Tag: Community Paramedicine / Mobile Integrated Health (MIH)

EMS.gov | Telemedicine Framework for EMS and 911

New Resource: Telemedicine Framework for EMS and 911

Communities and organizations considering EMS and 911 telemedicine programs will find design concepts and considerations, suggestions for identifying community partners, checklists and other helpful material

Although it was the COVID-19 pandemic that accelerated the adoption of telemedicine by EMS and 911 systems across the country, its use is likely only going to continue to grow. Telemedicine in EMS and 911 has many potential benefits and will be a key tool to help communities achieve the vision of a people-centered EMS system described by EMS Agenda 2050.

To help EMS and 911 organizations who are in the early stages of planning or implementing telemedicine programs, the Federal Interagency Committee on EMS brought together experts to create the Telemedicine Framework for EMS and 911 Organizations. The intent of this resource is to provide an understanding of opportunities to leverage telemedicine to deliver high-quality and cost-efficient care at the right place and the right time. The framework offers suggestions for how to engage stakeholders and policymakers and how to assess financial considerations when implementing a program. It also cites and links to a number of other resources, making it a great starting place to learn about telemedicine in EMS and 911 and find more information.

Read the Telemedicine Framework now and continue your organization’s journey to providing more effective, people-centered care.

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ET3 | Model Medical Triage Line Notice of Funding Opportunity

From CMS on March 12, 2021

Emergency Triage, Treat and Transport (ET3) Model Medical Triage Line – Notice of Funding Opportunity (NOFO) Available

 

Today, the Centers for Medicare & Medicaid (CMS) is releasing a Notice of Funding Opportunity (NOFO) for the Emergency Triage, Treat and Transport (ET3) Model. Through the NOFO, CMS will fund state and local governments, their designees, or other entities that operate or have authority over a Public Safety Answering Point (PSAP) to establish or expand Medical Triage Lines aimed at reducing inappropriate use of emergency ambulance services and increasing efficiency in Emergency Medical Services (EMS) systems.

The NOFO complements the ambulance payment component of the ET3 Model, which began implementation on January 1, 2021 and for which the final list of Participants was posted today. Applicants to the NOFO must share at least one ZIP Code with the ambulance providers and suppliers that are participants in the model. Under the ET3 Model, CMS provides greater flexibility to ambulance care teams to address emergency health care needs of Medicare Fee-for-Service (FFS) beneficiaries following a 911 call, by paying ambulances to transport beneficiaries to Alternative Destinations or to facilitate Treatment in Place with a Qualified Health Care Partner, either in-person or through telehealth.

The NOFO is available at grants.gov under Opportunity Number CMS-2F2-21-001.

For more information, please see the ET3 Model’s webpage. Stay up to date on the latest ET3 Model news and updates by subscribing to the ET3 Model listserv or contact us at ET3Model@cms.hhs.gov.

Senate Passes Ambulance Treatment in Place Language

On Saturday, the U.S. Senate passed language for Medicare coverage of emergency treatment in place of lower acuity patients by ground ambulance services providers and suppliers during the COVID-19 public health emergency (PHE). The language is from S. 149 by Senators Cortez Masto (D-NV) and Cassidy (R-LA) and passed as part of the $1.9 Trillion American Rescue Plan (H.R. 1319). The House is scheduled to vote and expected to pass the package tomorrow.

The American Ambulance Association along with the International Association of Fire Chiefs, International Association of Firefighters, National Association of EMTs and National Volunteer Fire Council pushed for passage of the bill language.

S. 149 would authorize the Centers for Medicare and Medicaid Services (CMS) to waive the transport requirement under Medicare for treatment in place for 9-1-1 or equivalent ambulance responses in which community EMS protocols dictate that the patient not be transported to a facility. The waiver would apply during the public health emergency.

Similar to other waivers provided by Congress for Medicare coverage during the pandemic, CMS would not be required to implement the policy. However, CMS has done so in all other situations and has also made the coverage retroactive to the beginning of the PHE. Upon passage of the language, the AAA will strongly advocate for CMS to implement the waiver and make it retroactive.

