Home Health, Hospice and EMS Team Up to Tackle the Triple Aim

The drive to achieve the IHI’s Triple Aim has fostered the creation of many innovative partnerships. This column focuses on the synergistic relationships and integrations developing between mobile integrated healthcare (MIH) and the home healthcare industry.

One of the main goals of MIH is to navigate patients through the healthcare system, not replace healthcare system resources already available in the community. Home health and hospice are valuable links in the chain of healthcare—and, for qualifying patients, a logical care delivery model that can be enhanced through a partnership with a mobile player like the local EMS agency.

Increased Referrals

Home health providers are increasingly being challenged by hospitals and insurers to reduce preventable emergency department visits and hospital admissions. Patients on home health services tend to have multiple chronic diseases with polypharmacy and are at significant risk for ED visits or hospital admissions. Under the transitioning healthcare system, hospitals are held financially accountable for certain unplanned readmissions. And, if the hospital is part of a risk-sharing financial arrangement such as an ACO, they are financially at risk for the admission.

Consequently they desire to refer eligible patients to home health agencies that can ensure the patient safely transitions to the home environment without returning to the hospital unnecessarily. A home care agency that can appropriately prevent unnecessary ED visits or admissions gains an advantage over other agencies in today’s new healthcare environment. MedPAC is recommending to CMS that home health agencies also receive penalties for patients who return to the hospital. The policy recommendation outlines a savings to the Medicare program; if approved in 2015, it could save $50–$250 million. MedPAC suggests that, with the growth in healthcare utilization and the growing population, penalties to home health agencies for any readmissions could save as much as $1 billion by 2020. This paves the way for partnerships.

While home care agencies instruct patients to call them for any changes in their condition and routinely staff a registered nurse 24/7, often patients and families call 9-1-1 out of panic as opposed to true medical emergencies. Developing a partnership with EMS first responders in the home care service provides an opportunity for the home care on-call registered nurse to be notified by the first responder while they are en route to the patient’s residence.

Klarus Home Care has this type of innovative partnership with MedStar in the greater Fort Worth and surrounding areas. MedStar enrolls Klarus patients in their first-responder service area into their database, which allows the call center to identify that a patient who calls 9-1-1 receives home health services from Klarus. In addition to sending an ambulance, MedStar also dispatches a specially trained mobile healthcare paramedic (MHP) to the scene. The on-scene MHP then works directly on the phone with the Klarus RN to do real-time care coordination for minor medical issues. Perhaps the patient can be managed at the scene with a follow-up visit by the home health nurse, thereby preventing an avoidable ED visit or hospital admission. Hospitals are looking for home health providers who are utilizing innovative approaches and whose data can demonstrate a reduction in avoidable hospitalizations. Klarus absorbs the costs in their partnership to accomplish the goal of reducing hospitalizations from 9-1-1 calls.

EMS-MIH and Hospice Care

The goal of the hospice agency is to help the patient at home transition to their afterlife with comfort and compassion. The family is instructed in the proper way to access the hospice nurse if the patient begins to struggle. Unfortunately, in the panic of seeing their loved one struggle, many families call 9-1-1. This starts a domino effect. The EMTs and paramedics assess the patient and find them in clinical distress. The family is scared and cannot locate the DNR. EMS does what it is trained to do: Start treatment and take the patient to the ED. Once in the ED the hospital initiates care, and the family may decide this is all too overwhelming and voluntarily disenroll the patient from hospice. The patient’s wishes are not fulfilled; the hospice agency now has ambulance and ED bills to pay and loses the per-diem fees normally available had the patient stayed on service.

In Fort Worth we can see a different outcome from the same scenario thanks to an innovative partnership with VITAS Healthcare. When the family calls 9-1-1, the computer-aided dispatch system notifies the 9-1-1 call taker that this patient is enrolled in the VITAS partnership. This causes an alternative domino effect: A hospice-trained MHP joins the ambulance response team, and the patient’s hospice nurse is notified of the response. When the MHP arrives on scene, they assess the patient and determine if the clinical issue is part of the hospice plan of care. If so, they access the patient’s comfort pack, alleviating the patient’s suffering; remind the family of the goal of hospice care and wishes of the patient; and inform them that the hospice nurse is on their way. They offer to wait with the family until the hospice nurse arrives and release the ambulance back into service. No transport, no disenrollment, and the patient’s wishes are achieved.

