A pilot study from McKinney Community Health Paramedicine program and BEST EMS

 *Adapted from a piece appearing in EMNews October 2010
Could Fire Based Advanced Practice Paramedic home visits decrease the frequent 911 calls/hospital readmissions in patients with stable chronic diseases; while also increasing In-Service time for fire apparatus?-----A pilot study from McKinney Community Health Paramedicine program and BEST EMS.

Liz Fagan MD, Hao Wang MD, Larry Bean MD, Dan Frey FF-APP, Brian Roether FF-APP, Chris Waller FF-APP, Fire Chief Danny Kistner, Operations Chief Tim Mock, EMS Chief Jason Hockett
With special thanks to:  Robert Leavitt FF-APP, JC Stinson FF-APP, McKinney City Manager Jason Gray, Sharon Malone MD, Tim Hartman MD, the Case Managements department, and The Entire McKinney Fire Department


Goals/Vision
Our goal is to enhance the health of the McKinney Community/Align with Institute for Healthcare Improvements Triple AIM, while providing a cost savings to the fire department, city of McKinney and local hospitals.  We hope to accomplish this by reducing non-emergent 911 calls while simultaneously reducing the need for 911 calls in the high utilizers group (HUG).  This should be reflected in unnecessary fire engine/fire truck calls and cost as they are disregarded when the squad takes the calls for them accompanying the MICU on medical 911 calls.

Introduction/Objectives
When patients with chronic disease in stable condition use fire-based emergency medical service (EMS) to transport to the Emergency Department (ED) for routine health care it is considered inappropriate ED utilization as determined by the New York University algorithm.  When 911 is called, an ambulance as well as a fire engine or truck is dispatched.  While treating this routine patient, the truck/engine is “Out Of Service”, and their service area has to be covered by either the neighboring district in the city or a neighboring city (mutual aid) for emergency calls. The ambulance charges from these patients who use EMS as a safety health care network result in an increased health care budget within the fire department. The aim of this study is to determine the effectiveness of CHP-APP home visits in minimizing the ambulance calls and hospital visits among these patients; while increasing in-service time for fire engines and trucks by having the squad disregard them on 911 calls.

Materials & Methods
Patients who had more than four “911” calls in the previous six months were enrolled in this study. After patients were discharged from the hospital, frequent home visits by fire-based advance practice paramedics were arranged in a step-wise manner as determined by individual evaluation of needs assessments.  Intensive and personalized plans of care were developed in conjunction with program medical directors (BEST EMS). Collegial coordination with hospital case management departments allowed maximal use of available community resources.  Patients were assigned to a category (Figure 1) which determined the frequency of their visits.  The patient’s general characteristics, number of 911 calls, number of ED visits/hospital re-admissions, number of fire engine calls disregarded, time of engine in-service time, and total CHP-APP home visits with time spent were collected. The outcome was measured for 180 days after enrollment to determine whether frequent home visits by CHP APP affected the number of 911 calls among these patients. Logistic regression analysis was performed to determine the potential independent risk factors that could affect the frequent 911 calls. Data were analyzed using STATA 12.0 statistical software.

Results
From June 2013 till present, a total of 23 patients were enrolled in this study. The average age of the patient was 65.65±2.97 (95% CI 59.48-71.81). 65.22% (15/23) of patients were female. The average length of each CHP APP home visit was 44.57±7.95 min (95% CI 27.39-61.75 min). The total number of  911 calls before CHP APP  home visits was 9.14±2.88 times, and 5.17±1.91 times after CHP APP home visits (p=0.0412). Furthermore, the number of 911 calls after CHP APP visits for over 120 days were 0.8±0.5 times compared with those of before CHP APP visits (4.6±0.8 times, p= 0.0045). The odds ratio of the number of 911 calls 30 days after ED discharge among these patients was 1.82 (95% CI 0.66-4.98, p=0.24) by logistic regression analysis.  The average number of hospital admissions per patient pre-enrollment was 2.83 and 1.16 admissions after enrollment*.  The average number of ED visits/patient pre-enrollment was 8.67; which reduced to 2.16 after. There was a 59% reduction in hospital admissions and a 75% reduction in ED visits after enrollment in the program.  The Fire Engine/Truck was disregarded by the squad on 50% of the 911 medical calls during the pilot study.  This resulted in a more than an 8 hour Increase of In-Service Time for one engine during the 202 hours of the disregard pilot.