The AAA will be offering educational services to our members on the requirements of the proposed new policy and how to bill for covered services.

Treatment In Place in Senate Draft

Ambulance Treatment in Place Bill Included in Senate Draft Budget Reconciliation Package

The draft bill by Senate Democrats on a Budget Reconciliation package includes the language of S. 149 which would waive the transport requirement under Medicare for certain 9-1-1 ground ambulance services during the public health emergency. The Senate is expected to consider the package as soon as tomorrow.

Senators Catherine Cortez Masto (D-NV) and Bill Cassidy, M.D. (R-LA) introduced S. 149 on February 3 which is supported by the AAA, International Association of Fire Chiefs, International Association of Firefighters, National Volunteer Fire Council and National Association of EMTs.

Under S. 149, the Centers for Medicare and Medicaid Services (CMS) would have the authority to waive the requirement that a patient must be transported to a medical facility in order for a ground ambulance service organization responding to a 9-1-1 emergency call to be reimbursed by Medicare when there is a community-wide EMS protocol restricting the transport of the patient.  Ground ambulance service organizations whose paramedics and EMTs are on the frontlines of this pandemic are struggling financially due to the reduction in ambulance transports and higher costs such associated with responding to medical emergencies that cannot be reimbursed because of the transportation requirement. S. 149would greatly help address part of that problem and recognizes the critical role that ground ambulance service organizations are playing in controlling hospital surges and reducing the spread of COVID-19 .”

The House has already passed their version of Budget Reconciliation and would still need to pass a Senate version before sending to the President. S. 149 would provide CMS with the authority and, if passed, the AAA would advocate for the agency to exercise that authority and follow through with the waiver starting at the beginning of the public health emergency.

JAMA | Ontario | Economic Analysis of MIH Delivered by EMS

From JAMA on February 24, 2021

Economic Analysis of Mobile Integrated Health Care Delivered by Emergency Medical Services Paramedic Teams

Question  Is mobile integrated health care (MIH) delivered by emergency medical services more efficient than regular ambulance responses in addressing the needs of urgent care in the community?

Findings  This economic evaluation compared 1740 calls serviced by MIH in 2018 to 2019 with propensity score–matched ambulance calls for the same period and 2 years prior and found that MIH was associated with a decrease in the proportion of patients transported to the emergency department and saved health care costs compared with regular ambulance responses.

Meaning  These findings suggest that MIH is a promising and viable solution to meeting urgent health care needs while improving the efficiency in using emergency care resources.

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Senators Cortez Masto and Cassidy Introduce Bill on Ambulance Treatment in Place

Yesterday, Senators Catherine Cortez Masto (D- NV) and Bill Cassidy, MD (R-LA) introduced legislation (S. 149) to allow for Medicare reimbursement under certain circumstances of treatment in place by ground ambulance service organizations during the COVID-19 public health emergency. The AAA applauds the efforts of Senators Cortez Masto and Bill Cassidy as well as the Senate Finance Committee and Leadership.

S. 149 would provide the Centers for Medicare and Medicaid Services (CMS) with the authority to waive the requirement that a patient be transported to a medical facility in order for the ground ambulance service provider or supplier to receive Medicare reimbursement. The waiver would apply to 9-1-1 emergency ambulance services in which the transport did not occur as a result of “community-wide EMS protocols” due to the public health emergency. While the bill would not apply to situations in which a patient declines transport due to COVID-19 exposure concerns as advocated by the AAA, S. 149 is a significant step in the right direction to recognize ground ambulance services not being reimbursed during the pandemic.

The American Ambulance Association (AAA) along with the International Association of Fire Chiefs (IAFC), International Association of Firefighters (IAFF) and National Association of Emergency Medical Technicians (NAEMT) have spearheaded efforts for the Congress to provide CMS with waiver authority for treatment in place. We will be pushing to include the language of S. 149 in the COVID-19 stimulus package currently being negotiated between the White House and the Congress.

