COVID-19 is challenging healthcare systems across the country, with many communities already seeing an increased demand for EMS, emergency department and critical care services. A systems approach to developing crisis standards of care, defined as a “substantial change in unusual healthcare operations and the level of care it is possible to deliver,” is critical for EMS systems preparing for any public health emergency. In this webinar, hosted by NHTSA’s Office of EMS, you’ll learn: – Why crisis standards of care planning is so critical in the prehospital setting – How one state is preparing for a surge in demand for EMS services – Implications for local EMS leaders who may have to implement crisis standards of care in their communities The three panelists will share their expertise on crisis standards of care from public health, legal, medical and operational perspectives: – James G. Hodge, Jr., JD, LLM, is the director of the Center for Public Health Law and Policy at Arizona State University and a professor at the Sandra Day O’Connor College of Law. A leading expert in public health emergency law, he has helped draft several model public health regulations and advised public health officials across the country. – Aaron Burnett, MD, FACEP, is the EMS medical director for the State of Minnesota and an associate professor of emergency medicine at the University of Minnesota. As a member of Minnesota’s State EMS Regulatory Board, he helped the State put in place recent changes to regulations to help communities and EMS organizations respond to COVID-19. – John L. Hick, MD, serves as deputy chief EMS medical director and medical director for emergency preparedness at Hennepin County Medical Center in Minneapolis. An expert on disaster response, he also advises the U.S. Department of Health and Human Services Assistant Secretary for Preparedness and Response as the lead editor for the Technical Resources, Assistance Center, and Information Exchange. The NHTSA Office of EMS will moderate.
About EMS Focus
EMS Focus provides a venue to discuss crucial initiatives, issues and challenges for EMS stakeholders and leaders nationwide. Be sure to visit ems.gov for information about upcoming webinars and to view past recordings.
Join Dr. Ed Racht, Chief Medical Officer, and Randy Strozyk, Executive Vice President Operations for Global Medical Response and Hanan Cohen, Director of MIH-CP and Jim O’Connor, Vice President for Empress Ambulance Service for a compelling webinar straight from the front lines of the COVID-19 pandemic. The panelists will discuss workforce safety and wellness, treatment and transport changes, lessons learned, and the challenge of providing services in some of the hardest-hit areas of our country.
Ed Racht, M.D. Chief Medical Officer, Global Medical Response
Dr. Ed Racht has been involved in Emergency Medical Services and healthcare systems for more than 30 years. He currently serves as Chair of the Texas EMS, Trauma and Acute Care Foundation, an organization that provides advocacy, strategic planning and healthcare system credentialing in the State of Texas.
Dr. Racht has been Chief Medical Officer for American Medical Response (AMR) since 2010. Prior to this role, he served as the Chief Medical Officer and Vice President of Medical Affairs for Piedmont Newnan Hospital in metro Atlanta. Dr. Racht was the first full-time Medical Director for the Austin/Travis County Emergency Medical Services System, where he spent 13 years. The System was nationally recognized in the Institute of Medicine’s Report on the state of emergency care for its collaborative approach to challenging healthcare integration issues.
Dr. Racht received his undergraduate and medical degree from Emory University in Atlanta and completed his residency at the Medical College of Virginia.
Dr. Racht is the recipient of numerous awards including being named EMS Medical Director of the Year for the State of Texas, the American Heart Association’s Paul Ledbetter MD Physician Volunteer of the Year Award and was named a “Hero of Emergency Medicine” in 2008 by the American College of Emergency Physicians. In 2015, he was the first recipient of the Joseph P. Ornato Excellence in Clinical Leadership Award, and in 2011 received the Slovis Award for Educational Excellence by the U.S. Metropolitan Municipalities Medical Director Consortium. He is also the third Inductee in the Texas EMS, Trauma and Acute Care Foundation Hall of Fame.
Randy Strozyk Executive Vice President of Operations, Global Medical Response
Randy Strozyk has been a leader in emergency medical services for more than 40 years and is an integral part of the GMR/AMR executive team. As SVP of Executive Operations, he is engaged in our overall operations and specific areas such as internal and external integration and our event Medical Services. He has extensive experience in EMS operations and management. He is a long time member of the American Ambulance Association and is presently the AAA Secretary. Strozyk began his career as a paramedic. He holds a Bachelor of Science degree in microbiology from Washington State University and an MBA from California State University.
Jim O’Connor Vice President, Empress Ambulance Service
Jim O’Connor is the Vice President of Empress Ambulance of Yonkers, New York. Empress is part of the PatientCare EMS Solutions organization. He has been involved in the Emergency Medical Service (EMS) for over four decades and was one of the first paramedics in Westchester County, New York.
