Community Paramedicine Webinar

- To the EMS section webinar. As you know, this is probably our third webinar we've had. We plan to have these on a quarterly basis going forward. So you'll see some future postings on the website eList regarding additional topics in the future. We're very excited to have a very distinguished panel today. Some housekeeping items. First, if you would, if you're an attendee, if you will mute your microphone, that'll help us control some of the background noise. There's a couple of ways to interact with the presenters. If you have a question or a comment, you can use the raise your hand option. There's also a chat box option where you can enter comments or questions and we'll make sure the presenter gets those and responds. I'm sure there'll be question and answer sessions after each presenter, and then there's a round table at the end. So with that, I will turn it over to Dr. Brent Myers. He is our lead presenter, and he'll introduce the rest of our panelists, Dr. Myers.

- Great, thanks Rick, and thanks everybody for joining us. This is a topic I think near and dear to a lot of our hearts, and we're going to try to go through it in kind of three phases, and we'll go over those in just a moment. I do want to make sure that we show our disclosure slides, and so these are the disclosures that we each have to make. And then the agenda goes something like this. I'm going to briefly touch on the fundamentals of EMS reimbursement, and then the options for treat-in-place that are in front of us and a little bit around the telemedicine piece. We'll then turn it over to Jose Cabanas from Wake EMS, and he will talk about their falls and nurse navigation. Dr. Holman will reflect on some issues with the fire department in DC and their success with nurse navigation. And then we will have the last presentation for Meg Marino to talk about the telemedicine piece and its interaction with EMS and the field. We'll pause between each of these to take any questions or comments that people may have. And with that, we'll just go ahead and get started briefly with the overview. So a couple of things, there are just some general concepts most of us are familiar with, but just as a part of the level set here, the compensation obviously for EMS or with very few exceptions, occurs as a result of transport. For the 911 service, that degree of compensation is almost a bean counting exercise, as most folks know. No interventions, one intervention, three or more interventions give you different billing levels around the 911 side. Medical necessity on the other hand, is often required for interfacility, air ambulance, and then any of the scheduled transfers. We have noticed over the past 12 to 24 months, the lines between emergent, non-emergent, and scheduled are not quite as clear as perhaps we may have thought they were. The notion of reimbursement and how it is being judged around medical necessity has become more under scrutiny. I think many of us believe, and through our time, a lot of medical necessity for 911 around CMS has been more or less determined by the patient's request via the 911 line. And we are hearing anecdotes of even that being challenged over time. So we're kind of setting ourselves up for this incredible conflict. Which is the only mechanism for reimbursement is transport. But more and more the necessity of that transport is being called into question, but yet there's no alternative, particularly on the 911 side for the provider. In other words, the call may not meet medical necessity, but there's no reimbursement for any other options. So this type of scenario is very ripe for disruption. Right before 911, excuse me, right before our COVID interruption, we know that ET3 was rolling out. Interestingly, as those that have followed this graphic over time may recognize, this graphic is yet again changed in a couple of ways from its original. The first of those is you'll see nurse navigation is no longer present here on the graph. And then the second is ambulance suppliers and providers language has been added. It used to say only ambulance suppliers or suppliers of EMS and that type of thing. But otherwise, I think we're fairly familiar with this, and the panel, I think, as we go along, will have some interesting insights into why this may or may not be a successful model going forward and why some of our participants are participating in ET3 and some are purposefully not participating in ET3. And that I think will be a point for good discussion and questions. Finally, I think is most folks are aware, during the public health emergency around COVID, there is a waiver for ground ambulance transport. And the government has committed to both the states and various hospital associations that they will give a 60-day notice prior to the termination or the expiration of the public health emergency. We are now inside that 60-day window for the October expiration. So it is anticipated that the public health emergency will continue at least until January of next year unless something very unusual happens because they've done 90 day renewals every time, and it doesn't appear they're going to let it expire in October. So this opportunity will remain. There's some very particular things around this, and not the least of which is that one has to determine that this patient would otherwise have been transported, were it not for the public health emergency, which obviously gives a lot of room for interpretation. The other piece to keep in mind is that as this expires, and we know there's some difficulties with ET3 being implemented, there is also the opportunity to continue this treat-in-place in the absence of the public health emergency. So we may see some of that as well. Finally, as we've been preparing for today, there were some common themes that the panel developed as we discussed ways that things could be successful in any of these community paramedicine alternative destination scenarios. The first of those was strong physician medical direction, and it was observed that not all EMS physicians, not all emergency physicians may have expertise in population health. Some do through their EMS fellowship or their masters in public health, et cetera, but that that notion of understanding not just the acute care episode, but the full population health and the opportunities in a community was important for a successful program. The third is this common savings metrics. What are we doing, what describes success? And something probably beyond the bean counting of avoiding EB transports, but moving on to is the patient satisfied? Are there transports in the next 24-72 hours a week, et cetera? And then finally, a clear and sustainable funding mechanism. And for some in the pilot program, ET3 may be the start. Nurse navigation may be re-emerged in shared savings, telemedicine may have a direct fee for service. But thinking about these concepts as all of these programs are set up, not just on a single one cycle grant, but mechanisms that could promote at least some interim stability, if not long term stability in the payment structure. So with that, by way of introduction, I'm gonna hand it over to our good friend Jose from Wake County to describe what's going on in their community, Jose?

