Community Health Programs - RCCP · Community Health Programs Emergency ambulance triage and...

Lessons from Reno’s CMS Innovation Grant PINNACLE 2013

Brenda Staffan 1

Community HealthPrograms

REMSA’sREMSA’s

Health Care Innovation AwardHealth Care Innovation Award

AUGUST 8, 2013

Acknowledgment & Disclaimer

This program was made possible by a grant from the Department of Health and Human Services Centers forDepartment of Health and Human Services, Centers for

Medicare & Medicaid Services.

The contents of this presentation are solely the responsibility of the authors and have not been

approved by the Department of Health and Humanapproved by the Department of Health and Human Services, Centers for Medicare & Medicaid Services.


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Agenda

• Background on Healthcare Innovation Awards

• Describe the CMMI award process

• Introduce REMSA’s Community Health Programs

• Share experience with improvement methods and learning

• Identify potential new reimbursement methodologies

No findings at this stage – pilot – launch – learn

Health Care Innovation AwardsHealth Care Innovation Awards


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Health CareInnovation Awards

• 107 Health Care Innovation Awards (HCIA) in first round

• Over 3,000 submissions; collectively, awards serve most or all states; HCIA awards range

$ $from approximately $1 million to $30 million for a three‐year period

• REMSA Award: largest EMS grant, only urban EMS grant, only Nevada‐based HCIA grant

Patient Protection and Affordable Care Act

1 Fi M di1. Fix Medicare

2. Cover the uninsured

3. Control costs

4. Improve quality & efficiency

5. Improve insurance coverage

6. Focus on prevention & wellness

Signed into law by President Obama March 23, 2010


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Center forMedicare & Medicaid Innovation (CMMI)

The CMS Innovation Center has a growing portfolio testing various payment and service delivery modelsthat aim to achieve better care for patients, better health for our communities, and lower costs through

improvement for our health care system

www.innovations.cms.gov

TRIPLE AIM

Better Health

Better Care

Improve the quality andImprove the quality andexperience of care experience of care

Improve the healthImprove the healthof populationsof populations

Lower Costs

Reduce per capita costReduce per capita cost


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Impact of National Health Care Reform on EMS

Unique Opportunity for Healthcare System Redesign Unique Opportunity for Healthcare System Redesign

Leverage the population‐based coverage of emergency medical services to improve the health care delivery system

Deliver value‐added services

Build workforce & health information technology capacity

CMMICMMIAward ProcessAward Process


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CMMI Award Process

• REMSA application – Jan 2012

$• Negotiation to reduce grant from $16.9M to $9.6M – June 2012

• Notice of Award (NOA) – June 2012

• Revised Notice of Award (NOA) – Dec 2012

A l B d t R i i A li ti f• Annual Budget Revisions, Application for Award Continuation, NOA Updates

• Quarterly Reports & Annual Report

[Insert TEXT]

Now the real work starts!Now the real work starts!


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Million‐dollar Murray

was a homeless alcoholic manin Reno, NV

REMSA’sREMSA’sCommunity Health ProgramsCommunity Health Programs


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REMSA’s Healthcare Innovation Award

• $9.6 million invested / $10.5 million saved

• Three (3) Years

o July 1, 2012 through June 30, 2015

• 19 grant‐funded positions

o 9 Community Health Paramedics

o 7 RN Nurse Health Line/Health Navigators

o Project Director, IT Specialist, Outreach Coordinator

Community Health Programs

Emergency ambulance triage and treatment redesignEmergency ambulance triage and treatment redesigncreates new referral pathways assuring patients receivethe safest, and most appropriate, level of quality care