Empress is the contracted provider of 911 emergency medical services (EMS) for the cities of New Rochelle, Yonkers, White Plains and Mount Vernon. Empress has a staff of over 500 employees and has been operating in Westchester County since 1985. They also provide all levels of inter-facility ambulance transportation services for some of the most prestigious hospital systems in the New York metropolitan area.
Jim has been active with many EMS organizations and has held Board positions locally, regionally and on a national level. He was a founding member and first Chairman of the Westchester County Regional EMS Council and has served on the Hudson Valley Regional EMS Council, the New York State EMS Council and the American Ambulance Association in Washington, D.C.
Hanan Cohen Director of MIH-CP, Empress Ambulance Service
Hanan Cohen is the Director of Corporate Development and Community Paramedicine at Empress EMS a large progressive regional ambulance service and EMS provider. He is a Paramedic and Community Paramedic with 30 years’ experience in EMS and Hospital Administration. His focus has been on new program design and application. He has been the administrator for multiple hospital clinical departments as well as a Level 1 Trauma Center. His EMS career has included, rural, suburban and urban EMS systems.
He has spent the past several years researching, developing and implementing MIH-CP programs at Empress EMS providing collaborative community health programs with multiple hospitals in Westchester County and New York City. He is a Certified Ambulance Compliance Officer and member of the American Ambulance Association Payment Reform Committee.
The National Business Emergency Operations Center (NBEOC) is FEMA’s virtual clearing house for two-way information sharing between public and private sector stakeholders to help people before, during, and after disasters.
The NBEOC was created to enhance communication and collaboration with private industry partners and ensure their integration into disaster operations at a strategic and tactical level. During response operations, NBEOC members are linked into FEMA’s National Response Coordination Center (NRCC), activated Regional Response Coordination Centers (RRCCs), and the broader network of emergency management operations to include our state and federal partners.
The NBEOC offers a platform to share information on impacts, operating status, and recovery challenges, as well as access to information to support business continuity decisions, and integration into planning, training, and exercises. Participation in the NBEOC is voluntary and open to all organizations with significant and multistate geographical footprints in the private sector, which include large businesses, chambers of commerce, trade associations, universities, think-tanks, and non-profits.
The New York Times summarizednew CDC data showing that nearly 40 percent of patients sick enough to be hospitalized were aged 20 to 54. But the risk of dying was significantly higher in older people.
American adults of all ages — not just those in their 70s, 80s and 90s — are being seriously sickened by the coronavirus, according to a report on nearly 2,500 of the first recorded cases in the United States.
Based on work by Lispsitch and colleagues, we used a middle-level estimate of COVID-19 infection rate of 40 percent. We assumed lengths of stay based on published studies. We calculated the capacity gap between current bed occupancy and anticipated COVID-19 demand assuming six, 12 and 18 month transmission curves. In our primary model, we made the very aggressive assumption that 50 percent of currently occupied beds could be freed up to care for COVID-19 patients.
Nationally, based on 40 percent prevalence of COVID-19 over the course of the pandemic, we estimate that 98,876,254 individuals will be infected, 20,598,725 individuals will likely require hospitalization and 4,430,245 individuals will need ICU-level care. We found that inpatient and ICU bed capacity to handle expected patient volumes varied significantly by Hospital Referral Region (See exhibits 1 and 2).
If the infection curve is not flattened and the pandemic is concentrated in a 6-month period, that would leave a capacity gap of 1,373,248 inpatient beds (274 percent potentially available capacity) and 295,350 ICU beds (508 percent potentially available capacity). If the curve of transmission is flattened to 12 months, then the needed inpatient and ICU beds would be reduced to 137 percent and 254 percent of current capacity. However, if hospitals can indeed reduce current bed occupancy by 50 percent and flatten the transmission curve to 18 months, then the capacity needed would be reduced to 89 percent of inpatient and 166 percent of ICU beds. If the infection rate is only 20 percent (low end of current estimates), we would largely be able to meet the needs for inpatient care if we flatten the curve to 12 months.
I write to you today during what we all recognize as an extraordinary time for EMS. As we collectively serve on the very front lines of the COVID-19 epidemic, we know that the most challenging times are still ahead. However, I am heartened by the collective resolve of the members of the American Ambulance Association to provide 24/7 on-demand mobile healthcare, no matter the circumstances.
As President of the Association, I am sharing below a brief summary of the AAA’s activities to support its members in the face of this devastating disease.