- Thank you, Brent, thank you all, good morning. Jose Cabanas here, medical director Wake County EMS, and also present government of NAEMSP. Thanks so much for the invitation. So this is a great conversation that I think our industry has been working through through the past several years, but the pandemic has sort of magnified this conversation. For Austin and Wake County, some of the topic of discussion around providing care in different ways is also associated to the fast pace of growth that we're experiencing in our community. And I think a lot of folks in your communities are feeling the same pressure of just growth and increased demand for services. Next slide, Brent, get one, thanks. So if in a growing community, in the context of the sort of the pressure with regards to the effects of the pandemic, something has to change. Because for example, in our community in Wake County, if the growth rate model that we have experienced based on the pressure points from COVID has been around 15% more ambulance responses. Typically we grow around three to 5%, COVID sort of, when restrictions were lifted, sort of magnified that fast pace of needing access services by members of the community. So if that pace keeps constant with regards to the need for ambulance services, we need to add more and more additional resources every year, which is not sustainable. And for context, an average ambulance in our community is expected to run around 2,700 calls per year. So this is forcing the question on the same lines that Brent mentioned, how do you provide services in a way different? So one point that I wanna highlight here, I think everybody in this call on this webinar likely agree as well, is that the pandemic and the things that we have learned from the pandemic has magnified the need for EMS systems to take a very hard look at how we operate and explore new ways to enhance and diversify service delivery. In Wake County, we have sort of done along, many, many years now, different innovative ways providing services for specific segments of the population, tried to connect them with better access sponsored healthcare. Today I'm gonna have a little bit about our learning experience that we've had with nurse navigation this past six, seven months, and also talk about our falls in assisted living program, which has helped sort of connect patients with right care at the right time, right place. So our nurse navigation program, which is something that is very new for our community in essence, was built out of the sort of the necessity to help connect patients with low acuity calls to all the access points to relieve the pressure from the EDs and the overall healthcare system, including the EMS system. So in essence, in our community, the nurse navigation program is structured in this way. So if somebody calls 911, obviously if they have a life-threatening emergency, it goes through a regular sort of call processing protocol of MPDS, which we have, if it's a life threatening problem, it goes regular route. If you have a sort of a what appears to be a non-life-threatening complaint type, the call gets transferred to a nurse navigator, which pretty much will do a more in depth sort of assessment and of what's going on at the time. And then based on that assessment, the nurse may advise you to sort of follow up with a primary care provider based on their protocols. They may actually offer you a ride share service to go to one of our network clinics or urgent cares in the community. If you have a non-life-threatening problem, or if there's a concern that comes up in that secondary assessment, a call will comes back to 911, and we send an an EMS resource. So this is sort of the framework of how we have structured nurse navigation program, which is not that different from other communities in the country. So our experience in the first six, seven months is we have sort of navigated or sent for processing or eligibility for nurse navigation around 3000 calls in those first few months. We don't send any falls or seizures, MPDS calls for obvious clinical reasons. We've had around a thousand calls as of this week that have been managed successfully outside of EMS. We've actually high satisfaction scores, 670 calls around, pretty much given self-care instructions and follow up. Around 225 alternate destinations that I'm gonna talk a little bit more about that network, and 104, 105 sort of telehealth consults. Most patients are very satisfied with this level of service. Which is something interesting that we're learning through. The average phone pickup time for our program is around 22 seconds, and sort of the call average takes around eight minutes. Now, a significant proportion of calls come back to EMS, and you will see here in this numbers. But that's in essence it's a reflection of the access patients are seeking for. A lot of these calls are related to weekends or clinic after hours, which as the nurse navigation program matures, something that we're trying to build upon. And most, most of these calls a BLS resource would be appropriate to meet that need, which is something that we're integrating as we're deploying BLS assets into our system. So our nurse navigation line, one thing that we're learning so far is the healthcare network that has to be embedded within this system has to be strong and has to sort of be very interconnected. Since we're still learning as a community in this process, we have a telehealth provider, we have 15 urgent cares locations across the entire county within two healthcare systems. And then we have three sort of primary care clinics that are federal qualified centers that are able to take patients. And then we also have an alliance, which is our kind of mental health managed care organization in our region who provides health crisis sort of, not lines it's well connected to the nurse navigation line. And then we have a company that we sort of integrate with for mobile urgent care services. So this are sort of our network for nurse navigation resources. Now we are, again, we're still learning through sort of this program in our community. One things that I wanna share with the group here in this call is most patients that actually have access services through 911 for nurse navigation have some sort of insurance coverage. We tend to have what appears to be an older population call 911 with what appears to be a low acuity complaint. And then access and clinic hours is a consistent reason for requesting for EMS service. It was something that is not, you know, foreign concept for folks in this call, but it's something that is sort of is confirmed based on the lessons learned that we've had so far. So in addition to nurse navigation, we have, and for now over six, seven years, been working on sort of a program which is a falls at assisted living facilities program as an alternative care options protocol for this population. As you all know, EMS often transport patients with falls from assisted living facilities and often is because these facilities have sort of a policy or a concern from a risk management standpoint. And a lot of times these patients are uninjured and at their baseline health. So the goal that we embedded into this process was to find a protocol that avoids unnecessary transports for many of these patients. So the falls program sort of highlights a little bit of the convergent interest that I think a lot these programs in a way have in common, which is we have, for example, a facility or a provider corporation that wants to limit the liability for this encounters. We have permanent care physicians who wanna do right for their patients and minimize complications and discomfort, but sometimes they're not involved when events happen to trigger 911 call. And then we have sort of patients and family that they want to get appropriate care at minimal disruption and minimal cost. And then you have the pressure point that EMS and emergency medicine has with regards to space, availability, and resources. So the falls program's goal was to find the ideal care within all this convergent interest. And I think we've hit that balance even though we're still evolving in this program. So the ideal situation is if somebody has a fall at a assisted living facility, obviously all patients with a time sensitive illness will be transported to appropriate hospital, that's the goal. Patients without a time critical or time sensitive illness ideally would have timely follow up with a primary care provider and not be transported. And the patient and the decision maker for the patient will guide that treatment and be empowered to in the decision making process. So in 2015 we actually built a protocol that was retrospectively validated and published and you all can look up the citation in this paper trying to sort of build the decision language tool for these patients. So I wanna just hit the highlights on how the program works, next slide. In essence, we have three tiers. You know, somebody who meets Tier 1 criteria, those are patients that need absolutely go to the hospital. They have what appears to be a time critical or time sensitive condition. On the other spectrum, Tier 3 patients are patients that obviously don't have a complaint, don't have an obvious injury, don't have hip pain, and have a very simple bruise or something that clearly doesn't require a transport to the hospital. And then Tier 2 is sort of the middle where we actually want to have that consultation and real time discussion with the primary care provider for that patient population in that setting. So Tier 2, Tier 3, we engage the primary care physician in those discussions. So Tier 1, the notification, patients go to the hospital. Tier 2, we have a conversation with the provider covering for that patient, and we make a decision jointly. And then Tier 3 patient will be follow up within a timeframe at their location of residence in the facility and not be transported to the hospital. So we have published our results, I'm gonna highlight the data here, but obviously we can pull the papers and have more discussions, but retrospectively we showed that around 644 patients, almost 197 had a what appeared to be a sort of a time sensitive illness. The protocol identify 190 of those patients and a negative predictive value of 97%, which means 97% of people in this cohort who the protocols said were negative or a TSI truly did not have a time sensitive illness. We did a prospective validation of this study, that was published, and with, you know, we have a very clear definition for primary outcome. That was the need for a TSI patients who have a wound repair, fracture, admission to ICU operating room, cardiac cath lab or death within 72 hours from any cause. So prospectively a total of almost 260 patients had 840 ground level falls. The 553 recommended for no transports, and 11 had what appeared to be a TSI. For context, nine of the 11 were actually discussed with the PCP. Four of the 11 patients, even though were recommended for no transport, patient and family wanted them to go to the hospital. So we obviously respect that. And then three of the 11 actually preferred to stay on site at a facility and receive care. So 549 out of 553 actually got what we define appropriate care based on the prospective evaluation of the study. So pretty safe, and in a sense patient and primary care doctors were very satisfied with this process. Obviously our falls program is very integrated, to our ET3 sort of program. And since ET3 has implemented in our community, we've had a total 170 successful ET3 TIPs consults for patients that suffer a fall at a assisted living facility. Obviously this population is mostly Medicare beneficiary, so they will be ET3 eligible in that sense. So key learning points for me obviously here is paramedic can safely non-transport on this population. We've known that from our falls program. We had similar results based on retrospectively and prospectively. And an EMS protocol allowing EMS clinicians shared decision making regarding transport for assisted living resident with simple falls is cost savings compared to standard care. I didn't get into the details of the cost savings, but for purpose of time, but we did a cost analysis with some healthcare economists in UNC Chapel Hill. And treating a patient under this protocol on average is significantly less compared to just taking them to the ER. And I've put sort of the high level numbers here. Obviously this is only Medicare patients and Medicare as a payer, but when you scale these numbers up, the savings are very significant. With that, I will stop here and take any questions or Brent, any additional transition points here.

