By Michael Colman, MPA, NRP, EMS1 Contributor
Grady EMS is the 911 provider for the majority of the City of Atlanta and is hospital-based owned and operated by Grady Health System, a safety-net hospital in a major metropolitan area. Grady EMS sought to provide expanded EMS services to reduce the number of ambulance transports among frequent utilizers.
The expanded services included outreach to those frequent utilizers with an advanced practice provider (MD or nurse practitioner) who could address patient needs proactively in order to reduce the number of emergency transports.
A pilot test of the program visited 60 patients at home out of 102 identified for outreach in the pilot program. Among patients accepting the home visit, the average number of calls per 30 days was reduced 59.1 percent, and sustained a 44.5 percent reduction in the 90-day period after the intervention. In 26.7 percent of visits, the clinician identified active medical problems that could not have been addressed by EMS services alone.
A review of Grady EMS 911 call records in 2016 revealed that 1,529 individuals had five or more EMS responses to 911 calls. In total, these individuals representing 1.25 percent of total patients accounted for 13,282 calls, or 10 percent of the total calls.
Sustained reductions in EMS utilization
Grady EMS paired an MD or nurse practitioner with a broad scope of practice, including prescribing authority, with a community paramedic to reach frequent 911 utilizers to provide participating patients appropriate acute care in the moment. EMS staff then connected patients to follow-up care and transportation to help patients establish a primary medical home, which should result in sustained reductions in emergency services utilization in the long term.
The immediate objective of the Grady MIH High Utilizer Pilot program is to demonstrate that pairing a community paramedic with an advanced practice provider to visit patients at home is feasible and successful in reducing emergency service utilization. The intent is to bring a comprehensive social and medical approach to preemptively intervene with patients likely to present in the emergency department. Patients’ immediate care needs should be addressed in the moment by the pilot program staff and patients should be provided with necessary follow-up support to connect to primary health care and other social services. The intervention is expected to yield an immediate and sustained reduction in the utilization of emergency and hospital services among the patients served.
Grady EMS has successfully operated a mobile integrated health program featuring a community mental health unit which pairs specially trained EMS staff with a licensed social worker since 2012. The Grady EMS program recognized the opportunity to play a productive role in offering services to a broader population of patients at higher risk for health complications, uncoordinated care, and patterns of frequent use of emergency and hospital services.
Past success in operating other MIH outreach programs and existing full-access to the Grady EHR system, along with the financial ability to contract a part-time physician, and the very close relationship between the EMS service and care nodes throughout the health system created a climate that permitted a pilot program to begin with minimal limitations and delays.
MIH pilot program patient criteria
The team created exclusion criteria:
- Patients that reside in a SNF, jail or prison;
- Homeless without cell phone;
- Under the case of a pain management clinic;
- Under 18 years of age;
- Pregnancy related; and
- History of significant substance abuse or persistent mental illness.
For the remaining patient cases, the team next considered potential interventions that could have been offered other than transporting to the ED. The resulting list included a wide variety of interactions based on the specific cases and EMS staff experience, including:
- Refusal or re-scheduling of service, or need for emergency service transport
- Help picking up medicines or establishing medication delivery
- Scheduling appointments with primary care or specialist providers
- Transportation support for follow-up visits
- Medicine management help including training and assistance with injectable medicines, medical device assistance, re-order or provide supplies, first aid and wound dressing changes, order new or refill medicines, on-scene labs and x-ray
- Order additional medical services, re-order home health, schedule medical appointments, refer/connect to social support programs
This process to identify patients was repeated throughout the duration of the pilot to continuously identify patients who could benefit from the outreach. EMS support staff made calls to patients using the last-known contact information to schedule visits. Not surprisingly to the team, many patients were unreachable by phone, so the MIH team also attempted unscheduled visits at last-known addresses.
Community paramedic scope of practice
When patients were reached at home, the community paramedic made introductions, explained the reason for the visit and gained patient consent. Often, several minutes of small talk and exchanges with family and cohabitants passed before any attempt at assessment was begun.