For the official statement of the AAA on the introduction of S. 149, please click here.

S.149 Treatment In Place

The American Ambulance Association Urges Immediate Passage of  S. 149 to Allow CMS to Support Local Ground Ambulance Service Responses to the Public Health Emergency

Treatment in Place Supports Patients and Sustains 9-1-1 EMS Providers During the COVID-19 Pandemic

Washington, DC, February 2, 2021 – The American Ambulance Association (AAA), our nation’s voice for ground ambulance service organizations commends Senators Catherine Cortez Masto (D-NV) and Bill Cassidy, M.D. (R-LA) for the introduction of S. 149 and urges its immediate passage. This legislation would remove a statutory barrier that has stopped ground ambulance service organizations from being reimbursed for health care services they provide consistent with local emergency medical service (EMS) protocols.

“S. 149 will empower ground ambulance service organizations to better meet the emergency medical needs of their communities, which are struggling during the pandemic,” stated AAA President Shawn Baird. “I applaud Senators Cortez Masto and Cassidy for their leadership on introducing this vital piece of legislation, as well as the Senate Finance Committee and Leadership for their support of these efforts.”

Under S. 149, the Centers for Medicare and Medicaid Services (CMS) would have the authority to waive the requirement that a patient must be transported to a medical facility in order for a ground ambulance service organization responding to a 9-1-1 emergency call to be reimbursed by Medicare when there is a community-wide EMS protocol restricting the transport of the patient.  “Ground ambulance service organizations whose paramedics and EMTs are on the frontlines of this pandemic are struggling financially due to the reduction in ambulance transports and higher costs such associated with responding to medical emergencies that cannot be reimbursed because of this transportation requirement,” said Baird. “This bill would greatly help address part of that problem and recognizes the critical role that ground ambulance service organizations are playing in controlling hospital surges and reducing the spread of COVID-19 .”

The legislation would benefit patients by reducing their risk of exposure to the virus, which is often the focus of the local protocols requiring them to remain at home. It would also help hospitals experiencing surges during the pandemic by allowing hospital beds to be reserved for higher acuity patients.

The AAA will help push for swift passage of the bill. President Baird called on the Congress to address the legislation as part of negotiations on a new COVID-19 economic relief package. “The American Ambulance Association fully endorses S. 149 and we ask for all members of Congress to help their ground ambulance service organizations, their patients, and the communities they serve by supporting passage of this bill.”

About the American Ambulance Association

The American Ambulance Association safeguards the future of mobile healthcare through advocacy, thought leadership, and education. AAA advances sustainable EMS policy, empowering our members to serve their communities with high-quality on-demand healthcare. For more than 40 years, we have proudly represented those who care for people first. For more information about the AAA visit our website at www.ambulance.org.

JEMS | Paramedicine Strategic Planning

By Brian J Maguire, Dr.PH, MSA, EMT-P, Scot Phelps, JD, MPH, Paul Maniscalco, PhD(c), MPA, MS, EMT/P, LP, Daniel R. Gerard, MS, RN, Andy Gienapp, NRP, Kathleen A. Handal, MD and Barbara J. O’Neill, PhD, RN

… Many of the system deficiencies can be traced to three main factors. First, there is no single U.S. federal agency solely charged with supporting paramedicine operations. Second, no legislative mandate exists to engage in paramedicine operational research. Third, there is no paramedicine-specific financial support to advance core initiatives at the federal, state, tribal and local levels…

Read full article►

Spotlight: Desiree Partain, Medstar Mobile Healthcare

Desiree Partain
Mobile Integrated Healthcare Manager
Medstar Mobile Healthcare
Fort Worth, Texas

Other Titles & Roles

MIH Manager at Large, IBSC, NAEMT member

Tell us a little about yourself.