- [Participant] I have a question if I may.

- Yes, please, sorry we have a little issue here, go ahead.

- [Participant] You mentioned in your Tier 2s where you reached out and spoke with a physician. Was that an emergency medical command physician or a PCP covering or both?

- So that's a great, that's a great question. Sorry for the little fire truck in the background here. Since the inception of the program, the program was actually very structured around the fact that we had a very big primary care physician group that pretty much was interconnected or embedded in most of our assisted living facilities in the community, so that was a big leverage point. So their primary care physician group obviously had somebody on call, so we integrated with them because they knew their patient population very well and they gave us access to their EHR. So when the paramedic was on scene doing the assessments and embedding that communication with their PCP, they actually are folks documenting their EHR and arrange with them to follow up within 18 hours.

- [Participant] Thank you.

- [Jose] Yes sir.

- Jose, looks like Doug Kupas has a question as well.

- Doug, how are you sir?

- Hey there Jose, terrific, how are you? And can you hear me okay?

- Yes, sir.

- Right, my question with the falls is, and part of this may be because, you know, you have PCPS versus emergency physicians, but you know, we basically structured a program following your article and that sort of thing and it goes well with some people, but I find that it's difficult to get some physicians to be comfortable with an older person that has fallen and struck their head and not want them to come and get a CT. And obviously your data shows that you did not miss any bleeds, but I think the literature would show that, you know, people that are elderly with a lump on their head plus minus anticoagulants do have a risk of intracranial hemorrhage. And how do you overcome that? You know, sort of pulling in both directions, one, wanting to keep these people there. Not be disruptive to their routine and their family's routine and everything, and then versus they must all get a head CT if they've had a head strike.

- That's a great question and obviously I could go into very lengthy detail into some of those conversations, but high level I would say, Doug, part of it is it's kudos to the leadership of that group in the sense that they were very sort of proactive and knew the population well, and had in a sense, you know, in a way accepted and wanted to adhere to patient and the family wishes how they receive care. On the other hand, there was very good interconnection between the EMS systems and the leadership. So there was always ongoing communication and feedback, and they were very adhering to following patients in the timeframe that they committed to. I will tell you one of the things that we learned over time was most patients and family actually were happy that their loved one didn't go to the ER, and they actually, they felt very comfortable staying in their facility. So we did our best due diligence to make sure that our decision tool was not missing some of those potential scenarios, and it didn't and we haven't.

- And that's what we have found too is that the patients and families really are willing to accept a lower risk, or a low risk, do you do anything to specifically communicate the risk of a potential head bleed to them even though that it's low just so that you've documented or somehow shown that you have had that discussion or informed them of the low risk to make them more comfortable, or to make your providers more comfortable that they have, you know, had that communication.

- Right, so part of when this program got rolled out, there was a lot of sort of engagement education with the facilities who also had the initial concerns, the groups, but also when they have these encounters, there's an ongoing shared decision making conversation that gets documented. And part of it is, you know, they understanding, you know, risk of an injury or so, but they, I guess in the context of a specific injury, those conversations are discussed with the patient, with the PCP and the provider, and those get documented. Do we have a specific language? I think that we would defer a little more to the primary care physician who is over the patient, but we do have those conversations.

- Thanks, I've got one more from Marv Wayne, but right before.

- Oh, Marv.

- Right before, let me just ask.

- Warning in progress.

- Rick, if you could look at the chat for me. What I've figured out is me trying to open the bar to look at the chat is what's inadvertently forwarding these slides. So if you could just let me know if there's anything in the chat. Marv, you'll ask you your question, that'd be great.

- [Marv] Yeah, hey guys. First thanks for sending us Steve Cone. Question, I'd rather we keep going. Have you looked at any of the commercial telehealth companies to facilitate? We've been approached by a couple of them. One, Jose, you sound like maybe you're using something like that. And two, and if not, have you guys explored that option? And our biggest block right now is we are one hospital covering a large area and we cannot get them to play 24/7 with alternative services.