The MIH program did not pre-determine any specific assessments or evaluations, but rather each professional was permitted to work within their experience and scope of practice to assess, triage and respond to identified health concerns. For community paramedics this scope of practice included:
- Providing scene safety,
- Coordination with 911 communication center, and
- Scheduling outpatient appointments and MIH follow-up visits
They also assisted with:
- Patient evaluation,
- Education,
- Self-management,
- Monitoring, and
- Administration skills for medical devices and therapies.
Community paramedics applied their knowledge of the community and experience in serving patients in the home environment to aid in identifying non-clinical determinants of health and assisting in connecting the patients with community service providers.
The advanced practice providers conducted a full patient evaluation, including most common laboratory tests for blood and urine samples using the I-stat® portable laboratory device on the MIH truck. Mobile x-ray services could be ordered with a local provider typically available to respond within two hours if the patient’s home was accessible.
Community paramedics assessed home, social and family dynamics, focusing on solutions that exist in the community. They also provide scene safety for the clinician, communicated with the 911 dispatch, recorded encounter notes, and arranged follow-up and referred services.
Community paramedics were typically able to respond alone to follow-up visits (e.g., to repeat vital sign monitoring and lab tests, or provide medication management and device assistance following new orders from the initial visit under the direction of the advanced practice provider).
Grady EMS operates under the oversight of Medical Director, Arthur Yancey II, MD, MPH, and EMS staff can also contact either of two EMS Fellows assigned to the service. As Grady EMS does not have specific protocols for the MIH paramedics, any encounter that results in needed treatments or procedures must fall within their normal EMS scope of practice under their clinical care guidelines.
Feasibility and impact of MIH-CP
In total, 102 patients were identified for outreach in the pilot program. Sixty-one eligible patients were reached at their homes and 60 accepted the home visit, yielding a 58.9 percent proportion of eligible patients successfully receiving the pilot intervention service (Measure 1). Some patients were reached by phone, while many were met in their homes during unannounced visits.
Patients accepting the MIH home visit averaged 3.96 calls each within the 30 days preceding the visit, with a total of 238 calls for the 60 patients. In the 30-day period following the initial home visit contact, these patients averaged 1.62 calls each, with a total of 97 calls. This represents a 59.1-percent reduction in the rate of 911 calls for the intervention group (Measure 2). These same patients averaged 5.53 calls each in the 90-day period preceding the intervention (total of 332 calls), which was reduced 44.5 percent (Measure 3) to an average of 3.07 calls in the 90 days following the first visit.
The frequency of calls within the preceding 30 days for patients reached by the intervention service ranged from one to 13, with only seventeen patients reaching the originally intended threshold of five or more calls. Among these patients, the average call volume in the period before the intervention was 7.53 calls, which was reduced by 49.5 percent to an average of 3.8 calls in the period following the visit.
Following the conclusion of the pilot program, a chart review was completed to classify and quantify the types of services offered. The categories listed in the table below were developed by the MIH program staff to capture the range of potential services that could be delivered during home visits grouped by the scope of practice required to offer the service. Of the 60 patients accepting the home visit, 16 received services that are exclusively permitted by the expanded scope of service of the advanced practice provider.
The findings of the 911 High Utilizer Pilot project support the rationale behind the approach to pair a community paramedic and advanced practice provider clinicians to visit patients in their homes. The complexity of health and social concerns among loyalty customers was reflected in broad criteria necessary to exclude patients from eligibility due to a range of concerns.
The pilot intervention achieved the goal of reducing future emergency service utilization, both in the short term (59.4-percent reduction) and sustained over a 90-day period (44.7-percent reduction). At the conclusion of the pilot program outreach, the team felt confident that the feasibility and positive impact of the EMS-APP team had been demonstrated.
About the author
Michael Colman is vice president, Grady EMS, Atlanta, Ga. Michael has been with Grady EMS for eight years in various leadership roles and currently oversees the MIH programs.
Two additional authors contributed to this article who were not authorized to be disclosed due to their employment affiliation.