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Implementing Emergency Triage, Treat and Transport

The tasks and timeline ahead for the 205 organizations selected under ET3 as we remove the perverse incentive of only getting paid for taking a patient to the wrong place


CMS expects its applicants to begin implementing their programs and “prepare by beginning to form partnerships with alternative transport destinations and other healthcare professionals.”

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The long-awaited ET3 announcement has been made and is something to call home about – 205 applicants from 36 states and Washington, D.C., covering 350 individual counties from Androscoggin to Multnomah, and Kalamazoo to Bernalillo (extra points if you name the states in the comments below) were named.

The even greater news is they represent the entire cross-section of the mobile healthcare world. Fire departments, private, not-for-profit, hospital-based EMS and municipalities all combine to be the trial trailblazers that will help us redirect the flow of appropriately selected patients to the right place, first time, every time. This move will also signify the beginning of the end of the perverse incentive that only rewards us for taking a patient to an ED and nowhere else.

Just to get to this point has taken a lot of leg work. Having been a part of a team that submitted a successful submission, it took time and effort to craft and develop the partnerships and win the confidence of collaborators from other elements of the healthcare and insurance professions. Then there was the application, that required a succinct submission in a character-limited proforma and accompanying letters of intent pledging cooperation, collaboration and teamwork. The work so far has developed 205 ideas that identify novel ways to deliver true MIH, and I’m not talking just community paramedicine, as I have always considered MIH not to be a word or acronym but a doctrine for the future.

Mobile. Integrated. Healthcare.

Health information exchange under ET3

Successful ET3 plans have all identified how they will conduct corporate and clinical governance, the criteria of who will be treated and who will be transported, and whether that takes place on the phone or in person. They also start to eat another EMS elephant – the sharing of data in a health information exchange that goes far beyond the back of the traditional patient handover – a sync of a call to the organizational server. As we go forward, we will inevitably have to combine technology, non-emergency medicine and interoperable cooperation, all within the ET3 patient-centered designed parameters that “will engage beneficiaries and their caregivers in shared decision-making, taking into account patient preferences and choices.”

CMS expects its applicants to begin implementing their programs and “prepare by beginning to form partnerships with alternative transport destinations and other healthcare professionals.” By the fall, the programs should all be up and running, a window of six months to get underway.

The relatively short timetable means selectees must hit the ground at a reasonable pace. One hopes that having gone through the formation of partnerships and the actual submission over four months ago, plans and planning have continued, and we will now see a flurry of activity as programs get underway.

High up on the to-do list is the requirement to inform and educate patients about the future (and different) interventions that will occur at the time and scene of a response. In fact, under ET3, the response may not even involve a visit to the patient at all, and conclude with a “hear and treat” treat-in-place solution from a telehealth provider, which departs from the patient-understood norm and will require strong and persistent publicity in the opening months.

ET3: Next steps

So what now? To help identify the immediate and recommended next steps, I turned to the acknowledged thought leader of all things MIH and the President of NAEMT, Matt Zavadsky, MS-HSA, EMT, chief strategic integration officer for MedStar Mobile Healthcare in Fort Worth, Texas. Matt suggested six actions that organizations should take immediately after their notification as an ET3 selectee:

  • Advise all partners about the selection. While it would be assumed that all partners and signatories have been keeping up with the progression of the ET3 program, it would be advisable to share widely. Also, think about the notification of boards and allied healthcare providers.
  • Confirm that key the contacts from payers and partners that were involved in the preparation stage are still in post as turnover may have occurred.
  • Update any economic modeling that occurred before the submission of the application (in reality, that initially occurred over six months ago) when going from planning to operationalization. Situations may have changed.
  • Continue working with your medical director in training and orienting your field staff. It’s likely that field staff will need to be educated on payer types – traditionally something they have not had to consider before – and alternate dispositions based on payer classification.
  • Determine what documentation requirements are required for your partners, regulatory agencies and quality assurance. Pay attention to those around video capture and retention.
  • Check the required documentation. It is possible that as part of the Participation Agreement, CMS may require specific language in agreements with QHPs and clinics. In any case, start the discussions with partners about what they will need in a subcontract.

It is excellent news that the announcement has been made and the countdown clock to implementation has begun. We will all watch closely as this unfolds and I’m sure the looming conference season will have presentations and updates as we go. This is the first step in a great journey, but one that will take a few years to play out as the 205 agencies have to implement, deliver and report out.

The true positive to my mind so far must be the relationship with the payor, as this move represents an opportunity to not only get into partnership but also in-network and that can only benefit the long-term sustainability of pre-hospital mobile healthcare.

Listen: ET3 – EMS One-Stop With Rob Lawrence

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Read next: Can ET3 push the field of medical direction to where it should be?

Rob Lawrence has been a leader in civilian and military EMS for over a quarter of a century. He is currently the director of strategic implementation for PRO EMS and its educational arm, Prodigy EMS, in Cambridge, Massachusetts, and part-time executive director of the California Ambulance Association.

He previously served as the chief operating officer of the Richmond Ambulance Authority (Virginia), which won both state and national EMS Agency of the Year awards during his 10-year tenure. Additionally, he served as COO for Paramedics Plus in Alameda County, California.

Prior to emigrating to the U.S. in 2008, Rob served as the COO for the East of England Ambulance Service in Suffolk County, England, and as the executive director of operations and service development for the East Anglian Ambulance NHS Trust. Rob is a former Army officer and graduate of the UK’s Royal Military Academy Sandhurst and served worldwide in a 20-year military career encompassing many prehospital and evacuation leadership roles.

Rob is a board member of the Academy of International Mobile Healthcare Integration (AIMHI) as well as chair of the American Ambulance Association’s State Association Forum. He writes and podcasts for EMS1 and is a member of the EMS1 Editorial Advisory Board. Connect with him on Twitter.