- Gotcha, so I can get into a lot of more details there. So we've had a lot of learning experiences with the telemedicine sort of structure around connecting. I will tell you that the group that we have worked with for this specific project, even though it's with ET3, the group has their own telehealth sort of platform structure that we have interconnected into our devices. So it's not like we went on our own and sort of created something or found something. The primary care group that mostly does sort of the elderly population in this facility, they have their own sort of telehealth infrastructure for lack of a better word, and they're still kind of refining it. So we didn't have to go around doing that exercise, if that makes sense.

- [Marv] Thanks, and I'll contact you offline about specifics.

- Yeah, please do.

- Rick, is there anything in the chat we need to address before we move on to these?

- [Rick] Yeah, there's two questions. First one is which EHR?

- Oh, I don't, the primary care group CH chart. They have changed recently and I don't have the name top of my head. I can definitely follow up on that later on.

- [Rick] Okay, the other one is Dr. Seabold, "Just an observation, may have missed a point. It seems that there is still quite a high cost of the shared decision making algorithm. Can you comment?" And then "It seems to me that a robust protocol for medical clearance at ER triage would be more inexpensive than the $5,000 plus," and then he says, "Is my logic flawed?"

- That's a great question. When we went through the exercise, that initial sort of cost analysis, that still needs more work, but that was an initial sort of run at it. That cost includes everything. So the ongoing training, EMS training, CME, the reimbursement to EMS within that sort of space. So that accounts for that sort of that number. Most of the data that I have seen, and in regards to once patients get transported and they pretty much end up getting a lot of additional imaging and work that actually drives that number. But our initial sort of gestalt when we did this. And again, it needs additional refined work because it was only taking into account Medicare reimbursement rates. Is that actually this could be still an underestimate.

- Anything else in.

- [Rick] Got one, let's see, one new comment. Let's see, gotcha. So more of a global cost analysis than a cost to an individual patient.

- Yeah, fair enough, that's a good point, thank you.

- [Rick] Yeah, and that's it for the comments for now.

- All right, well, that's perfect timing. We're like literally at exactly the right time to go to the next one. I know that Dr. Holman was having a little issues with his internet, but hopefully he's still with us. Bob, are you still there?