Ambulance Transport Alternatives

Launched Dec 2012

• Ambulance‐based f l i

Community Health Paramedics

Launched June 2013

• Specially trained i h l h

Nurse Health Line / Nurse Navigators

Launch August 2013

• Registered nurse health i id 24/7payments for alternatives

to transport to the emergency department, including transport to urgent care center, clinic, mental health hospital, detoxification center, medical group office

community health paramedics perform in‐home delegated tasks to improve the transition of care from hospital to home, perform point of care lab tests and improve care plan adherence

navigators provide 24/7 clinical assessment, education, triage and referral to health care and community services via a non‐emergency nurse health line available to all Washoe County residents regardless of insurance status


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Three InterdependentInterventions Achieving a Balance

Over‐triage

Under‐triage

AIMBy 6/30/2015, improve access to appropriate levels of quality care and

treatment by 40% and reduce total patient cost by $10.5 million over three years for Washoe County 911 acute and non‐acute patients.

Benefits

• Patients

• Community

• Hospitals

P bli S f

Measures

• Increase patients receiving better care via transport to non‐ED site by 9%

Goals

• Integrates EMS, medical, mental health and social services systems

• Expands access to • Public Safety

• Payer

• REMSA

• Increase patients receiving better care via community paramedics by 5%

• Increase calls to nurse health line by 5%

pearly health care intervention

• Builds health care workforce to support insurance expansion in 2014


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By 6/30/2015, improve access to appropriate levels of quality care and treatment by 40% and reduce total patient cost by $10.5 million over

• Design integrated health information technologies and uniform electronic patient care reporting system across multiple health care providers and facilities.

Primary Drivers Secondary Drivers

9‐1‐1 emergency ambulance triage and treatment redesign: Alternative pathways are provided to patients seeking medical evaluation of urgent medical conditions.

Aim• Training: specialized paramedics and nurses.• Protocols: to assess and match patient care needs to

appropriate health care provider or community service.

Community Health Early Intervention Team Driver Diagram

y $three years for Washoe County 911 acute and non‐acute patients.

• Exchange patient care data across targeted patient care delivery settings and networks (including 9‐1‐1 system, hospital emergency department (ED), urgent care centers, physician offices and medical home).

Enable exchange of data/communications: New health information technologies link emergency ambulance delivery system and the broader health care delivery system.

• Increase % non‐acute patients receiving better care and shorter ED wait times via treat and release or transport to non‐ED site

MeasuresStakeholder and community engagement: New linkages between the emergency ambulance delivery system and the

• Engage key health partners and community stakeholders; target patient populations receive better care from community health paramedics.

• Market community‐wide non‐emergency phone number (as an alternative to dialing 9‐1‐1) tied to a nurse‐staffed 24/7 call center which provides medical advice and triages patients to the appropriate health care provider or community service.

Version 101.31.2013

Aligned financial incentives: Reform of

existing payment systems achieves sustainable funding of patient care services.

• Establish shared savings model among key system partners.• Develop new reimbursement methodologies for 1)

ambulance‐based treat and release and transport to non‐ED facilities, 2) medical evaluation services by community health paramedics, and 3) community‐based nurse triage center.

• Establish ambulance‐based payment for transport to urgent care center; patient treatment at scene and release; and patient treatment and refer to alternate health care provider.

• Program integrity: Build fraud, waste and abuse prevention measures in partnership with payer, regulatory and national organizations.

or transport to non ED site by 9% per year by 6/30/15.

• Increase % targeted patients receiving better care via community health paramedic intervention by 5% per year by 6/30/15.

• Increase % patients calling the nurse triage center by 5% per year by 6/30/15.

y ybroader health care delivery system.

