Management Community partners and socioeconomic

The Importance of Developing Community Partners for Population Health Management Community partners and socioeconomic services are vital in primary care Example: Pharmacy-based medication reconciliation and management Improperly used medications, low medication adherence rates and unintentional interactions between multiple medications are key culprits in patient safety and ineffective treatment programs Non-adherence is a $337 billion problem which is exacerbated by patient forgetfulness, confusion and procrastination.

What is Healthcare Focusing on? Ill care or wellness and proactive chronic care? Hospital

What is Healthcare Focusing on? Ill care or wellness and proactive chronic care? Hospital payment models hinge on quality care metrics such as lowering hospital readmission rates In the past, hospitals were not invested in partnerships with the community No longer seeing the fee-for-service reimbursement model. . Now focus is towards value-based care programs Starting with the most at-risk patients, or the 5% of patients who account for nearly 50% of healthcare spending

Community Needs Assessment Healthcare organizations can identify potential partnerships by conducting a community health

Community Needs Assessment Healthcare organizations can identify potential partnerships by conducting a community health needs assessment Per the ACA – Affordable Care Act, assessments must be conducted at least once every three years for non-profit hospitals

Milwaukee Co. Community Health Needs Assessment Focus for Froedtert & Medical College of Wisconsin

Milwaukee Co. Community Health Needs Assessment Focus for Froedtert & Medical College of Wisconsin Implementation Plan for fiscal 2017 -2019: • Chronic Disease Management • Injury & Violence • Access to Care and Navigation • Behavioral Health

CHNA Implementation Strategy Froedtert & the Medical College of Wisconsin Fiscal Year 2017 -2019

CHNA Implementation Strategy Froedtert & the Medical College of Wisconsin Fiscal Year 2017 -2019 CHNA Area of Focus: Chronic Disease CHNA Community Health Need/Rationale: • 29% of Milwaukee County residents reported having high blood pressure • 20% of Milwaukee County residents reported having high blood cholesterol • 14 % of Milwaukee County residents reported having asthma • 11% of Milwaukee County reported having diabetes • 9% of Milwaukee County residents reported having heart disease/condition • 19% of Milwaukee County residents reported having poor health status F&MCW Strategic Plan: • Develop and demonstrate capabilities in population health and risk management • Align health system resources with identified health needs in the Community Health Improvement Plan for Milwaukee County (health literacy, care navigation, community health worker, evidence based models, best practice, community education) Goal: Improve self-management of chronic conditions for underserved populations in low socioeconomic areas in Milwaukee County Objective: Increase self-management for individuals living with chronic conditions and reinforce healthy lifestyles to encourage behavior change Anticipated impact of these actions: • Increase care for individuals suffering from chronic conditions • Increase enrollment in Living Well programs in Milwaukee County • Increase patient engagement in self-management of chronic conditions • Connect individuals to a Froedtert Primary Care Physician (PCP)

Health Care Problems Decreased access to primary care Growing number of uninsured/underinsured § Uninsured

Health Care Problems Decreased access to primary care Growing number of uninsured/underinsured § Uninsured are less likely to seek out preventive care services and defer care Increased ED visits/emergency care High readmission rates Lack of consistently coordinated, high quality care All of these lead to high costs of care

Readmissions Reduction Program The Affordable Care Act of 2010 requires HHS to establish a

Readmissions Reduction Program The Affordable Care Act of 2010 requires HHS to establish a readmission reduction program. Effective October 1, 2012 Designed to provide incentives for hospitals to implement strategies to reduce the number of costly and unnecessary hospital readmissions. Readmission = “an admission to a hospital within 30 days of a discharge from the same or another hospital. ” Great opportunity for free clinics to get involved

Readmissions Reduction Program 20% of Medicare patients are readmitted to a hospital within one

Readmissions Reduction Program 20% of Medicare patients are readmitted to a hospital within one month of discharge CMS considers this number excessive and believes that readmissions are an indicator of quality of care, or lack thereof Provides an incentive for hospitals to decrease readmissions by coordinating transitions of care and increasing the quality of care provided to Medicare beneficiaries

Hosptial Readmission Reduction Program Part of CMS’ goal is to transition to value based

Hosptial Readmission Reduction Program Part of CMS’ goal is to transition to value based purchasing paying for care based on quality and not just quantity These incentives are escalating penalties that decrease a hospital’s payments from all of its Medicare cases Purpose is to improve quality and lower costs for Medicare patients Ensure that hospital’s discharge patients when they are fully prepared and safe for continued care at home or at a lower acuity setting CMS withholds up to 3% of Medicare reimbursements if hospitals have a higher-than-expected number of readmissions within 30 days of discharge