Born and raised in sunny San Diego, California. I have a military ( marine grandfather and navy grandfather, brother, and nephew) and first responder (law enforcement mother) family background. Days were spent in the water, whether it was our backyard pool or the beach. My parents instilled a strong work ethic in me at a young age that began as the neighborhood babysitter, to various positions at assisted living facilities and finally in EMS. I learned to take pride in the things I had and my work, whether it was completing a household chore, a writing assignment at school, or the vehicles I owned.

Your history with EMS

My mother was a police officer in the town I was raised in so the police and fire department was often my home away from home. I can remember being so fascinated with the ambulance and in admiration of the paramedics when I would go to visit. I told my parents when I was little that when I grew up, I would become a paramedic. After graduating high school, I began the series of classes to obtain my EMT. When 9/11 occurred, I remember sitting in my advanced first responder class that day and knowing that I had made the best decision to be apart of the first responder industry. I got EMT certification in 2002 and my first EMS job that same year. I began the paramedic academy in 2005 where I was the academy leader and valedictorian. I received my paramedic certification and began working on the ambulance in 2006. I was also working for an air ambulance company and an adjunct instructor. In 2009, I moved to Fort Worth, Texas to gain further experience on the ambulance. I took a critical care course in 2010 and began working as a critical care/mobile health paramedic in 2011. I obtained my Bachelors in Health and Human Services in 2013 and began a quality assurance/training coordinator position specific for mobile integrated healthcare in 2014. In 2015 I began working as the MIH Manager where I obtain my CCP-C and CP-C certification and completed my Masters in Healthcare Administration in 2018.

What do you enjoy most about your job?

I love people and being able to help someone who may be having one of the worst days of their life. I view my position in EMS as more of an opportunity to be a life changer than a life saver. Being in management, my position is to lead other life changers. On the mobile integrated healthcare and critical care side, I love being a part of the innovation and out-of-the-box thinking. It’s great to be able to come to work and be in an environment that embraces change rather than the status quo of “we’ve always done it that way” type of thinking.

What is your biggest professional challenge?

Staying current. EMS and healthcare is in a constant state of change and with those changes comes new processes, protocols, and general information that need to be learned. Remaining current with the changes on top of daily responsibilities can be a challenging balancing act.

What is your typical day like?

Working in the administrative side of EMS, a typical day often involves multiple meetings either on or off site. I generally allow myself some time in the morning to go over my tasks for the day, read, and respond to emails. In between meetings, I will work on projects and to-do’s and filter questions or issues with team members. The end of the day is spent reviewing meeting notes, action items and my plan for the following day.

What are your predictions for EMS 10 years from now?

My vision for EMS 10 years from now is an industry that is even more integrated with the overall healthcare system. The use of systems to further enhance efficiency and communication in the emergency and non-emergency settings. Integrated care that starts at the time of the 9-1-1 call with the most appropriate resource deployment, on-scene management whether its offering care without transport or transport to a healthcare facility aside from an emergency room.

What advice would you give to someone new to EMS?

Take pride in what you do in this industry from your uniform appearance, to your ambulance, to the patients you serve, and to yourself. Take care of you first by practicing self care and finding a healthy balance between your personal and professional life. Create professional goals for yourself whether its through education, positions, or organizations and hold yourself accountable to accomplish those goals.

HHS OIG Issues Advisory Opinion on Community Paramedicine

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:

  1. 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.
  2. 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.
  3. The program was designed in a way as to minimize the potential for interference with clinical decision-making.
  4. 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.
  5. 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. 

MedPAC Examines Beneficiary Use of Emergency Departments

During its October meeting, the Medicare Payment Advisory Commission (MedPAC), reviewed Medicare’s current policies related to non-urgent and emergency care, as these topics relate to the use of hospital emergency departments (EDs) and urgent care centers (UCCs). The Commission is examining this topic because the use of ED services in recent years has grown faster than that of physician offices.  At the same time, the share of ED visits that are coded as high acuity has increased.