Conclusion
Frequent home visits by CHP APP after patients were enrolled in the McKinney Fire Department CHP program decreased the number of 911 calls, hospital readmissions, and ED visits, especially after 120 days. Among these patients, the potential risk identified that affected the frequent 911 calls was the number of calls within the first 30 days after discharge, though no statistical significant difference was reached due to the relatively small sample size. It is suggested that home visits by CHP APP should be emphasized heavily during the first month of patient discharge from the hospital.  The reduction in Fire Engine/Truck calls resulted in an increase in the In-Service time for the Fire Equipment.  The pilot has been determined to be a success, and will be continued with the addition of hospital case management referrals as well as CHF and COPD protocols starting 2014 (Figure 2)

“The Right Care at the Right Time, because it is the Right Thing to do”

*information only available from one of the two hospitals at time of submission.

 BestEMS

 

McKinney



 
BestEMS Figure2

Figure 1

 

Figure1

Figure 2


References

  1. Adams S, Smith P et al., Systematic Review of the Chronic Care Model in Chronic Obstructive Pulmonary Disease Prevention and Management. Archives of Internal Medicine, Vol 167 (6): 551-561, March 2007
  2. Coleman E, Eilertsen T, Kramer A, Magid D, Beck A, Conner D.  Reducing Emergency Visits in Older Adults with Chronic Illness A randomized, Controlled Trial of Group Visits.  American College of Physicians.  Effective Clinical Practice.  March/April 2001
  3. Counsell S, Callahan C, Clark DO et al.  Geriatric Care Management for Low Income Seniors: A randomized controlled trial.  JAMA. Vol 298 No 22 P 2623-2633
  4. Debusk R, Miller N, Parker K, et al.  Care Management for Low Risk Patients with Heart Failure. Annals of Internal Medicine, Vol 141 No 8 p 606-613
  5. Del Sindaco D, Pulignano G, Minardi G, et al.  Two-year Outcome of a prospective controlled study of a disease management program for elderly patients with heart failure.  Journal of cardiovascular medicine. Vol 8 No 5 p 324-329
  6. Fire Service-Based EMS Advocates
  7. Frich LMH.  Nursing Interventions for patients with chronic conditions.  Journal of Advanced Nursing.  Vol 44. No 2. P 137-153
  8. Gagnon A, Schein C, McVey L, et al. Randomized Controlled Trial of Nurse Case Management of frail older people.  J Am Geriatr Soc. Vol 47 No 9 Sept 1999 P 1118-1124
  9. Goessl, C.  Is Community Paramedicine Feasible for a Public Fire Department? EMS Legal Issues. Spring Semester 2013
  10. IAFF Position Statement: Fire-Based Community Healthcare Provider Programs (AKA: Community-Based EMS or Community Paramedic Programs)
  11. Kizer W, Shore K, Moulin A, Community Paramedicine: A promising Model for integrating Emergency and Primary Care.  Report prepared for the California HealthCare Foundation and the California EMS Authority. July 2013
  12. Meyer J, HMA, Markham Smith B. Chronic Disease Management: Evidence of Predictable Savings. Health Management Associates November 2008
  13. NAEMT: Community Paramedicine & Mobile Integrated Healthcare
  14. Patterson D, Skillman S. A National Agenda for Community Paramedicine Research. AHRQ
  15. Patterson D, Skillman S.  National Consensus Conference on Community Paramedicine: Summary of an Expert Meeting. AHRQ
  16. Peterson, B.  How competition, Obamacare will change the future of fire-based EMS.  Fire Chief.  May 22, 2013
  17. Parboosingh E, Larsen D. Factors influencing frequency and appropriateness of utilization of the emergency room by the elderly. Med Care. 1987;25:1139-47
  18. Tan D, The Role of EMS in Community Paramedicine.  JEMS. April 2013 Issue
  19. Thorpe K, The rise in health spending and what to do about it. Health Affairs 24 (6) 1436-1445, 2005
  20. Thorpe K, Howard D, The rise in spending among Medicare beneficiaries: the role of chronic disease prevalence and changes in treatment intensity. Health Affairs August 22, 2006
  21. Wagner E, Austin B, Von Korff M, Organizing Care for Patients with Chronic Illness.  The Millbank Quarterly Vol 74, No 4, 1996
  22. Wolff J, Starfield B, Anderson G.  Prevalence, Expenditures, and Complications of Multiple Chronic Conditions in the Elderly. Archives of Internal Medicine 11 November 2002 p 2269-2276
  23. Zhang N, Wan T, Rossiter L, et al.  Evaluation of Chronic Disease Management on outcomes and cost of care for medicare beneficiaries. Health Policy Vol 86: 345-354

 

Back to Newsletter

Feedback
Click here to
send us feedback