- I still am, I've only received seven notices that I have an unstable internet connection, so I apologize if something happens in advance. I'm the medical director from Washington DC's Fire and EMS, and I wanted to share our four year experience with our Right Care, Right Now nurse triage line. So the questions that we wanted to ask and answer in this webinar is how do we divert these low acuity callers away from EMS, and actually can we send them to another destination? And then the other question for this group is, is ET3, or was ET3, the way to do this? And we started this in 2016, and we've launched two years later. We had an enormously broad based build, and I'm really happy that we spent a lot of time building a firm foundation. But to summarize, we had, you know, well over a hundred and well, we had 160 people attending meetings. There were probably a core of about 40 people working feverishly on this for a long time. I think the essential building blocks for this program included political endorsement, and they actually made the EMS medical director brief the mayor of Washington DC and our city council. We relied on a robust system of federally qualified health centers, and a few, just three urgent care centers. The proportion's a little different than Dr. Cabanas's system. We also felt an essential building block was same day urgent transportation for our Medicaid patients. We had to have a nurse navigation system with a robust portal that could communicate with our transportation vendor and our clinics and rely on a robust health information exchange that was updated with current information from the Medicaid patients every 24 hours. And then lastly, a strategic public education effort, which I'll describe later. So in 2016 we looked at where in the District of Columbia our low acuity callers are coming from, and you can see yellow hot spots. And then for super hot spots, the four super hot spots really center around a large homeless shelter in the south. And then one of those two red towers next to each other is the largest homeless shelter in the country that houses over 1,500 men per night. And then the other places are where the poor and homeless people congregate. But we knew, you know, the district has been historically racially and economically segregated. It continues to a great extent still, so that the area in the east part of the city and then especially in the southeast are areas, neighborhoods where there are higher levels of low socioeconomic status citizens. And then when we looked at our FQHCs, well, they were located right where they needed to be, right where that population was so that they could be community based neighborhood health centers. And that's exactly what they are. They're robust, they're well organized, they've gotten boosted lately with tobacco money and so they really function very well. Our urgent cares are also favorably situated. One of the things that we thought was absolutely essential is to have same day urgent transportation. What we know is that 3/4 of our Right Care, Right Now users are Medicaid beneficiaries, and we knew that in another city, they closed their nurse triage line after about a year because they had two features. One is they required consent, the other is they provided no transportation. So after a year they shut it down. We knew that we needed to build transportation. We also knew that Medicaid would only pay for non-emergent medical transportation when and if it was scheduled 72 hours in advance. Now that might work for somebody who has a chronic disease, who has Medicaid, who needs to go to dialysis three times a week. Certainly that's perfect, but it wouldn't work for our 911 callers. And so after we briefed our mayor, she really took that briefing to heart, and after two or three months she really came out swinging when she met with our DC Medicaid people and told them with a fist on the table, if you will, that they needed to change it so that Medicaid in DC would pay for non-urgent medical transportation on an urgent basis. And we became the only place, the first place and the only place for a long time that Medicaid would pay for same day urgent non EMT, non-emergent medical transport. So how have we done? So we celebrated our four year anniversary in April of this year. And in the first four years we had triaged 48,000 low acuity callers. We're four days away from a 53rd month anniversary. So the data is from about 3 1/2 weeks ago at 52 months, and we've triaged over 53,000 callers in that period of time. In the first four years, we diverted 18,000 patients out of the EMS and ED system to primary and urgent care, home visits, or telehealth. And that home visits is really home mobile urgent care. In the first 52 months, we have diverted away more than 20,000 low acuity callers. We follow our performance metrics very closely. Our average phone call length is six minutes. Our average Lyft ride pickup is in 9 1/2 minutes. And we know that the average ride time to the clinics takes just under 20 minutes. So this shows our sort of progress over our four calendar years. And if you'll follow me from 2018 to 2021, I can show you that in our first calendar year of operation, which really represents about eight months time, 2/3 of our callers were sent back to 911. And in the light gray color, we were kind of happy with that because we were very concerned and really wanted safety built in. But you can see over time that proportion sent back to 911 in the ensuing years, dropped to 53%, and then in 2020 it dropped, not to 31%, but if you combine the light gray with the charcoal gray, it's 36% because we added our private BLS transport AMR as part of our ambulance transport direct from the nurse triage line. And that number is 42% in 2021. Likewise, in 2018, that bright blue wedge, referred to clinic changes, and I'm sorry it changes color, but it does, to a darker gray, but it go grows from 15% to 23% now for the last two years at 42 and 40%. So we think that's terrific, and we've achieved what we would consider stability there. And then you see the self care wedge is basically the same between 19 and 22% over time. So I want to nod to Jose, and say you're sending a lot back this year to 911 and I think that proportion will drop over time. This is a similar data set graphed differently, and if you look at the clinic referral proportion of all of our EMS calls in the light green, it's between 2 and 4% or 2 and 3 1/2% over time. Our total diversion is roughly around 10% into the nurse triage line. And then self care referrals in the blue stays around 2%. And then return to EMS is initially in the reddish brown, and then includes both the reddish brown and the gray with the gray being our private BLS transport. So these numbers are roughly stable over time. About 10% of our calls, or under 10% of our calls are diverted to the nurse for triage. And then a roughly 4% or a little bit more, depending, are diverted to either clinic referral or self care. Now this slide shows roughly 3,200 calls over time from our largest Medicaid managed care organization or MCO. And what they did is they tracked whether our patients, once they had spoken to the nurse and been diverted, were really truly diverted out of the ER or whether they went to the ER that day or within a seven day period. And so I'm going to point out the forest green, or forest green box shows that about 2/3 of the patients in their particular MCO were referred to the clinic. And then if you follow the four horizontal bars, the two in the middle, referred to clinic and self care, show roughly the same proportions experienced an ER visit within the day of incident, about 30%, a much smaller number end up in the emergency room in the next seven days. But 60 to 64% do in fact stay out of the ED and EMS system. Those that are sent back to 911, they don't all end up back in the emergency room, or about 28 to 35% of those two groups will actually not be seen in the emergency department in a seven day period. We follow our metrics very closely, and just over the last 16 months we know that 4% of all of our clinic referrals were subsequently sent from the clinic to the emergency department. And if we exclude one of our roughly 20 sites, the total number is 3%, but one of them, which used to be an emergency room, and basically wants to get lots of scans on everybody, has a much higher rate, distorting the total number. But 4% is I think for us, an acceptable number with which we're very pleased. So what happens to the patient? So, and I would just add here that our patient satisfaction rate for either satisfied or very satisfied for 2021 was 95%. And that number has dropped down to 89% for this calendar year so far, which is matching what Wake County's satisfaction of 90% is. But the patient's experience, they're either referred by the 911 call taker to the nurse triage line or they're referred from the field after an in-person assessment with vital signs. And after the field triage with that six minutes phone call, our crews will then leave, and the patient is waiting for 9 1/2 minutes for the Lyft driver to drive her to the clinic. Our alternative destinations for our providers, much more complicated. In the good old days it was ALS versus BLS, and now they have a rich and somewhat complicated menu. It's ALS, BLS, nurse triage line, private BLS transport, or transfer to the Sobering Center. So it is complicated for them and we appreciate that. So here I really want to say why did we turn down ET3? So we launched in April of 2018 before ET3 was developed or launched. And what we know is that after field triage, our crews leave after the six minute call. They don't have to wait for a telehealth provider to come on the call and wait for that call and they don't have to, after that call, then transport the patient often to a clinic. They leave, and Lyft comes and does that. So we have a faster time to back in service than what would be provided through the ET3. In addition, the national rate of Medicare use in the country is 19%, and we have a lower rate in DC of 13%. In DC we have a 34% Medicaid beneficiary rate, which is higher than the national average. So I think those are the things that really colored our decision for ET3. Next. So as I mentioned, about 9% of all of our calls are now sent for triage, and about 4% of all calls are diverted from the ED system. What's interesting is we regularly review a sampling of all of our BLS dispatches by our quality review team in the 911 call center. And consistently over the last 15 months, it shows that about a little bit more than 1/3 of all of our BLS dispatchers actually meet criteria to be referred to the nurse triage line. We struggle with that. So we think that it looks like our numbers are a little bit low on this slide, but actually we know that we have many other calls that could be referred from the the 911 call center. But we think that there may be also calls from the field that could also be referred as well. So what about cost savings? So excuse this simplistic slide. This is back of the envelope math, in my house, it's called cowboy math, but it's really, really rough. So the District of Columbia government pays about a million dollars for the nurse triage line every year. Our largest Medicaid managed care organization states that they pay 550 for an ambulance ride, and 550 for the most basic of visits in the emergency department, absent any radiology or lab fees, which we know are considerable. And they pay $250 for a combo of both the Lyft drive and the clinic visit. So they tell us that they're saving about $850 per case that's diverted out through the nurse triage line out of the ED and into a clinic. So in the first four years we did 18,000 diversions, and we know that not all of them stayed out of the emergency room, but if you just did that simplistic view, that's $15 million. If you subtract the cost, you know, maybe it's more than $10 million in four years, obviously we need to look at this, and we have a group of scientists that worked for the District government and they and we are committed to engaging in a very detailed cost savings analysis with our DC Medicaid office this fall. And so we hope to have that analysis forthcoming. I want to mention the last essential building block, and that was strategic digital engagement. So 3/4 of our nurse triage line users are Medicaid beneficiaries, and we know how difficult they are to reach with standard media, whether that's electronic or paper or television. But we do know that all of our citizens that are eligible have access to a government issued emergency phones. Now those are designed to report fires and other emergencies and they have limited numbers of call minutes, something like about 180 per month, but they have unlimited texting. And in my previous position using this system, we knew that most of the phones didn't have call minutes, but they could text 30 days out of the month. So we thought that we would develop a system where we had SMS texting to communicate news updates and features of the Right Care, Right Now nurse triage line to this population. Next slide. So just to give you an example of its effectiveness, we have a population in the District of just over 700,000, and about 240,000 or so have, or more, have Medicaid. Those that don't have Medicaid who choose to be in on this system or who have been in our nurse triage line and wanna stay on this system are in this SMS text recipient group. So we sent out a single text on February 28th of this year notifying people that we were adding pediatrics to our nurse triage line. This text had a unique open rate of 36%, meaning that over 90,000 individuals in DC, out of 700,000 residents opened this one text about our Right Care, Right Now. So we think this is a very efficient way to get the text messaging out to this population that otherwise is very hard to reach. And I'm happy to answer any questions.