The Commission is exploring Medicare beneficiaries’ use of EDs and UCCs for non-urgent services. In addition, the Commission is analyzing ED coding to determine if the increase in coding high-acuity visits reflects real change in the patients treated in EDs. This slide deck shows the potential savings Medicare could realize if beneficiaries shift certain care to the UCC setting.

During the meeting, the staff sought feedback from Commissioners for developing next steps. This topic will likely continue to be addressed in future meetings.

From the perspective of ambulance payment reform, the observations made by the Commissioners and staff would also seem to support incorporating scope-appropriate ambulance services in the context of community paramedicine or treatment at the scene with referral. While additional work needs to be done by the ambulance community before these services can be incorporated into the Medicare reimbursement program, discussions like the one at MedPAC last week, show the importance of getting the details right so that ambulance services can be part of new payment models likely to be considered.

The American Ambulance Association is leading the effort with the Medicare program to develop appropriate models that account for the cost of providing services through sustainable reimbursement rates, rather than the use of temporary grants. We are also focused on ensuring services align with the scope of practice laws. Led by the Payment Reform and the Medicare Regulatory Committees, our efforts include regular meetings and discussions with leaders at the Centers for Medicare & Medicaid Services, as well as key Members of Congress. Follow us on Facebook and Twitter to learn more about our ongoing efforts.

Ambulance Cost Data Collection is Coming

Although the most prominent ambulance provision passed in the Bipartisan Budget Act of 2018 (H.R. 1892) was the five-year extension of the Medicare add-ons, the Act also included important language directing the Centers for Medicare and Medicaid Services (CMS) to collect cost and other financial data from ambulance service suppliers and providers.

This week, an editorial from AAA Senior Vice President of Government Affairs Tristan North was featured in the June issue of JEMS‘s “EMS Insider”. Read the full article►

Changing the Face of EMS for the New Century

EMS has always been the forefront of medicine, delivering care to the sick and injured in various roles dating as far back as the Civil War. It has come a long way from the days of horse and buggy. Yet, where are we going now?

One look at the trajectory of Nursing indicates where we are headed. When Nursing first started, the profession was comprised of caring women who were viewed and treated as indentured servants, subservient to the male dominated physicians. Nursing evolved when the “servant” became educated. What followed were thousands of women beginning to diagnose, conduct research and improve outcomes in the healthcare field. Soon thereafter, they broke free of the care assistant model they were in. I see EMS following the same path.

The ambulance industry started out as transporters, with a curriculum that was adopted and funded by the Department of Transportation (DOT). The industry has roots in DOT, Police Departments, Fire Departments and the military, but are truly physician extenders that should be firmly rooted in Health Departments. EMS is now developing a language, doing research, obtaining national accreditation for our schools, even supporting continuing education with CAPCE. But we need to do more.

Outreach will help accomplish what many have started.  We need to consider the picture the public has of EMS, especially when we have overlooked self-promotion for decades.

Let’s be the ones who show the public what EMS is and is capable of.  I look forward to EMS education mirroring, “The Georgia Trauma Commission,” which collaborated with the Georgia Society of the American College of Surgeons and the Georgia Committee on Trauma to create the “Stop the Bleed” campaign. This inspiring crusade is designed to train school teachers, nurses and staff across the state on how to render immediate and potentially life-saving medical aid to injured students and co-workers while waiting for professional responders to arrive.” (2018, para. 4)  This type of training gives us face time with the public so they can learn what we do and what we do not.

One of the other important outreach programs to help us in this endeavor is the Community Paramedic Program. We are seeing this education transform EMS into new and exciting roles in the community. “First responders frequently respond to calls for social services. So, the emergency responders may know of people who need some sort of services or resources,” (Todd) Babbitt, a former fire chief, said. “This team could help connect those people with the services they need. It’s about getting everybody to work together and communicate.” (2018, para. 4)

What we can do is start to get EMS in front of the public. Teach. And open our historically closed doors to the folks that make it easier to do our jobs. Educate others and learn together how our roles are changing modern day healthcare while embracing the change. Otherwise we risk being left in the dust by our progressive healthcare brethren.