COVID-19 Content & Approach
Coronavirus Working Group—AAA Region III Director Tom Tornstrom, Executive Director of Gundersen Tri-State Ambulance, has been appointed to lead the AAA Coronavirus Working Group. The team includes AAA’s lobbyists, leadership, staff, and members from across the nation. We meet frequently and collaborate constantly to track challenges and find solutions to EMS issues relating to COVID-19 response. Sample topics include:
First responder safety and wellness
Reimbursement for alternative destinations, treatment in place, and mobile testing
Paperwork reduction / waivers
Advocating for policies in federal legislation that support mobile healthcare and redacting those that can negatively impact the industry
Members will receive updates via our Digest e-newsletter as we continue to make progress on these and other issues.
Representation in Stakeholder Groups—From CMS to Congress to local mayors, AAA has representatives and members working with legislators, regulators, and officials at every level of government to advocate for EMS. Simultaneously, AAA leaders are working to showcase mobile healthcare’s unique strengths and capabilities for addressing the viral threat.
Member Newsletter—The frequency of our member Digest e-newsletter has been increased from weekly to near-daily to ensure that we are curating and communicating the most relevant and important information.
COVID-19 Archive—All AAA posts related to the virus can be found on our website. A COVID-19 resource link has been added to the top navigation of the AAA website for easy access by providers.
Association Events & Operations
Stars of Life—Out of an abundance of caution, the Stars of Life event in Washington has been canceled. All blocked rooms will be canceled and refunded by the hotel, and all attendee registration fees will be refunded by diflucan. Staff is working on the development of meaningful ways to celebrate 2020 Stars outside of the context of an in-person event.
Ambulance Cost Education (Cost Collection)—A plan is in place to move ACE Gold cost collection education from face-to-face to an interactive online learning environment. Subscribers can expect additional updates in early April.
Headquarters—Association staff is all working remotely whenever possible. Staff is adhering to strict health, hygiene, and social distancing. All order fulfillment, mail processing, and other functions have been moved offsite.
Please don’t hesitate to reach out to staff at email@example.com or 202-802-9020 if we can be of any assistance. Thank you again for your service to your communities during this very difficult time.
President, American Ambulance Association
At the regular meeting of the Interstate Commission for EMS Personnel Practice (EMS Compact Commission) on Tuesday, March 10, 2020, the EMS Compact Commission approved use of the EMS Compact process effective Monday, March 16, 2020 in response to personnel needs associated with COVID-19. This decision enables EMS personnel licensed in Compact member states (home states) to cross state borders using a privilege to practice and work in other Compact states (remote state) without getting an EMS license in the remote state.
Updated PPE recommendations for the care of patients with known or suspected COVID-19:
Based on local and regional situational analysis of PPE supplies, facemasks are an acceptable alternative when the supply chain of respirators cannot meet the demand. During this time, available respirators should be prioritized for procedures that are likely to generate respiratory aerosols, which would pose the highest exposure risk to HCP.
Facemasks protect the wearer from splashes and sprays.
Respirators, which filter inspired air, offer respiratory protection.
When the supply chain is restored, facilities with a respiratory protection program should return to use of respirators for patients with known or suspected COVID-19. Facilities that do not currently have a respiratory protection program, but care for patients infected with pathogens for which a respirator is recommended, should implement a respiratory protection program.
Eye protection, gown, and gloves continue to be recommended.
If there are shortages of gowns, they should be prioritized for aerosol-generating procedures, care activities where splashes and sprays are anticipated, and high-contact patient care activities that provide opportunities for transfer of pathogens to the hands and clothing of HCP.
Included are considerations for designating entire units within the facility, with dedicated HCP, to care for known or suspected COVID-19 patients and options for extended use of respirators, facemasks, and eye protection on such units. Updated recommendations regarding need for an airborne infection isolation room (AIIR).
Patients with known or suspected COVID-19 should be cared for in a single-person room with the door closed. Airborne Infection Isolation Rooms (AIIRs) (See definition of AIIR in appendix) should be reserved for patients undergoing aerosol-generating procedures (See Aerosol-Generating Procedures Section)
Updated information in the background is based on currently available information about COVID-19 and the current situation in the United States, which includes reports of cases of community transmission, infections identified in healthcare personnel (HCP), and shortages of facemasks, N95 filtering facepiece respirators (FFRs) (commonly known as N95 respirators), and gowns.
Increased emphasis on early identification and implementation of source control (i.e., putting a face mask on patients presenting with symptoms of respiratory infection).