- Rick, I think there's a few in the chat there for you.

- [Rick] Yes, I've got from the chat a couple. The first one here says, "Did you look at if the patient went back to the ED within seven days for an unrelated complaint?"

- So that's a great question, and we haven't done that kind of level of drill down. We would love to be able to do that. I think the volume is going to preclude some of that, but I would love to be able to do some sampling.

- [Rick] Next question says, is this system in, excuse me, "Is this system in place 24 hours a day or only during business hours?"

- So for the first 8 1/2 months, we were open only from 7 am to 11 pm, and then we went 24 hours about month nine.

- [Rick] And let's see, Dr. Wayne shared, "We're in the process of adopting an AI dispatch system. We hope when we finally implement some of these ideas, we'll have a more reliable decision making process and quality improvement review."

- [Bob] Great, great.

- [Rick] Yeah, that's all the comments for that.

- Any other questions for Dr. Holman? Okay, well, we'll all be around at the end for round table. Dr. Marino.

- Thank you so much, I'm Meg Marino. I am the Director and Medical Director for New Orleans EMS and I am also the Medical Director for MD Ally. And today I am gonna talk to you about public safety telehealth. So my objectives today, first we're gonna talk about what is telehealth for public safety, why do we need it, when we should use it, and what are the outcomes from this one particular telehealth for EMS system? So the first thing is that we have this virtual tier response for public safety. So our 911 providers are able to dispatch either directly to telehealth or able to dispatch EMS services. If EMS services arrive on scene, they can then assess the patient, and decide whether or not this patient is a good fit for telehealth. And both 911 and EMS use evidence-based protocols to determine a patient's eligibility for telehealth. Then the telehealth provider does an assessment, and can decide whether or not the patient needs mental health resources, primary care resources, social services, pharmacy delivery, prescriptions or other things. So many low acuity patients call 911 because they don't know that they have other options. So many of our patients have no access to primary care. And so it's really important that we create opportunities for these patients to get the right care for these patients using the right resources. So patients call 911 because they don't have another way to get care, some don't have transportation. That's something that Dr. Holman was able to figure out and solve for in DC. They're also afraid that they're having a medical emergency. So so much of this is about education, and then sometimes they're just lonely. So some of the common complaints for 911 calls include prescription refills. They've called their regular doctor, and their doctor won't refill their prescription or they don't have a regular doctor. Cold and flu, we're seeing a lot of this with COVID, patients just call in because they've had a positive COVID test, but they have no shortness of breath. All they really need is a Paxlovid prescription and some reassurance and return precautions. Rashes, skin irritation, chronic pain. We've had a number of calls of patients with chronic pain who really just need a referral to a chronic pain specialist instead of a trip to an emergency department. A lot of our patients have nausea, vomiting, diarrhea, constipation, dehydration, allergies, and migraines. And all of these are issues that can be very easily addressed through a telemedicine encounter. So why telemedicine? It's actually much better for the patient. So they don't get an expensive hospital bill. There are no long ER wait times. I will be honest, none of our patients enjoy being in the emergency department. And I say this as an emergency medicine physician, we wanna make sure that we are preventing patients from going to the ER unless they really need to be there. It addresses the patient's problems where they are. We have improved patient satisfaction, and we also decreased the likelihood of catching COVID or the flu or one of the other things that we often see in our patients who end up going to the ER. EMS professionals are experiencing a lot of burnout right now, and we know that most EMS professionals cited abuse of 911 services from, you know, by low acuity patients as a leading cause of burnout. I know at New Orleans EMS, in talking to my team, they often cite, you know, this patient calls all the time, there's nothing wrong with them, as one of the reasons for job dissatisfaction. And so we know that it's important that we address any opportunities that we have for improvement and job satisfaction improvement for our teams, especially in the setting of COVID, and increasing burnout among our teams. We really feel like telehealth for EMS is better for our EMS providers as well. We have improved provider satisfaction. EMS can clear the scene once the patient is connected to telehealth. So once they make that introduction, the physician says, okay, we're good to go. EMS clears the scene, and is not required to wait for the conclusion of that telemedicine visit. We're eliminating, well, eliminating might be a strong word, but we're decreasing pre-hospital wall times. And this is really important. You know, every time we have a patient that doesn't go to the ER, that's one more space in the ER for a patient that really needs to be there. So our goal is to, by reducing the number of low acuity patients who end up being transported to the ER, that we are creating capacity in the system for those higher acuity patients. We're also decreasing unit hour utilization for our low acuity patients. And for those of you who aren't aware, unit hour utilization is the way we determine how much of the resources we're using per patient in our ambulance services. And so anything that we can do to decrease our unit hour utilization is a big win, and has many downstream effects, both financially, and as far as job satisfaction for our providers. And again, we're increasing capacity to care for those higher acuity patients, both in the ER and in EMS. So which patients do we serve with telehealth? So you know, we've got some patients that absolutely need emergent life saving interventions and these patients definitely need an ambulance. These are our patients with cardiac arrest, chest pain, anaphylaxis. These patients need an acute intervention. They need their lives saved by our very skilled paramedics and EMS providers. Then we have the patients that urgently need care in the emergency room and need transportation. So these are the ones that don't really need anything in the pre-hospital setting, but definitely need to go to the ER and need to go to the ER quickly. These are not the patients that we're gonna be able to care for With telehealth. For telehealth, we're able to take care of those patients that need minor in-person care in the next 24 hours. So this is gonna be your patient with a migraine, your patient with some nausea and vomiting without severe dehydration, any patient with a rash without signs of anaphylaxis. So a telehealth provider can refer this patient to urgent care or primary care if needed. So those are gonna be the patients with a laceration that can be repaired. Then we have the patients where the care can be provided entirely by telehealth. So these are mostly the patients who need a prescription refill, some reassurance, COVID without shortness of breath, that just need a Paxlovid prescription, things like that. And for these patients, the telehealth care