References

(2018, Feb 1st, 2018). Ga. School Nurses Train to Stop the Bleed. The Brunswick News. Retrieved from https://www.emsworld.com/news/219782/ga-school-nurses-train-stop-bleed

(Ed.). (2018, January 30th, 2018). Conn. Fire Chiefs to Form Community Action Team. Norwich Bulletin. Retrieved from https://www.emsworld.com/news/219757/conn-fire-chiefs-form-community-action-team

Cataldo Ambulance’s Ron Quaranto on Mobile Integrated Health

As a current mobile integrated health provider, we recognize the values of an MIH program which most importantly provides quality patient care to those in need, often in the comfort of their own homes. This is often done under the direction of the patient’s primary care physician in conjunction with the patient’s healthcare team. This allows for the patient to maintain their quality of life while receiving the medical attention they need—and ultimately reducing the healthcare expenses of hospitalization.

Ron Quaranto
COO, Cataldo Ambulance Service

Sept 28 Webinar: Fallon Ambulance on Alternative Destinations

Join Patrick “Sean” Tyler, executive vice president and chief operating officer of Fallon Ambulance Service, on September 28 for Alternative Pathways to Care: The Massachusetts Experience.

Alternative Pathways to Care: The Massachusetts Experience
Speaker: P. Sean Tyler, Fallon Ambulance
September 28 at 2:00 PM ET
$99 for Members | $199 for non-Members
REGISTER NOW►

EMS systems around the US have historically been incentivized by Center for Medicare and Medicaid (CMS), private insurers and other payers to transport all patients encountered through accessing 911 emergency call systems, to an acute care facility emergency department (ED). The reimbursement model for ambulance services in place currently only provides payment for transport of any patient to a state licensed ED according to CMS. The changing healthcare system in the US, through the Affordable Care Act (ACA) 2010, looks to healthcare systems and contractors to provide healthcare at a lower cost. CMS is prescribed, as part of the ACA, to test innovative delivery models to reduce program expenditures…while preserving or enhancing quality of care furnished to individuals.”

This session will review the concepts and programs of implementing a modified system of care whereas trained EMS providers, under the supervision of a physician Medical Director, can transport patients experiencing a psychiatric emergency or require drug abuse services to a destination other than the acute care emergency department. This session also will review existing research papers, conclusions and data available for several existing programs for EMS utilization of permissive alternative destination for behavioral and mental health patients and patients requiring services for drug or alcohol use, in the absence of any acute medical condition.

Wall Street Journal: Paramedics Aren’t Just for Emergencies

Yesterday’s Wall Street Journal featured several promising community paramedicine programs, as well as some great quantitative results.

“Paramedics are a readily deployable, nimble, clinically trained resource who can help close a gap in American health care,” Dr. Schoenwetter says…

From March 2014 to June 2015, the Geisinger mobile health team prevented 42 hospitalizations, 33 emergency department visits and 168 inpatient days among 704 patients who had a home visit from a paramedic, Geisinger calculates. In the case of heart-failure patients, hospital admissions and emergency-room visits were reduced by 50%, and the rate of hospital readmissions within 30 days fell by 15%. Patient satisfaction scores for the program were 100%.”

Read the full article on wsj.com. (Hat tip to Matt Zavadsky.)

Cross-Cultural Communication for EMS

Ambulance services interact with people from all walks of life, and from all parts of the world. AAA checked in with expert Marcia Carteret, M.Ed., for some tips for communicating more effectively with people from other cultures. Marcia is an instructor of intercultural communications at University of Colorado School of Medicine in the Department of Pediatrics. She trains residents, faculty, and staff in healthcare communication with a focus on cross-cultural patient care and low health literacy. She has also trained in over 120 private pediatric and family practices across Colorado.