The New England Journal of Medicine has rapidly published a peer-reviewed paper on the Snohomish County WA ‘Patient 1’. This was the first reported case of COVID 19 in the US. This seminal document, which given the magnitude of the case and its initial findings is released in full here
The work by Michelle L. Holshue, M.P.H., Chas DeBolt, M.P.H., Scott Lindquist, M.D., Kathy H. Lofy, et al for the Washington State 2019-nCoV Case Investigation Team was turned round in just over 5 weeks and below is an ‘Executive summary’ ( as extracted from the paper) but the full paper and range of results should be read in full.
On January 19, 2020, a 35-year-old man presented to an urgent care clinic in Snohomish County, Washington, with a 4-day history of cough and subjective fever. On checking into the clinic, the patient put on a mask in the waiting room. After waiting approximately 20 minutes, he was taken into an examination room and underwent evaluation by a provider. He disclosed that he had returned to Washington State on January 15 after traveling to visit family in Wuhan, China. The patient stated that he had seen a health alert from the U.S. Centers for Disease Control and Prevention (CDC) about the novel coronavirus outbreak in China and, because of his symptoms and recent travel, decided to see a health care provider.
On admission, the patient reported persistent dry cough and a 2-day history of nausea and vomiting; he reported that he had no shortness of breath or chest pain. Vital signs were within normal ranges. On physical examination, the patient was found to have dry mucous membranes. The remainder of the examination was generally unremarkable. After admission, the patient received supportive care, including 2 liters of normal saline and ondansetron for nausea.
Both upper respiratory specimens obtained on illness day 7 remained positive for 2019-nCoV, including persistent high levels in a nasopharyngeal swab specimen (Ct values, 23 to 24).
Stool obtained on illness day 7 was also positive for 2019-nCoV (Ct values, 36 to 38).
Nasopharyngeal and oropharyngeal specimens obtained on illness days 11 and 12 showed a trend toward decreasing levels of virus
Day 8: Condition Improves
On hospital day 8 (illness day 12), the patient’s clinical condition improved. Supplemental oxygen was discontinued, and his oxygen saturation values improved to 94 to 96% while he was breathing ambient air. The previous bilateral lower-lobe rales were no longer present. His appetite improved, and he was asymptomatic aside from intermittent dry cough and rhinorrhea. As of January 30, 2020, the patient remains hospitalized. He is afebrile, and all symptoms have resolved with the exception of his cough, which is decreasing in severity.
This case report highlights the importance of clinicians eliciting a recent history of travel or exposure to sick contacts in any patient presenting for medical care with acute illness symptoms, in order to ensure appropriate identification and prompt isolation of patients who may be at risk for 2019-nCoV infection and to help reduce further transmission. Finally, this report highlights the need to determine the full spectrum and natural history of clinical disease, pathogenesis, and duration of viral shedding associated with 2019-nCoV infection to inform clinical management and public health decision making.
There is little doubt that this paper is about to become a globally sited document as we continue to deal with COVID 19. As far as EMS and our first response to it goes, the paper reinforces the key actions currently being taken
Sample COVID-19 Policies for Mobile Healthcare Providers
Thank you to the following organizations for sharing their policies as examples.
Global Medical Response maintains a COVID-19 page to provide information to all members of the GMR community—clinicians and non-clinicians.
Updates from GMR Chief Medical Officer, Dr. Ed Racht
The intention of the COVID-19 Process/Policy Template is to provide agencies, medical directors, or others who want to utilize it, an outline/template on which to build an agency-specific policy/protocol to address COVID-19. This includes suggestions for development and/or oversight committees, outside partners and stakeholders, as well as preparation and process for EMS workers who provide best practice care for patients as well as providing for the protection of pre-hospital providers and medical director(s). Its application is totally up to the user.
This document is meant to be a living document that can be revised as circumstances or guidance changes. It can also be a discussion piece for those who choose to develop a different type of policy but may want to use some of the components of the document as a starting point.
This guidance is written to offer American Ambulance Association members the situational background and a list of resources and websites with which to draw guidance and further updates on the latest situation with COVID-19, colloquially referred to as “Coronavirus.” Key information for this update has been drawn from the NHTSA EMS Focus series webinar What EMS, 911 and Other Public Safety Personnel Need to Know About COVID-19, which took place on February 24, 2020. The on-demand recording is available below.