Predicted costs to hospitals

Predicted costs to hospitals

Medicare – Readmission Stats Spends $12 - $15 billion a year on hospital readmissions

Medicare – Readmission Stats Spends $12 - $15 billion a year on hospital readmissions 1 in 5 (20%) of Medicare patients are readmitted into the hospital within 30 days of discharge • 50. 2% of the patients who were re-hospitalized within 30 days after being discharged, there was no follow up with a physician's office between the time of discharge and re-hospitalization 1 in 3 (33%) of Medicare patients are readmitted into the hospital within 90 days of discharge

Readmission Diagnosis 30 -day readmissions for the most common initial diagnoses in rural hospitals

Readmission Diagnosis 30 -day readmissions for the most common initial diagnoses in rural hospitals are: • Pneumonia • Congestive Heart Failure (CHF) • Chronic Obstructive Pulmonary Disease (COPD) • Arrhythmia • Kidney/Urinary Tract Infection (UTI) CMS also looks at: ü AMI ü Total Hip and/or Knee Replacement

Follow-up Care Who will provide the follow-up care for these patients? Doctors? Chronic shortage

Follow-up Care Who will provide the follow-up care for these patients? Doctors? Chronic shortage Patients do not schedule follow-up appointments with PCP Nurses? Chronic shortage Too many other opportunities for career development Home Health? Prepared to service “homebound” and “hospice” patients only What about Free Clinics? ? ?

History of Community Paramedicine • First pilot programs between 1995 – 2000 • Rural

History of Community Paramedicine • First pilot programs between 1995 – 2000 • Rural vs Urban • International Community Paramedicine Programs • US Community Paramedicine Programs • Evolution of Community Paramedicine

Why a hospital would use a CP Hospitals are at risk for up to

Why a hospital would use a CP Hospitals are at risk for up to 4. 5% of their total Medicare payments based on readmissions (3%) and value-based purchasing (VBP) measures (1. 5%). All-cause readmissions are measured for patients discharged with MI, heart failure and pneumonia diagnosis related groups (DRGs). In October 2014, COPD and hip and knee replacements were added to the list of DRGs. The three-year trend for most hospitals has seen increasing readmission penalties. CMS added the metric of Medicare spending per beneficiary (MSPB). This evaluates the average spent by Medicare for the three days preadmission, during the inpatient stay and for 30 days post discharge. If the MSPB is higher than the state or national average, the hospital may face additional financial penalties. For some hospitals, the financial incentive to reduce high readmission penalties may outweigh the actual payments they receive for the admission.

Positive outcomes for CP program…. • Viable option for improving the experience of care,

Positive outcomes for CP program…. • Viable option for improving the experience of care, improving the health of populations and reducing cost of health care • Bridge existing health care gaps, avoid duplication • Reduce the cost of overall health care expenditures • Reduce stress on vulnerable patients and improve care coordination • Reduce hospital readmissions and emergency department utilization and avoid penalties • Decreasing nonessential ambulance transports • Improved patient outcomes • Patients can be discharged earlier with proper continuation of care and no decrease in Medicare compensation • Better patient retention due to higher patient satisfaction as hands-on care follows through home recovery period

The Advisory Board Company May 2015 Community Paramedicine: Case Profiles of Successful Care Models

The Advisory Board Company May 2015 Community Paramedicine: Case Profiles of Successful Care Models Organization Primary Program Service Results Regional Medical Services Authority (REMSA) CP perform post-discharge home visits for high risk patients for up to 30 days post-discharge Within 1 st year – reductions in readmissions, ED visits and ambulance transports yielded an estimated cost savings of $1. 6 M Wake county EMS CP work with a multidisciplinary team to monitor diabetes and CHF patients and support patient selfmanagement 25 patients studied. Total ED visits dropped 34% from 641 -424 between 2012 -2014, with a cost savings of approx. $325 K Allina Health System CP provide post-discharge home visits within 48 hours and sometimes an additional follow-up visit Medicare 30 -day readmission rates for CHF, COPD and DM patients in the program is 5% compared to national average of 18. 4% Abbeville County Emergency Services CP persom home visits to support patient self-management for three months on average 51 patients studied. ED utilization down 64% HTN patients had decrease of 10% in BP readings and DM patients showed an average blood glucose level decrease of 31 points

SJH Community Paramedicine Dashboard West Bend Fire and Rescue Updated 5/2/2018 Metric Category Number