provider can diagnose, prescribe, care, and ensure follow up as well. So we do have some pretty strict exclusion criteria. So we wanna make sure that we're really providing care for the patient and we're not keeping any patients that need to be in the ER at home. So if a patient requests to go to the ER, we absolutely send them. If they have signs or symptoms that require ALS services, we definitely send them. Any chest pain, acute abdominal pain, shortness of breath, syncope, any neuro complaints or signs of stroke, any abnormal vital signs, patients that are less than one years old, or someone who's greater than 65 years old with a comorbidity or with a head injury. And you know, based on the data that I've just heard from Dr. Cabanas, I think that there's a possibility that we'll be changing this criteria because he's had such wonderful success with his fall program. So people are often asking me, okay, but how long does it really take? I know one of the concerns that Dr. Holman had about ET3 was having the EMS team wait on scene. So let's look at how long it actually takes. So this call is answered in less than 30 seconds. We've got about five minutes for physician contact time, and after the physician makes contact, that's when we release EMS on scene. It's about 15 minutes for an encounter duration. Sometimes it's a little bit longer than that, and about five minutes for documentation and follow up. So approximately 20 minutes total for the patient, and approximately 20 minutes total for the physician. So let's look at some cases, and see what kind of patients we've been caring for. So we had a 71 year old male with back pain, and EMS found the patient just in need of transport to a local methadone clinic, and he had no other acute complaints. The physician did an assessment, found that the patient did not need any other interventions at that time. And we arranged for alternative transport to the methadone clinic. The patient was connected to the Department of Veteran and Social Services and also received an opportunity to get four free mental health visits, virtual mental health visits as well. The next patient that I wanna tell you about is a 39 year old male with history of seizures and he just ran out of his seizure medicine, called his PCP several times, the PCP said, no, you're gonna have to come in for an appointment. When he talked to the receptionist to schedule an appointment, she said it was gonna be over a month before he was gonna be able to see the patient. So the patient felt like he didn't have any other options and called 911. He had no other medical complaints. He was prescribed a refill for his seizure medicine, and we were able to set up prescription home delivery for him. We also connected him with Veteran and Human Services and social services as well. Okay, so one of the things that I think makes our program so successful is that we're able to provide additional support as well. So we have a care concierge, and this is a non-clinical patient navigator that's able to arrange for mental health services, set up prescription home delivery, arrange for alternate transportation, schedule care appointments, do coordination for social services, and securing orders for home health. They're also able to do anything else that the patient needs. So let's look at some of our patient demographics. And I don't actually have an explanation for this, but if anyone has any suggestions for why we're seeing this, I'm all ears. We've actually have had 70% female and 30% male patients. We've also been seeing patients that range in age from two to 90, with a median age of 56. Our average response time is five minutes. Our average duration of calls is between 15 and 21 minutes. 39% receive a prescription medication, and 16% are connected to social services. Okay, so this is a number that I'm very proud of. So there are 0% of our patients, so none of our patients needed 911 reactivation within 48 hours with transport. So of our patients who called 911, had a visit with us, none of them had an emergent issue in the following 48 hours. So none of them had an emergent issue within the following 48 hours. 8% were direct patient calls, so this is very exciting. We had 8% of our patients were able to call in directly to us instead of calling 911. So these are patients who had trouble with a positive COVID test, some other issue, called into us through 911, and then needed something else a few days later and called us directly. We've also had some referrals of friends and families of patients that have called us through 911 who have called us directly through a phone number that they receive via text message. So we're very happy about that. Next slide, please. So here's another number that we're really proud of. So 96% of our patients do not call 911 in the following seven days. So of the patients that call us, only 4% call 911 in the following seven days. We've got a couple of chronic 911 users who have played into this. We had one patient who called multiple, multiple, multiple times a day. I think he called three to eight times per day. We found that through our interventions with this patient, he is now calling a few times a week instead of a few times a day, which is very exciting. But I think that this number really represents that we are addressing the problems that the patient has in real time, and solving their problems as opposed to just, you know, I think so often we see patients who are sent to the ER, they're given a bandaid and a high five and told to follow up with their regular doctor, but none of the problems are actually solved. So we feel like through our interventions, through the use of our care concierge, that's really there to help solve our patients' problems, we've been successful in addressing those problems. Okay, so what are our patients saying? One patient said "This is how healthcare should be." "The doctor was so nice and took time to listen." "There was no wait, and I got exactly what I needed." "I was worried I would catch COVID in the ER. So I'm so glad I was able to be seen at home." And then what are our medics saying? So "The telehealth physician was so fast. We were back in service quickly." "The patient just needed a refill, and we were able to get the patient the meds without transporting, big win." "We had no waiting on the wall in the ER." And "One of our frequent flyers used to call multiple times a day. Now he calls much less frequently, amazing." All right, so thank you so much for the opportunity. We really appreciate, really appreciate everything. And does anyone have any questions?

- Meg, while we're waiting on one, just for the group, what was the approximate number of patients, that were in the table and so forth?

- About a hundred. This data came from a small sampling, small sampling of patients, of our patients.

- It's just outstanding that nobody got referred. I think that's just wanted to make sure. And now the chat is filling up. But Rick, if you don't mind, because I'll end up, God only knows what slide it'll end up on if I try to open the chat.

- [Rick] Yeah, we have two questions. "So how is this service billed or paid for, and what is the per patient cost for the service?"

- Okay, these are great questions. So these visits are billed to the insurance companies for a physician visit. The physician writes a note, just like they would any clinical encounter, they are billed with ENM codes. So either emergency medicine codes or primary care codes, depending on how the patient got to us and what the patient's condition is. And the average reimbursement is pretty typical of what you would find for just those ENM codes.

