Over the past year, EMS leaders have been engaged in high-level discussions about an emerging delivery strategy for EMS. Dubbed “mobile integrated healthcare practice,” the strategy emphasizes a broader role for EMTs, paramedics and EMS systems in fulfilling a variety of community health needs by collaborating with hospitals, doctors, nurses, social services, nonprofits and public safety. Eric Beck, medical director for the City of Chicago EMS System and Chicago Fire Department, has emerged as one of the movement’s leaders.
Growing up near Cleveland, Beck got his start in EMS in high school as an EMT for a volunteer fire department. He finished his paramedic training as a senior in 1999, later graduating from the fire academy. “I grew up in a community where I was used to my neighbors responding to emergencies,” Beck says.
As a college student, the death of a fellow student at John Carroll University of sudden cardiac arrest led Beck to found a campus EMS service, which involved training its 75 volunteer EMTs.
While in medical school at Ohio University, Beck continued to work as a paramedic for a third-service agency in southern Ohio and for a critical care transport provider. As a resident and fellow, he worked as a helicopter and fixed-wing flight physician. In 2011, he was named associate EMS medical director for the City of Chicago EMS System and the Chicago Fire Department and later became medical director. Beck is currently finishing a master’s degree in public health and outcomes performance management, and is also assistant professor of medicine and assistant director of the emergency medicine residency program at University of Chicago Medicine.
Beck spoke with Best Practices about mobile integrated healthcare practice. He also discusses a harrowing experience he and his family had on a remote island in the Caribbean that served as a powerful reminder of the importance of having a robust EMS system for responding to life-threatening injuries.
What is mobile integrated healthcare practice?
It’s about bringing together a variety of stakeholders that traditionally have not come together to address healthcare delivery for a defined population, whether it’s a municipal community that you would typically define by a 911 region or a sub-population such as a high system utilizer group or a mental illness or substance abuse population. When you look at a population, you can determine what the health needs are for that group of people. You can then develop activities and mobilize a spectrum of resources around that health need.
Who are the stakeholders?
The stakeholders include patients, communities and a full spectrum of providers, from primary care to community health workers to social workers, pharmacists, EMTs, paramedics, community paramedics, law enforcement, dispatchers, public health, payers, regulators, government and community leaders, as well as hospitals, clinics, health systems and advocacy groups—anyone who has a stake in the health of a community.
How did discussions surrounding mobile healthcare get started?
A number of medical directors, some of whom have been doing community medicine or advanced practice paramedicine; EMS providers; EMS educators; and former EMS providers were all talking informally for several years. In December 2012, a group coalesced. It was 12 folks who started a dialog about the concept of community paramedicine. We were less interested in who the provider was or the curriculum, because there was already great work being done on that. Hats off to Minnesota for having community paramedicine as a new, legislated provider with a new scope of practice. Hats off to Gary Wingrove and colleagues who have put out a fantastic training program and curriculum.
But what this group said is, Let’s back up. How does EMS integrate into the larger healthcare landscape? That’s when we realized we’re talking about something larger than community paramedicine and larger than EMS. The question was, how do we bring together all of the appropriate resources to have a collective impact around the health needs of a population?
We had people in EMS saying, I want to do that, but I’m not sure how we fit in our community. How do we integrate? How do we figure out what we want to do? How do we do it in an inclusive and collaborative way?
So we all got together for a two-day meeting in Chicago. A grant from Medtronic Philanthropy offset travel. Out of that emerged the general concept, the mobile integrated healthcare practice framework, a list of core components and ideas about how we can share it with a larger group.
We then reached out to folks involved with the National Association of State EMS Officials, the National Association of EMS Physicians, the American College of Emergency Physicians’ EMS Committee and the National Registry of EMTs and asked, Is there a way to bring more people to the table? A second meeting, also funded by Medtronic, took place in March. We brought in people from the CDC, a healthcare actuarial consulting firm, the Minnesota state department of public health, leaders in the Minnesota community paramedic world, and folks in leadership positions from other EMS organizations to bring in more points of view and expertise. We envision this being a series of dialog that needs to include not only people in EMS but those outside the traditional EMS world.
