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Q&A: Chicago’s former medical director talks mobile integrated healthcare

Eric Beck shares his thoughts on where mobile integrated healthcare is headed, and how it goes beyond community paramedicine to connect healthcare providers

By Jenifer Goodwin, EMS1 Contributor

Over the past year, EMS leaders have been engaged in high-level discussions about mobile integrated healthcare, a strategy that emphasizes a broader role for EMTs, paramedics and EMS systems by collaborating with hospitals, doctors, nurses, social services, nonprofits and public safety to meet a variety of community health needs by

Eric Beck, Associate Chief Medical Officer for Evolution Health and American Medical Response, is focusing on their efforts in the area of mobile integrated healthcare. He previously served as the Medical Director of the EMS System for the City of Chicago.       

Growing up near Cleveland, Beck got began his EMS career in high school working as an EMT for a volunteer fire department. He finished his paramedic training as a senior in 1999, later graduating from the fire academy.

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.

We spoke with Beck to get his insight on mobile integrated healthcare. 

What is mobile integrated healthcare?

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 envision this being a series of dialog that needs to include not only people in EMS but those outside the traditional EMS world.

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.

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. 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?

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.

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?

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.

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