SJH Community Paramedicine Dashboard West Bend Fire and Rescue Updated 5/2/2018 Metric Category Number of patients consulted about Paramedic Program 44 Number of patients enrolled 20 Number of patients declined 24 Acceptance Rate 45% Total number of Paramedic home visits 33 Number of patients completing all recommended visits 16 Average HARRD Score of referred patients 4. 47 Average length to first home visit (days) 4. 3 Number of patients co-managed by CP Care Coordinators Comments/Notes 5 30 Day Readmission Rate (Enrolled Patients) 30% 6 readmissions 30 Day Adjusted Readmission Rate (Enrolled Patients) 20% 4 readmission Number of patients referred to community agencies or programs 7 Home Care Eligible/Assisted Living (Post Discharge) 3 % of self-management goals met 50%

What is a Solution: Community Paramedicine Programs Non-competitive program that is designed to fill

What is a Solution: Community Paramedicine Programs Non-competitive program that is designed to fill in healthcare gaps Provide primary healthcare, improve emergency response capabilities, and strengthen community healthcare collaborations in our community n A Community Paramedic is part public health, part disease management, part prevention, part social worker, part patient educator, and part treatment

What’s next PAAW - Worked on legislation. Future focus may be on standard curriculum

What’s next PAAW - Worked on legislation. Future focus may be on standard curriculum for CP education and Medicare reimbursement. Future funding once initial one year pilot is complete Changing name to “Mobile Integrated Health Care” Continue to collect data- to demonstrate the impact on healthcare processes and outcomes in terms of… Effectiveness (does it produce the desired effect)? Value (does it reduce the cost with comparable or better outcomes)? Safety (does it reduce patients’ risks)? Access (does it connect patients to needed care)?

What about the education? • Program at Hennepin Technical College in MN developed program

What about the education? • Program at Hennepin Technical College in MN developed program in 2008 • Program has been adopted by CP programs in several states • In Wisconsin, no standard or mandatory curriculum as of yet • Individuals must be EMT-Paramedic level with at least 2 years of experience • MN’s curriculum includes 72 hours in-person and 72 online hours of classroom time, along with 196 hour of clinical training • Froedtert’s CMH & SJH CP class curriculum has been modeled after the Minnesota program

Froedtert’s program will focus on: • The CP will understand their role in the

Froedtert’s program will focus on: • The CP will understand their role in the health care system, community, public health and primary care • Expanded patient assessment: well-person check, follow-up on chronic diseases, medication reconciliation, mental health screenings and assessments, home safety evaluation and community resources available • Chronic disease management • Screening, assessment and management of behavioral health and AODA issues • Development of communication skills, motivational interviewing and cultural competence • Patient teaching strategies • Medication familiarity • Clinical experience

Roles and Responsibilities Role of a CP Medical Director • PI/QA oversight • Development

Roles and Responsibilities Role of a CP Medical Director • PI/QA oversight • Development of patient care guidelines/protocols • Paramedic training WHO? WHAT? • Medical informational resource • Collaborator for Nurse Practitioner • Case review/staffing meetings • Advocate for the program to other providers and communities

Role of a CP Nurse Practitioner • Assist in PI/QA • Development of patient

Role of a CP Nurse Practitioner • Assist in PI/QA • Development of patient care • Assist in determining specific care needed to meet goals guidelines/protocols • Scheduler of paramedics to patient home visits • Paramedic training • Be knowledgeable and network with post • Provide clinic mentoring to paramedics hospital options in the community to provide • Role as liaison between patient, caregiver and specific levels of care the patient is in need of PCP and facilitate interdisciplinary • • • Remain available and serve as the single collaboration contact person to paramedics/patients should Oversee paramedics day to day operations post discharge questions or concerns arise related to CP patient visits and development of • Work with entire healthcare team in the patients plan of care and changes to plan when comprehensive care of the patient for needed approximately 4 weeks post discharge Assist in developing short and long term goals for medical care of discharged patients taking into account red flags from discharge summary and Care Transitions Coordinator

Role of Paramedic • Chronic disease management as directed by Medical Director and/or Nurse

Role of Paramedic • Chronic disease management as directed by Medical Director and/or Nurse Practitioner and Care Transition Coordinators • Completion of history & physical (H&P) plus vital signs at each home visit • Timely documentation (including scanning) and communication with the healthcare team • Home safety assessment • Psychosocial assessment • Medication review/education • Chronic disease and self-management education • Wound check/dressing changes • Referrals to Community Resources as directed by healthcare team and assessment findings • Assist with access to clinical services as needed/scheduling appointments • Assess for clinical risk factors and communicate these risks with Medical Director and/or Nurse Practitioner and Care Transition Coordinators

CP Program Flow Process

CP Program Flow Process

Questions? ?

Questions? ?