The EMS world needs to have a general idea of where we’re headed with this before we bring in other people. If EMS isn’t united behind the concept and we try to talk to 10 or 12 other professional organizations in a big summit, they won’t want to hear what we have to say.
How is EMS uniquely positioned to offer mobile healthcare?
We are present in every community. We have a mobile footprint. We are the only healthcare entity that is available 24/7 and can respond immediately to provide the full spectrum of care from non-emergency to critical care. And we bring the care to the patient. We also have tremendous expertise in call triage and communications.
Don’t we have a new model for EMS in community paramedicine? Why not call it that?
Many perceive community paramedics as paramedics doing something new. That scares some people: Is this a new provider, with an expanded scope of practice? Are we talking about paramedics doing things typically in the nursing scope of practice or the social worker scope of practice? Nurses might say, Does that mean a nurse can’t participate because it says ‘paramedic,’ or that an EMT-basic can’t? The word ‘paramedic’ is very politically charged.
There’s also community paramedicine, the concept, which is not very well understood in the U.S., and it doesn’t convey to our non-EMS partners and perhaps even non-paramedic EMS that this is a team-based model. It sounds like an EMS construct, and it doesn’t open itself up to the full spectrum of providers who could participate, or even the full spectrum of EMS providers.
With mobile integrated healthcare practice, we’re talking about an interprofessional practice model that is open to a variety of providers, including EMT-basics, pharmacists, nurses, advanced practice nurses, physician assistants, community health workers, social workers, physical therapists. Community paramedics are an integral part of mobile integrated healthcare practice, assuming a community has community paramedics. But some places don’t even have regular paramedics.
I think anyone who is involved in community paramedicine will tell you that you solve problems through teams. To think community paramedicine will be a universal solution to healthcare reform is probably not being realistic. We need a team-based model.
To be fair, doesn’t community paramedicine bring EMS together with various partners to address healthcare issues for specific groups of patients?
A community paramedic is an example of a provider who could participate in mobile integrated healthcare practice. But I don’t think community paramedicine connects all the dots, or addresses a global strategy in terms of navigation, communication and
measurement. We need to think more broadly, more inclusively about defining how EMS is going to integrate into the larger healthcare landscape and how we’re going to engage a variety of colleagues from different professional backgrounds and disciplines.
Right now I’m at the American Academy of Home Care Physicians meeting. They are in the process of changing their name from Home Care Physicians to Home Care Medicine. They are choosing to rename their organization because Physicians isn’t an inclusive name and they see the future as care delivery through teams. If doctors making house calls are interested in changing their name to something more inclusive, that speaks volumes about where they see the future of care going.
How are changes brought on by healthcare reform influencing the mobile healthcare movement?
Healthcare reform is a train that’s left the station, and the traditional models of reimbursement for EMS and fee for service—that train is slowing down. We are in a transition state. Everyone is realizing that collaboration is going to be critical to the success in this next chapter of healthcare and EMS delivery.
What role would the fire service have in mobile healthcare?
It comes back to the community needs assessment. Fire departments, EMS agencies and our public safety colleagues, including law enforcement, are all stakeholders in a mobile integrated healthcare practice community needs assessment. They should all be at the table. What expertise, resources, manpower and investment they bring will depend on the health need in the population we’re talking about.
I don’t think we should say fire departments will do this or do that. In some areas, fire departments will engage on health needs, and in some they won’t be the ideal stakeholder in taking on that health need. In a large urban city fire department like Chicago, we respond to a tremendous number of calls for invalid assists and preventable falls in the frail and elderly population, for serial inebriates and for high system utilizers. Those are the types of patients fire departments do have a real interest in looking closely at to ask: Who is this population? What are their needs? And can we, along with a blended team, do better for these patients than we’re doing alone? Can that potentially improve our service? Can that create new flexible job opportunities, such as a light-duty, non-promotional senior experienced personnel type of position? Can we improve our community relations and engagement? Can we strengthen the prevention arm of our life safety mission, and is it something we can potentially receive revenue for?