The COVID-19 Coronavirus Disease was first reported in Wuhan China in December 2019. CDC identifies that it was caused by the virus SARS – CoV-2. Early on, many patients were reported to have a link to a large seafood and live animal market. Later, patients did not have exposure to animal markets which indicates person-to-person transmission. Travel-related exportation of cases into the US was first reported January 21, 2020. For reference the first North American EMS experience of COVID-19 patient transport, including key lessons learned, can be found in the EMS 1 article Transporting Patient 1.
Spread and Identification
Global investigations are now ongoing to better understand the spread. Based on what is known about other coronaviruses, it is presumed to spread primarily through person-to-person contact and may occur when respiratory droplets are produced when an infected person costs or sneezes. Spread could also occur when touching a surface or object that has the virus on it and when touching the mouth, nose, or eyes. Again, research is still ongoing, and advice and guidance will inevitably follow.
For the cases that have been identified so far, those patients with COVID19 have reportedly had mild to severe respiratory illness with symptoms including fever and shortness of breath. Symptoms have typically appeared 2 to 14 days after exposure. Both the WHO and CDC advise that patients that have been to China and develop the symptoms should call their doctors.
COVID-19 Prevention and Treatment
To date, 30 international locations, in addition to the US, have reported confirmed cases of COVID-19 infection. Inside the US, two instances of person-to-person spread of the virus have been detected. In both cases, these occurred after close and prolonged contact with a traveler who had recently returned from Wuhan, China.
The CDC activated its Emergency Operations Center (EOC) on January 21 and is coordinating closely with state and local partners to assist with identifying cases early; conducting case investigations; and learning about the virology, transmission, and clinical spectrum for this disease. The CDC is continuing to develop and refine guidance for multiple audiences, including the first responder and public safety communities.
As at the date of publication there is still no specific antiviral treatment licensed for COVID-19, although the WHO and its affiliates are working to develop this.
The following are recommended preventative measures for COVID-19 and many other respiratory illnesses:
Wash your hands often with soap and water for at least 20 seconds.
Use an alcohol-based hand sanitizer with at least 60% if soap and water are not readily available.
Avoid touching your eyes, nose, and mouth with unwashed hands.
Avoid contact with people who are sick.
Stay home when you are sick.
Cover your cough or sneeze with a tissue, then throw it away.
Clean and disinfect frequently touched objects and surfaces.
The guidance identifies EMS as vital in responding to and providing emergency treatment for the ill. The nature of our mobile healthcare service delivery presents unique challenges in the working environment. It also identifies that coordination between PSAPs and EMS is critical.
Key points are summarized below:
Recommendations for 911 PSAP Locations
The link between PSAPs and EMS is essential. With the advent of COVID19 there is a need to modify caller queries to question callers and determine the possibility that the call concerns a person who may have signs or symptoms and risk factors for COVID19.
The International Academy of Emergency Dispatch (IAED) recommends that agencies using its Medical Priority Dispatch System (MPDS) should use its Emerging Infectious Disease Surveillance (EIDS) Tool within the Sick Person and Breathing Problem protocols. For those that are not MPDS users, IAED is offering its EIDS surveillance Tool for Coronavirus, SRI, MERS and Ebola-free of charge under a limited use agreement.
Recommended Personal Protective Equipment (PPE)
The CDC recommends that while involved in the direct care of patients the following PPE should be worn:
Single pair of disposable examination gloves
Disposable isolation gown
Respiratory protection (N95 or higher)
Eye Protection (goggles or disposable face shield)
EMS Transport of a Patient Under Investigation (PUI) or Patient with Confirmed COVID19
Notify receiving healthcare facility so appropriate precautions can be put in place
Discourage family and contacts from riding in transport vehicle
Isolate the vehicle driver from the patient compartment by closing the windows between compartments and ensuring that the vehicle ventilation system is set to the non-recirculated mode
Document patient care
Cleaning EMS Transport Vehicles After Transporting PUI or Patient
Don PPE for cleaning with disposable gown and gloves, facemask, and goggles or face shield if splashes are anticipated
Routine cleaning and infection procedures should follow organizational standard operating procedures
Use protect use products with EPA-approved emergent viral pathogens claims
Once transport is complete, organizations should notify state or local public health authorities for follow up. Additionally agencies should (if not done already) develop policies for assessing exposure risk and management of EMS personnel, report any potential exposure to the chain of command, and watch for fever or respiratory symptoms amongst staff.
While not specific to COVID-19, agencies should:
Assess current practices and policies for infection control
Job- or task-specific education and training
PPE training and supply
Decontamination processes and supplies
Local EMS Considerations
911 and EMD call taking activities
Appropriate approach to potential patients
Educational resources for EMS personnel
Interaction with local public health/healthcare systems/emergency management
Interaction with local fire and law enforcement
Considerations for local jails
World Health Organization (WHO)—For a wider perspective, the WHO provides both a daily live online briefing and written situation report.