In the Beginning


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Health Information Technology

Market community‐wide non‐emergency phone number

Community Outreach

phone number

Improve awareness by the public regarding how to access to the right choice of health care

Increase the health literacy of Washoe County residents


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Grant Teams

Elaine Messerli, RN

Jason Knight, CHP

Melissa Krall

Mollie Howerton, PhD, MPH

CMMI Project Officer

Ji G bb l CEO

Nancy Toy

Chris Watanabe

Don Vonarx

Bonnie Drinkwater, JD

Patrick Ruether, CHP

Diane Rolfs, RN

Jim Gubbels, CEO

Mike Williams, VP Operations

Joe Ryan, MD, Medical Director

Community HealthParamedics

L‐R: Patrick Reuther, Dr Joe Ryan, Ryan Ramsdell, Jason Knight, David Rathburn, Anthony Martinez, Dominic Polimeni, Katrina Travis, Jake Beck, Cleve Schuster


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Nurse Navigators

L‐R: Lisa Lee, Lisa McLaughlin, Elaine Messerli, Natalie Smith, Melane Marsh

Partners are criticalto innovation grant’s success

Health CarePartners

• Hospitals

• Urgent Care Centers, Clinics, Medical Groups

• Community Triage

CommunityPartners

• State EMS Office

• State Health Officer

• District Board of Health

Data/EvaluationPartners

• Federal CMS Innovation Center

• University of Nevada, Reno –School of Community Health

Center

• NNAMHS

• HAWC, Hopes

• Senior Groups

• Public Safety Agencies

Community Health Sciences

• Nevada Center for Health Statistics & Informatics

• Lewin Group, Rand


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Community Health Paramedic Graduation

Helping our patients to solve their medical, mental, social, life care problems


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Patient Benefits

Provides access to Nurse Health Line / Nurse Navigators regardless of insurance status via 24/7 non‐emergency phone number

Offers new services and focuses on expanded patient options in responding to urgent low acuity medical needs:

o Medication reconciliationo Compliance with primary care planso In‐home evaluation of patient’s medical needso Referral to array of community resourceso Assessment of in‐home environment/home safety checkso Build personal health literacy and injury prevention

awareness

Community Benefits

Strengthens the integration of EMS with medical, mental health and social services systems and expands access to early intervention

Coordinates delegated tasks with primary care, home health, visiting nurse, hospice and ED o e ea , s g u se, osp ce a dservices

Builds expanded health care service capacity to support Medicaid eligibility and coverage expansion in 2014


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Hospital Benefits

Tailors solutions to each hospital’s strategic priorities

Reduces uncompensated care via alternative pathways for indigent and uninsured patients to receive needed services

Delivers value‐added service which may reduce 30‐

d h it l d i iday hospital readmissions

Creates new health information technology capacity

to exchange patient care data across targeted

patient care delivery settings and networks

Public Safety Benefits

Improves efficiency of local healthcare resources in an integrated population‐resources in an integrated, populationbased system

Tailors protocols for each first‐response agency to match emergency response capacity with demand for services

Builds injury prevention and wellness promotion capabilities in order to conserve limited public safety resources


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Payer Benefits

Creates new referral pathways and services assuring patients receive the most appropriate and safest level of quality care

Improves patient satisfaction and reduces healthcare costs

Facilitates extensive data collection and analysis capability so that successful interventions are measureable, replicable and scalable

REMSA Benefits

Benefits our patients, community and partners

Creates numerous opportunities for professional and personal growth of employees

Positions organization for growth and Positions organization for growth and sustainability during national health care reform


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Examples of EMS Innovation Initiatives

• Trail Blazers

MedStar – Ft Worth, TX

Louisville Metro EMS – Louisville, KY

NHS – Nova Scotia, Canada

Community Paramedicine Insights Forum

HCIA I Th EMS G t i R d O• HCIA Issues Three EMS Grants in Round One

Prosser Public Hospital District – Eastern Washington

Upper San Juan Health District – Southwestern Colorado

Examples of EMS Innovation Initiatives

• Federal Agencies Issue EMS Innovations White PaperFederal Agencies Issue EMS Innovations White Paper

“Innovation Opportunities for EMS” – 7/15/13

DOT/HHS/ASPR/HRSA

www.ems.gov


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Operations PlanOperations Plan

Building the Operations Plan

• Develop a driver diagram

• Build project timelines and milestones

• Update approved budget

• Define a measurement strategy

• Establish project management infrastructureEstablish project management infrastructure