Marcia also developed a robust cross-cultural toolkit for AAA members. [Learn more about AAA membership]

Barriers to Understanding

In all healthcare settings, successful communication with patients and families depends on awareness of three key barriers to their understanding and compliance:

  1. Cultural Barriers: Understanding western medicine and the U.S. healthcare system is a challenge for many of us, but it is especially problematic for recent immigrants and refugees. 72% of U. S. population growth in the next 20 years will come from immigrants, or the children of immigrants.
  2. Limited English Proficiency: The number of people who spoke a language other than English at home grew by 38 percent in the 1980s and by 47 percent in the 1990s. While the population aged 5 and over grew by one-fourth from 1980 to 2000, the number who spoke a language other than English at home more than doubled.
  3. Low Health Literacy: While poor understanding of the health care system and difficulty understanding health care instructions may be associated with language and cultural barriers, low health literacy is also found in patients who are proficient in English and who share the common U.S. culture. This latter group may be especially at risk of having their low health literacy go unrecognized. 90 million “mainstream” Americans cannot understand basic health information.

Addressing These Barriers

How do people understand one another when they do not share a common cultural experience? Nowhere is this a more pressing question than in healthcare settings, especially in emergencies. There is no easy list of things “to do” or “not to do” that can be applied to each culture. What can be useful are communication guidelines that work for people from all cultures. These guidelines are also important for people with low health literacy.

[quote_left]“The essence of cross-cultural communication has more to do with releasing responses than sending messages. And it is most important to release the right responses.” — Edward T. Hall[/quote_left]

Perhaps the most important is framing questions to elicit appropriate answers. As Edward T. Hall, anthropologist and cross-cultural researcher wrote,“The essence of cross-cultural communication has more to do with releasing responses than sending messages. And it is most important to release the right responses.” What could be more crucial when, for example, an EMT or paramedic is attempting to establish level of consciousness by directly eliciting information from a patient? Being able to get quality responses from patients from any culture is a communication skill that comes with experience. Learning and practicing a set of strategically designed questions is key to building confidence in this important skill.

Key Communication Tips

  • Explain your professional role
    911 is the number to dial in an emergency, but some people may not understand the roles of different emergency responders. You can’t expect people who are still learning to function in the U.S. mainstream society – recent immigrants or refugees especially – to understand the role of the EMT or paramedic.
    Suggested explanation: “I am not a doctor. I am an emergency medical professional. I have come to help because someone called 911. I will take this person who is hurt/sick to the hospital safely.”
  • Use simple familiar words and short sentences
    “Stabilize” is a complex word, even though it might be the best word to describe what you do for a patient in an emergency. Help is a better word. With Limited English Proficiency (LEP) patients and families, the 5¢ word is always better than the 75¢ word.  Basics such as give, take, more, less will be better choices than administer, increase, decrease.
  • Be clear when you are asking a question versus giving an instruction.
    Running questions and statements together is confusing for second language learners. Avoid sentences like this: “It looks like you are having a reaction (a statement of observation) so I need to know if you have taken any medication that made you feel sick.”Examples of concise phrasing:

    • “What medicine have you taken?
    • “Show me this medicine.”
    • “Show me where it hurts.”
  • Avoid close-ended questions
    These usually begin with do, did, does, is, are, will, or can. These can be answered with a simple yes or no – or a head nod. Avoid the use of close-ended questions with Limited English Proficiency (LEP)  patients because in many cultures people will frequently simply say yes even if they don’t understand you.
  • Use open-ended questions
    These usually begin with the 5 Ws – who, what, when, where, why (and how or how many). It is awkward to answer these questions with a nod, shrug, or simple yes/no. For example, you might ask: When did you take these pills?” instead of “Did you take these pills?”
  • Avoid starting sentences with negations such as isn’t and didn’t.
    Though this is a common speech pattern in English, it may be confusing for people who speak a different native tongue. For example:  Didn’t you call 911? (Read more about this speech pattern.)
  • Clarify understanding – yours and theirs
    Even if you are using simpler words and shorter sentences, you can’t be certain there has been communication until the receiver acknowledges it with feedback. Remember, head nodding does not count as feedback with people from many different cultures. Even with Americans, and definitely with children, head nodding is often a sign of partial comprehension. So you must ask clarifying questions.
  • Repeat back what you have understood. 
    • Examples: “Yes? – you took the medicine?”
    • “Yes? – you are his/her grandmother?”
  • Not understanding vs. misunderstanding
    When people do not understand what you say, there is more likely to be an indication of confusion than when they MISunderstand you. A person struggling with English, for example, may ask you to repeat what you have said. Their face may show confusion. But when people MISunderstand, it can be far less obvious. For example, the English words want and won’t sound very much alike to a non-native speaker. You may say to a person, “I want to help you,” but she may hear “I won’t help you.” She may be perplexed that this is your response, but she may be very inclined to accept the word of a healthcare professional. She may perceive you as being uncaring, but certainly won’t say so. Many MISunderstandings go unnoticed by both parties. Asking clarifying questions is crucial.
  • Speak slowly and clearly—NOT loudly
    Often when people don’t understand our language, we treat them as if they are hearing impaired or “slow” without realizing we are doing so. Articulate your words in shorter phrases rather than just speaking more loudly.

Cultural Norms

Cultural norms vary around the world. Here are some key norms to keep in mind when assisting patients and their families.

    • Eye Contact
      An EMT or Paramedic will often be perceived as an authority figure by the people from more traditional cultures. If a person is avoiding eye contact while listening to you or while answering questions, be aware that in some cultures direct eye contact with an authority figure is very rude. In trying to be respectful, people may appear to be avoiding looking you in the eye. This is not to be taken immediately as any indication of disrespect, dishonesty, or evasiveness
    • Silence
      Silence may be the only response a person can muster if he or she is frightened. Silence might also be a way of showing respect, similar to avoiding eye contact. Being thoughtful about answering a question shows humility and real effort in giving the best answer. Unfortunately, silence on the part of the non-English patient or family member is often interpreted as open hostility by Americans. It can be helpful to say: “I need your help. Please try to answer my questions. Your answers help me help you.” Also, try not to rush answers. Americans allow very little time between questions and responses. Impatient and in a hurry we tend to start talking before the other person is able to answer the question asked.
    • Reverting to Native Language
      Bilingual patients may revert to their language of origin in times of stress, and while this hinders communication with an EMT, it should not be seen as manipulative or uncooperative. Calmly ask the person, “Can you speak in English? Please try English.” If the person does not speak any English, this will at least help them realize you can’t understand.

Summary

As first-responders, EMS is often working in high stakes situations where communication is a challenge even without the added barriers associated with the “triple threat” to healthcare communication—language barriers, cultural understanding, and low health literacy. No matter which culture an EMT or Paramedic is interacting with, the key to good communication is asking good questions and phrasing all dialogue in simple short sentences. It should be clear that a question is being asked or a statement of information is being made by the EMS professional. Asking for clarification is essential. Head nods and affirmative answers should not be accepted immediately as evidence of sufficient understanding or agreement. EMTs will find that enhanced communication skills will not only improve cross-cultural interactions, these skills improve outcomes with all people –  even “mainstream” Americans. Also, be aware that low health literacy is a problem for 90 million Americans. Never assume that same-culture communication in English requires less intentional speech on your part.

Community Paramedicine’s Growth Hindered by Reimbursement Issues

From Politico’s “Reimbursement issues block paramedics from expanded role“—

Despite the track record of [community paramedicine] initiatives in places like Nevada and Texas, where paramedics are providing in-home care, coordinating patient services and saving millions in the process, Medicare, Medicaid and most private insurance plans still won’t reimburse for such work. The program successes to date are only beginning to change that…

Nationwide, the impact from reducing ambulance calls and demands on ERs while freeing up doctors could be huge. A 2013 study in Health Affairs estimated that more flexible reimbursement for paramedicine approaches could save Medicare $283 million to $560 million annually and similar sums for private insurers.