In the event the patient’s condition on scene is such that management at home is not practical, care coordination occurs between the MHP on scene and the VITAS nurse to have the patient transferred to an in-patient hospice unit.

Under this program 168 patients at high risk for voluntary disenrollment have been enrolled by VITAS since 2013. These patients generated 49 EMS calls, but only 29 were transported. A dozen were transferred to an in-patient hospice unit, and 17 were transported to the ED at the insistence of the family and subsequently disenrolled from hospice (10%). The rest died peacefully at home.

These are examples of how EMS-MIH and home health can work collaboratively in a cooperative relationship designed to meet the needs of the patient.

Patient Experience: VITAS and EMS

• Priority 1 9-1-1 call identified as VITAS client in 9-1-1 CAD.
• Specially trained MHP added to response, arrives to find patient alone.
• Patient relates she became anxious and short of breath and is unable to move from chair to turn on her oxygen on her own.
• Client appears to be weak with limited mobility due to Parkinson’s.
• Paperwork for VITAS is laid out on the table with signed DNR.
• Patient has around-the-clock care with providers obtained by her family, but they leave Saturday mornings and are not back till the afternoon.
• She relates her caregiver is off today and she is supposed to have a substitute arrive at 11 a.m., but they are late.

EMS Care Coordination with VITAS:

• On-scene MHP speaks with VITAS triage nurse and discusses the situation.
• The client is on her oxygen and relates that prior to EMS arrival she took something for her spasms but was unable to determine what.
• Relates she feels much better now that she has her oxygen on.
• MHP releases ambulance and FD unit, waits for caregiver to arrive and explains the situation.
• Also speaks with the VITAS triage nurse.
• Patient is left in care of caregiver.
• VITAS does a home visit later in the day.

Outcome:

• Patient stabilized and made more comfortable.
• Patient and family wishes are met.
• Transport to ED, admission, potential voluntary disenrollment avoided.
• Care coordinated with VITAS.

Patient Experience: Klarus and EMS

• 67-year-old male, DX of cardiomyopathy, chronic heart failure, pleural effusion, diabetes type II.
• Exacerbation of CHF 2x in last 60 days, treated by RN using Klarus CHF protocols, 40 mg IV Lasix.
• Patient calls 9-1-1 due to exacerbation, does not call Klarus.
• Patient IDs as a registered Klarus client in 9-1-1 computer system, specially trained MedStar paramedic added to 9-1-1 response, on-call Klarus RN notified of response while units en route.

EMS Care Coordination with Klarus:

• Paramedic on scene assesses patient and contacts RN from scene.
• Paramedic assessment to RN: patient short of breath, legs swollen, edema 3+.
• RN advises specially trained paramedic to use CHF protocol & administer 40 mg IV Lasix.
• MedStar verifies CHF orders in Klarus EMR & consults EMS medical director.
• IV Lasix administered.
• MedStar provides follow-up visit later that night, checks potassium, consults on-call physician, adjusts patient’s PO potassium.
• Klarus RN follows up with patient within 24 hours.

Outcome:

• Patient not transported to emergency room.
• CHF exacerbation signs and symptoms eliminated.
• Klarus Home Care & MedStar coordination prevents hospitalization.
• Healthcare system cost savings: $9,203.

Meredith Anastasio is managing director at the Lincoln Healthcare Group (LHG) and leads the planning of Home Care 100 and Home Care & Hospice LINK.

J. Daniel Bruce is the administrator of Klarus Home Care in Fort Worth and is responsible for the ongoing relationship with MedStar. He is a leader in the development of partnerships to create value-based services.

John Mezo is the general manager for VITAS Healthcare in Fort Worth, overseeing program operations, developing business opportunities, hiring and mentoring new staff and representing VITAS throughout the community.