• Develop compliance processes

• Design pilot plan for execution

• Apply improvement methods to learn


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Project ManagementInfrastructure

• Six Cross‐functional Teams/Committees

• Basecamp On‐line Project Management System

o Milestones

o Action Items

o Calendar

o Files

o Assignments

o Notes

o Write board

o Messages/E‐mail


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Project ManagementInfrastructureInfrastructure

• Project

• Milestone

o Due date linked to driver diagram

• Action Items

o Assigned and date due

• Calendar

Original Project Timeline


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ImprovementImprovementMethods & LearningMethods & Learning

Science of Improvement

Measurement forResearch

Measurement forImprovementResearch Improvement

Purpose Discover new knowledgeBring new knowledge into daily practice

Tests One large “blind” testMany sequential, observable tests

BiasesControl as many biases as possible

Stabilize the biases from test to testp

DataGather as much data as possible, “just in case”

Gather “just enough” data to learn, complete another cycle

DurationCan take long periods of time to obtain results

“Small tests of significant” changes accelerates rate of improvement

Source: IHI Knowledge Center


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Improvement Methods & Learning

• Theory of change (driver diagram)

• Portfolio of projects (interventions)

• Small scale pilots, rapid cycle testing

• Repeat PDSA cycle, grow the scale

• Process mapping & root cause analysis

• Measurement & variation analysis

• Pilot to implementation to spread

Measurement & Evaluation

• Self‐Monitoring Plan

26 measures reported to CMS– 26 measures reported to CMS

– Outcome, Process, Structure, Balancing

– Quality, Cost, Utilization, Satisfaction

• Operations Plan

– Quarterly milestones

• Technical Support

– CMMI, Lewin, Rand, EMS Collaboration Work Group

– TrueSimple LLC

– University of Nevada, Reno

• REMSA CHP AIM & Measures Report


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Run Chart

Potential Reimbursement Potential Reimbursement MethodologiesMethodologies


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Components ofEMS System Design

Performance Requirements

Medical Control / Oversight

Financing Strategy

Business Structure

Legal Framework

Project Sustainability

• HCIA grant program requires planning for project sustainability

• EMS in unique position as population‐based health care delivery system

• Integration of EMS care delivery, dataIntegration of EMS care delivery, data systems, community‐wide coverage with the rest of health care system

• CMMI Aim: “Test new payment models”


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New ReimbursementMethodologies?

• New Service Delivery Modelsy

– Ambulance‐based payment for transport to alternative destinations

– Services by Community Health Paramedics

– Services by Nurse Navigators

• New Payment Models

– Fee‐for‐service, shared savings structures, bundling, accountable care organizations, global payments, program integrity

What’s Next?

• Launch Nurse Health Line

• Expand scale of ATA and CHP

• Evaluate patient satisfaction and patient quality of life

• Plan, Do, Study, Act

• Test early theories and refine

• Learn! Learn! Learn!


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TRIPLE AIM

Better Health

Better Care

Improve the quality andImprove the quality andexperience of care experience of care

Improve the healthImprove the healthof populationsof populations

Lower Costs

Reduce per capita costReduce per capita cost

Resources

• CMS Innovation Center

–www.innovations.cms.gov

• Institute for Healthcare Improvement

–www.ihi.org

• The Improvement Guide: A Practical pApproach to Enhancing Organizational Performance (2nd Edition)

– Langley GL, Nolan KM, Nolan TW, Norman CL, Provost LP


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Acknowledgment & Disclaimer

This program was made possible by a grant from the Department of Health and Human Services Centers forDepartment of Health and Human Services, Centers for

Medicare & Medicaid Services.

The contents of this presentation are solely the responsibility of the authors and have not been

approved by the Department of Health and Humanapproved by the Department of Health and Human Services, Centers for Medicare & Medicaid Services.

Community Health Programs - RCCP · Community Health Programs Emergency ambulance triage and...

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