The COVID19 situation constantly evolving. Agencies should defer to their local EMS authorities, Public Health departments, and the CDC for definitive guidance. Going forward, the AAA will continue to both monitor the disease and alert issues to the membership.
By Eric van Doesburg, MP Cloud Technologies This sponsored post is not endorsed by the American Ambulance Association. It reflects the views of the author.
Did you know that one of the most common practices in our industry could put your company at financial risk? Transporting patients not qualified for ambulance transportation is a hot topic these days as it has heavily contributed to the rise of Medicare fraud cases. This issue has grown even more relevant recently with a case in Florida, where not only was the EMS company found liable of fraud, but it was the first time several hospitals were held culpable as well.¹
While the burden of proof falls on the government to satisfy the statutes in the Federal False Claims Act, the fact is investigators are becoming more aggressive in fighting these types of billing schemes.
“The fact is investigators are becoming more aggressive in fighting these types of billing schemes.”
Yes, there are some bad actors in our industry like any other, but more times than not employees simply may be unaware of the qualifications needed when dispatching non-emergency transport.
Thankfully, a company can protect its financial future simply by having the necessary protocols in place.
For ambulance transportation to be covered by Medicare for a patient, the answer must be “yes” to at least one of the three criteria listed below:
“Is the patient bed-confined?”
“Does the patient require assistance to get out of bed?”
“Is the patient unable to safely sit in a wheelchair for the duration of the transport?”
Dispatchers must ask these specific questions in order to understand the scope of the situation – a step that should be incorporated into your business’ procedures immediately. If it is determined that the patient meets none of the above criteria, then an alternative transportation source must be sought and you have a couple of options.
Non-EMS Transport Options
Uber™ and Lyft™ have not only affected how we approach transportation as a society but have left a prominent mark on the EMS industry as well. According to a University of Kansas study, the use of ambulance transportation dropped 7% in cities that adopted ride-sharing platforms.² Consider the formation of a partnership with these companies as a low-cost alternative for non-emergency transport that could reduce your liability and develop a sustainable revenue stream for the future without a lot of overhead. Of course, just because the patient may not meet the Medicare criteria for non-emergency transport doesn’t mean that they are in a condition to be able to ride in a car by themselves. This is where the situation can become a little tricky. Is Uber™ or Lyft™ really the bestoption for an elderly person who may have some mild form of dementia and is being released after having a medical episode?
Add Non-Emergency Fleet
As an alternative, another option would be setting up your own fleet of non-emergency transport to cater to your clients’ specific needs. These non-emergency shuttles can ensure a consistent and legal discharge process to keep you in compliance and managing dispatch on your terms. It also allows for a higher level of patient care during the transport than a ride-sharing service can provide.
With the stakes for fraudulent claims getting higher, you’ll want to make sure you have a protocol in place that protects your business, employees, and clients from any hint of impropriety. However, with the right planning and core systems/partnerships, it will make the process for handling non-emergency transport that much easier… and possibly lead to new revenue channels not available in the past. That’s something we can all get excited about.
HHS OIG Issues Advisory Opinion Permitting Community Paramedicine Program Designed to Limit Hospital Readmissions
On March 6, 2019, the HHS Office of the Inspector General (OIG) posted OIG Advisory Opinion 19-03. The opinion related to free, in-home follow-up care offered by a hospital to eligible patients for the purpose of reducing hospital admissions or readmissions.
The Requestor was a nonprofit medical center that provides a range of inpatient and outpatient hospital services. The Requestor and an affiliated health care clinic are both part of an integrated health system that operates in three states. The Requestor had previously developed a program to provide free, in-home follow-up care to certain patients with congestive heart failure (CHF) that it has certified to be at higher risk of admission or readmission to a hospital. The Requestor was proposing to expand the program to also include certain patients with chronic obstructive pulmonary disease (COPD). According to the Requestor, the purpose of both its existing program and its proposed expansion was to increase patient compliance with discharge plans, improve patient health, and reduce hospital inpatient admissions and readmissions.