With mobile integrated healthcare practice, we are taking stock of what the issues are and who has the expertise, resources and availability to take on these challenges. With the fire service, we’re talking rural frontier to big city fire departments, so there will be a lot of variables. By appreciating there’s a breadth of activity that could be done by a fire department and that every department has different resources, there are lots of opportunities for them to engage, some of which are very complementary and overlapping with their current mission.
EMS in general, but perhaps fire-based providers more than anyone, have underappreciated our public health function, primarily when it comes to prevention. The incidence of deaths from structure fires has declined considerably with the advent of fire codes and building inspections, smoke alarms, fire extinguishers and educational campaigns in schools like Stop, Drop and Roll. You could argue the modern fire service has been the most successful public health demonstration project.
Yet the fire service doesn’t fix the violations; they engage someone to fix the problems. So in many ways the fire service has already been doing this type of work; it’s just that the health need was around structure fire prevention, carbon monoxide poisoning or car seat installation. The fire service is no stranger to public health preventive intervention and partnering with their community and other stakeholders to improve the health and welfare of the population they service. So taking that to the next step—going into someone’s home and making sure their welfare is intact and if not, contacting other members of your team—makes a lot of sense.
What is the community health assessment aspect of mobile integrated healthcare practice?
It’s a process. It’s an endeavor taken on by stakeholders to come together around goal formation, new and strategic partnerships and thinking outside the box to collectively impact a problem that they would perhaps be less successful in impacting on their own. It brings together expertise from public health, cultural competence, finance, patient safety, clinical care, community health, data collection, data analysis, public safety, public health, healthcare, community leaders and patients. You bring those people together, people who don’t usually sit at the same table, and you define their health need, what the goal is and how to leverage our expertise, talent and capacity to try to influence change.
‘Paramedic,’ ‘prehospital’ and other EMS terminology isn’t part of the mobile integrated healthcare practice name. To what extent will this model be EMS-driven?
We have an opportunity to drive it, but only if we all see value in it. It’s easy for us to romanticize our past, but progressive healthcare is thinking about how to change and adapt in a new world. EMS needs to do the same thing. Part of that is to have some candid discussions to figure out how we can best utilize mobile integrated healthcare practice and community paramedics to fill an important niche within this evolving landscape.
In some communities, EMS may be driving the ship and in some communities it may have a much lesser role. It will depend on the community health assessment, what the resources are in the community and what role EMS wants to play. To think there will be a single script for how EMS will integrate when EMS looks very different in every place isn’t realistic. Individual EMS systems and organizational missions will tailor involvement and how progressive people want to be with their mission, and how they strategically plan for the future.
In some communities, the answer has been to train paramedics to do that. But in some places there’s a scope of practice that says paramedics can’t do certain things. In some communities, they’re changing the law. But a paramedic will never be as good at medication reconciliation and safety as a pharmacist, for example. You can approach this by training paramedics to have that competence. The other way is to use a blended team that incorporates people who have that expertise, and bring those players to the population that has that need. It doesn’t mean a pharmacist has to go to someone’s home; it could mean that EMS through telemedicine is dialoging with the pharmacist or the primary care physician.
And it doesn’t necessarily mean that EMS isn’t trained to do some new things as well. Part of that community needs assessment is determining whether we’re going to invest in training paramedics to do new things, or in adding pharmacists, or nurse practitioners, or telemedicine, and so on. Those choices should be driven at a community level.
Illinois is a partner with Medtronic Philanthropy’s HeartRescue Project, with the goal of improving SCA survival by 50%. How is that going?