- [Rick] "What if the patient is not insured, or the insurance refuses to pay?"

- Great question, so those patients, we see patients regardless of their ability to pay. And so we wanna see the patients and care for the patients whether or not they have insurance. But great questions.

- One additional, while people may be thinking of others is, "Does any of your reimbursement rely on the existing public health emergency for COVID or is this available for billing even after the public health emergency?"

- I believe that this is available for billing even after the public health emergency. I'd have to double check on that, but I don't believe that that, you know, there is like the healthcare parity that says that telehealth needs to be reimbursed at the same rate as in person medicine. And I don't believe that that is contingent on the public health emergency anymore.

- [Brent] Great.

- [Rick] A couple of more here. "What is your reimbursement rate or uninsured rate?"

- Okay, great question. I don't have those numbers off the top of my head, and I don't wanna say the wrong thing, but great question. And if you leave your email in the chat, I will get back to you with that answer.

- [Rick] Another one here, "Are the medics directed to do interventions by the telemedicine physician?"

- No, so this is a great question. So the telemedicine physician is not online medical control. The way we think about it is it is a true disposition. So just like you would bring the patient to the ER, you're bringing the patient to telehealth, and then the telehealth physician is taking over. But the telehealth physician is never providing online medical control. If the patient needs online medical control, the EMS provider calls their online medical control, their medical director, or the regional hospital, whichever this system, you know, however the system is set up. Also, those patients that require interventions by EMS are not the patients that are typically appropriate for telehealth. But great questions.

- One more here. It says "ET3 allows the medics to do interventions on the direction of the telemedicine physician?"

- Correct. So ET3 does, this program is outside of ET3, but my understanding is yes, ET3 allows for treatment in place. But this program through MD Ally is outside of ET3.

- [John] Hi, this is Jonathan Busco. The reason I was asking those questions. So we're running a program in Maine using advanced practice paramedics where we've got paramedics who are suturing, who are removing foreign bodies from ears, who are doing all sorts of procedures. But it's a telemedicine visit, and the reason we're doing it is because the nearest hospital is an hour and a half away, and we estimate we've saved close to 2000 driven miles, and 10,000 hours of patient time. So, and maybe anyone else who's listening can reach out to me and I'll throw my contact in the chat. But one of the things we can't do, so we're billing the same way we bill standard ENM codes for the telemedicine visits, but we would love to be able to get reimbursement for the medics for the procedures they're doing on physician orders, because basically the town's paying.

- [Participant] If you have questions about participating, or about how to view the general welcome call.

- [John] We fell. So I guess in your case, you're not doing those interventions, so there's not really that billing piece for EMS, but I'll throw in my email, and if anybody is doing that or has a way, or a suggestion on how to bill so the medics can recuperate for those procedures or interventions they're doing, I think that's an important part of this.

- Yeah, I would love to connect with you on that. So please, please shoot me an email. I'd love to connect with you, and kind of learn more about your program. Thank you so much.

- Few more questions here. "What type of specialists are your telehealth providers?"

- Great question. So currently our telehealth providers are 100% board certified emergency medicine physicians. I have found that that's kind of using a sledge hammer for something that doesn't necessarily need that level of skill. So we are taking care of patients who are, you know, having those low acuity issues. These are often the patients that would be seen by an APP in the emergency department, or sometimes even a family medicine or internal medicine physician in the emergency department. So we are hiring internal medicine physicians and family medicine physicians with experience working in the emergency department as well. But currently 100% of our physicians are board certified in emergency medicine. Great question.

- Another question. "So if this is outside ET3, then the EMS provider is not billing despite responding and spending time on scene, is that correct?"

- That is correct. There's nothing from our program that says that they can't bill for whatever they wanna bill for. ET3 has kind of, you know, gone to the wayside a little bit with the COVID pandemic. I think that there are a lot of things that were initially part of ET3 that are now widely available to all EMS agencies, even if they weren't one of the few that were selected to participate in ET3. So there's nothing about our program that says that the EMS team couldn't bill if they are on scene and providing services that are billable per the program. So that they could bill independently from us. Currently none of our agencies are choosing to do that. They are trying to just go back in service as quickly as possible.

- A comment I believe from the San Diego system, "We've had the same question for billing, but regarding PAs and NPs in an EMS system."

- Great.

- And there are still direct billing codes that are outside the EMS system. So independent of ET3, that is an option in many states. The other thing to remember is I think the Medicare rules apply to Medicare beneficiaries. And we're aware of, you know, across the country, many of the private commercial insurance coverage has elected to pay for the non transport in the absence of guidance from CMS. Now that's not nearly as broad, I think, as everyone had hoped it might be. I think there was a notion that everyone would follow the ET3 guidance immediately and all of the, you know, the Blue Cross Blue Shields and Aetnas of the world would immediately start that reimbursement. That has not been the case, but there are those that can, and there's nothing that prohibits it, but it is not an automatic.

- Another comment, Austin, Travis County is doing billing by PAs.

- [Brent] So, yep, yep.

- Great, all right.

- All the comments in the chat box currently.

- [Meg] Thank you so much everyone.

- Any other comments for any of the presenters or questions? I appreciate that it's been pretty active so far, but we certainly, we still have a few minutes left before the end of our scheduled time if there are questions or comments that anyone would like to make. Okay, I'm trying to see if somebody's trying to come off mute here, just to make sure. It looks like there may be a couple looking, so I'll give it just a second. Well I would like to think the co-panelists, and then Rick, do you have any parting words of wisdom for the group?

- Yes, just want to thank Dr. Myers and the rest of the panelists. This was an excellent presentation, great information. As I mentioned in some of the private chats, I believe we have clearance now by the presenters to post this on our EMS section webpage. It'll be up on there, and whenever we get it posted we'll send out a message so you can view it. We had a lot of people who had inquired that had conflicts who couldn't make it and they were very interested in seeing this. So a very interesting and informative and timely topic. So again, thank you Dr. Myers for arranging this, and thank the other panelists. Great presentations. I've got two comments that just popped up. Let me make sure I don't miss something. Oh, just sharing a thank you to the group and the panelists and great information. So thank you again.

- Great, thanks everyone.