Under the existing program, clinical nurses screen patients to determine if they meet certain eligibility criteria. These include the requirement that the patient have CHF and either: (1) be currently admitted as an inpatient at Requestor’s hospital or (2) be a patient of Requestor’s outpatient cardiology department, and who had been admitted as an inpatient at Requestor’s hospital within the previously 30 days. The clinical nurses would identify those patients at higher risk of hospital admission based on a widely used risk assessment tool. The clinical nurses would also determine whether the patient had arranged to receive follow-up care with Requestor’s outpatient CHF center. Patients that do not intend to seek follow-up care with the CHF center, or who have indicated that they intend to seek follow-up care with another health care provider, would not be informed of the current program. Eligible patients would be informed of the current program, and offered the opportunity to participate. The eligibility criteria for the expanded program for COPD patients would operate in a similar manner.
Eligible patients that elect to participate in the current program or the expanded program would receive in-home follow up care for a thirty (30) day period following enrollment. This follow up care would consist of two visits every week from a community paramedic employed by the Requestor. As part of this in-home care, the community paramedic would provide some or all of the following services:
A review of the patient’s medications;
An assessment of the patient’s need for follow-up appointments;
The monitoring of the patient’s compliance with their discharge plan of care and/or disease management;
A home safety inspection; and/or
A physical assessment, which could include checking the patient’s pulse and blood pressure, listening to the patient’s lungs and heart, checking the patient’s cardiac function using an electrocardiogram, checking wounds, drawing blood and running blood tests, and/or administering medications.
The community paramedic would use a clinical protocol to deliver interventions and to assess whether a referral for follow-up care is necessary. To the extent the patient requires care that falls outside the community paramedic’s scope of practice, the community paramedic would direct the patient to follow up with his or her physician. For urgent, but non-life threatening conditions, the community paramedic would initiate contact with the patient’s physician.
The Requestor certified that the community paramedics would be employed by the Requestor on either full-time or part-time basis, and that all costs associated with the community paramedic would be borne by the Requestor or its affiliates. The Requestor further certified that no one involved in the operation of the program would be compensated based on the number of patient’s that enroll in the programs. While one of the states in which the Requestor operates does reimburse for community paramedicine services, Requestor certified that it does not bill Medicaid for services provided under the program.
The question posed to the OIG was whether any aspect of the program violated either the federal anti-kickback statute or the prohibition against the offering of unlawful inducements to beneficiaries.
In analyzing the program, the OIG first determined that the services being offered under the program offer significant benefit to enrolled patients. The OIG specifically cited the fact that one state’s Medicaid program reimbursed for similar services as evidence of this value proposition. For this reason, the OIG concluded that the services constitute “remuneration” to patients. The OIG further concluded that this remuneration could potentially influence a patient’s decision on whether to select Requestor or its affiliates for the provision of federally reimbursable items and services. Therefore, the OIG concluded that the program implicated both the anti-kickback statute and the beneficiary inducement prohibition.
The OIG then analyzed whether the program would qualify for an exception under the so-called “Promoting Access to Care Exception.” This exception applies to remuneration that improves a beneficiary’s ability to access items and services covered by federal health care programs and which otherwise pose a low risk of harm. The OIG determined that while some aspects of the program would likely fall within this exception, other aspects would not. Specifically, the OIG cited the home safety assessment as not materially improving a beneficiary’s access to care.
Having concluded that there was no specific exception that would permit the arrangement, the OIG then analyzed the arrangement under its discretionary authority, ultimately concluding that the program posed little risk of fraud or abuse. In reaching this conclusion, the OIG cited several factors:
The OIG felt that the potential benefits of the program outweighed the potential risks of an improper inducement to beneficiaries. The OIG cited the fact that beneficiaries must have already selected Requestor or its associated clinic as their provider of services before learning about the program. As the OIG indicated “the risk that the remuneration will induce patients to choose Requestor or the Clinic for CHF- or COPD-related services is negligible because patients already have made this selection.” The OIG also noted that the community paramedic will inform beneficiaries of their right to choose a different provider prior to referring the beneficiary to the Requestor or its clinic for services outside the scope of the program.
The OIG noted that, to the extent the program works as intended, it would be unlikely to lead to increased costs to federal health care programs. As noted above, Requestor had certified that it would not bill federal health care programs for the services of the community paramedic.
The program was designed in a way as to minimize the potential for interference with clinical decision-making.
The Requestor certified that it would not advertise or market the program to the public, thereby minimizing the chances of beneficiaries learning about the program prior to selecting Requestor for their CHF- or COPD-related care.
The OIG noted that the program appeared to be reasonably tailored to accomplish the goal of reducing future hospital admissions. For example, the OIG cited the fact that the Requestor limited inclusion in the program to patients deemed to be at a higher-than-normal risk of hospital admission or readmission, and that it made these determinations using a widely used risk assessment tool. The OIG noted that these patients would likely benefit from the continuity of care offered under the program. In addition, the OIG noted that the community paramedics would be in a position to keep the patients’ physicians appraised of their health by documenting all of their activities.