Initially, we’re focusing on the city of Chicago and the counties that ring Chicago, which represent two-thirds of the out-of-hospital cardiac arrests in Illinois. The last formal analysis of SCA survival was a paper published more than 20 years ago, which reported low survival. We do know anecdotally that our rates of return of spontaneous circulation have improved dramatically since 2011, when we began implementing incident command for cardiac arrest, which is our version of the pit crew. We haven’t formally analyzed those numbers, but thanks to a new electronic patient care record system, we have the ability to generate internal cardiac arrest quality improvement and participate in the CARES database.
One of the key things we do to keep cardiac arrest fresh in everybody’s mind is a deep dive, or a more focused look at a specific aspect of cardiac arrest care through monthly drills—shorter segments with a more narrow focus on an area such as CPR quality, capnography, post-arrest care or data collection. Much of this is about measuring progress, so ensuring that we get quality data is an important piece of it.
What are the biggest challenges you face in improving survival?
Like most systems, our focus is on working patients where they are found. A lot of the time, EMS providers are facing inhospitable conditions and very difficult families who can become intrusive during the resuscitation. A lot of EMS providers feel so uncomfortable on scene that they first get the patient in the back of the ambulance.
We are spending time with EMS providers to train on how to deal with families and bystanders on scene—how to manage the family presence during the resuscitation and how to manage the family when you terminate in the field.
Part of good cardiac arrest care in Chicago is making sure we know how to deliver culturally competent scene management and family interactions.
What do you see as the medical director’s most important role?
To provide education. It’s amazing what EMS providers will be moved to do when they have been educated and empowered with the knowledge to improve their own practice. A big piece of that is making sure they understand why we do what we do, making sure they are getting feedback on performance, and knowing the outcomes or the results.
In a system like Chicago, we really want the EMS providers to drive the process. What we are trying to do is take advantage of a public health concept called positive deviance, which means that you look to those who are doing things differently and having success and you call those out, recognize those performances and have them share their stories with others instead of telling them how to change.
In EMS, we’re striving to become better at what we do by looking for those providers who have incorporated proven strategies and are realizing success more quickly and reliably than others—this is the science of performance improvement. To have an EMS crew be singled out for their success and have that shared with the larger group goes as far or farther than telling people what to do. For example, the fire commissioner created the Clinical Resuscitation Ribbon, which is given to dispatchers, firefighters, EMTs and paramedics to recognize each provider who was involved in a confirmed, neurologically intact cardiac arrest survival. It’s more powerful to have EMS providers share their stories to inspire others to change practice than to provide education and direction from traditional leaders. You need both, of course, but those stories from providers are very important.
Can you tell us something surprising about yourself?
I love to read and travel. That’s what I look forward to in my free time.
Two years ago, my father suffered a terrible accident on an island in the Caribbean that had very little EMS infrastructure. He was run over by a boat and suffered an open skull fracture and wet drowning. We called for an ambulance; it arrived 45 minutes later and had almost no equipment. My brother is an EMT, and we had to intubate my father. We took turns squeezing a bag for four hours while we waited for a plane to come to get him back to the States.
This accident gave me a special connection to the EMS system there, and I have pledged to try to help them improve it. I don’t think I’m going to be the solution, but perhaps offering some support and education and trying to provide some key pieces of equipment, like basic airway equipment, could go a long way. That is the silver lining in this horrific accident—so is the fact that our story had a happy ending and my dad has recovered and is back to work.
This experience also crystallized for me the critical role EMS plays in communities, and how fortunate we are to participate in this noble work. Even as a physician, I defaulted to my EMS roots.
One of my favorite quotes is from Vijay Govindarajan, a management expert. He talks about the challenge for CEOs being to manage the present, selectively forget the past and create the future. I think that sums up where we are as a profession. It doesn’t matter if you’re a physician, provider or administrator, that’s the challenge we share.