Potential Impact on Mobile Integrated Health and/or Community Paramedicine Programs
OIG advisory opinions are issued directly to the requestor of the opinion. The OIG makes a point of noting that these opinions cannot be relied upon by any other entity or individual. Legal technicalities aside, the OIG’s opinion is extremely helpful to the industry, as it lays out the factors the OIG would consider in analyzing similar arrangements. Thus, the opinion is extremely valuable to ambulance providers and suppliers that current operate, or are considering the operation of, similar mobile integrated health and/or community paramedicine programs.
Empathy is about trying to understand, as best we can, someone else’s situation or experience. The question is, do we in EMS truly understand the word? Are we empathetical to ourselves and to the people we work with?
While some say that empathy comes from proper upbringing, today’s decline in civility means we see less and less of it displayed. A major contributing factor is the “tough” exterior we favor in each other: how often have you heard comments like “come on, just suck it up buttercup,” “you need to be tougher than that to be a medic,” or “we’re EMS, we eat our young.” Why are we like this, and why can’t we reinforce the empathy that naturally resides in all of us?
Empathy is a big part of our jobs, and we need to teach it to our students, our employees and each other. People need to feel that it’s OK to be empathetic and that it’s a natural part of the whole EMS picture.
One of the best techniques to foster empathy is active listening — not only to our patients but also to staff and co-workers. When you actively listen, you H.E.A.R. …
Halt: Stop whatever else you are doing, end your internal dialogue on other thoughts, and free your mind to give the speaker your attention.
Engage: Focus on the speaker. We suggest a physical component, such as turning your head slightly so that your right ear is toward the speaker as a reminder to be engaged solely in listening.
Anticipate: By looking forward to what the speaker has to say, you are acknowledging that you will likely learn something new and interesting, which will enhance your motivation to listen.
Replay: Think about what the speaker is saying. Analyze and paraphrase it in your mind or in discussion with the speaker and other classmates. Replaying and dialoguing the information you have heard will aid in understanding what the speaker is attempting to convey.”1
So always look at the other’s point of view and try to understand what he or she is facing. It just might change your attitude and make you a better provider.
Your EMS Reputation Depends on Three Cs—Credentials, Courtesy, Community
In EMS, your reputation is critical. Your character moves with you from provider to provider and from squad to squad; EMS is a small world where people know about you before you even step foot in the door.
People react to you based on judgments from not only real life, but also your digital life. With Facebook, Snapchat, Instagram and other social media networks so prevalent today, your social media profile serves as the basis of your reputation both professionally and privately.
Unfortunately, social media blunders abound among EMS providers, affecting their reputations and their future hiring ability. You can find hundreds of examples doing a quick online search; here are just two.
Three South Carolina responders fired for making statements like “idiots shutting down I-126. Better not be there when I get off work …” (Kaplan, 2016, para. 3)
A Brockton, Mass. dispatcher who said of a pregnant overdose patient, “She needs to be left to rot …” (Shephard, 2018, para. 5)
A better way to think of your reputation is the “Three Cs” — Credentials, Courtesy and Community.
Credentials may also be called Continuing Education, as it’s vital to keep learning throughout your career. Many of the best paramedics and EMTs are lifelong learners; in contrast there are others who take the NREMT exam and then never do more to see EMS from a wider perspective.
Courtesy means being courteous not only to your patients and coworkers but also to yourself. When others feel comfortable around you, it is easier to develop those close ties and professional relationships that boost your reputation.
Community refers to both where you live and the broader EMS community at large. The public and our industry look to us to build and improve a framework where we can all grow and thrive. Professional norms promote collaboration, knowledge sharing and a collective responsibility for improving ourselves and our treatments.
So, let’s follow the “Three Cs” to improve EMS as a community. Let’s have better, more convenient education that goes beyond the “same old, same old.” Let’s push our medical directors for improved, evidence-based treatments. Let’s pull each other up and be leaders at the healthcare table. Lastly, let’s stand out in the community with reputations that reflect the consummate professionals we truly are.
Scott F. McConnellis Vice President of EMS Education for OnCourse Learning and one of the Founders of Distance CME, which recently launched a new learning platform. Since its inception in 2010, more than 10,000 learners worldwide have relied on Distance CME to recertify their credentials. Scott is a true believer in sharing not only his perspectives and experiences but also those of other providers in educational settings