Future of Emergency Medicine: Mobile Integrated Healthcare
As members of the ACEP Emergency Department Practice Management and Health Policy Section, we wanted to share some thoughts on mobile integrated healthcare and community paramedicine. Mobile integrated healthcare is an emerging practice in EMS but has been present since the early 1990’s. It directly impacts the Institute for Healthcare Improvement’s Triple Aim: Population Health, Experience of Care, and Per Capita Cost (1). One of the first programs can be traced to rural New Mexico and was a public-private partnership that provided early lessons that guide our current practice (2). One of the earliest successful programs was MedStar (TX) that started in 2009 that focused on readmission rates of heart failure patients, length of stay, and associated cost (3). As our healthcare system transforms from fee to service to value-based, mobile integrated healthcare programs will only play a larger role in tomorrow’s healthcare system. The Centers for Medicare and Medicaid (CMS) have launched ET3: Emergency Triage, treat, and Transport Model. This program starts in fall 2020 and is a voluntary five year payment model that provides flexibility for alternative destinations and treatment in place (4).
The premise of mobile integrated healthcare is simple yet execution is complex. Using paramedics to evaluate and treat patients in the home setting could have wide-reaching implications for patient satisfaction, health management, cost of care and patient safety in many populations, including homebound older adults. Our program in Grand Rapids, MI was a partnership between a private health insurance company (Priority Health) and a third party community paramedicine program (Tandem 365). We compared elderly patients who triggered EMS dispatch with urgent medical calls over the course of 2019 who had comparable demographic information and past medical history. During 2019, we had over 3,300 calls from elderly patients with high acuity conditions. Overall, our home based community paramedicine members had reduced ED transport (15.0% vs. 73%) (p<0.001) with higher admission rates (51.7% vs. 20.4%) with a LOS (4.6d vs. 4.6d) (p<0.001), mortality rate consistent at 3%. For the HBPC patients not transported, they had a 64% chance of ED utilization within 30 days. This fact necessitates down-stream planning, flexibility, and affords telemedicine solutions. More research is needed in mobile integrated healthcare and it is likely coming or in a community near you.
Nicholas Cozzi, MD MBA
Nicholas Cozzi is the EMRA Representative to the ACEP Practice Management and Health Policy Committee and PGY-3 in Emergency Medicine and Spectrum Health / Michigan State University College of Human Medicine. Special thanks to our research team in Grand Rapids: Dr. Jeff Jones, Dr. Todd Chassee, Dr. Michael Rushton, Dr. Gil Nelson, Phil Feenema, Chad Barnhardt, Sean Anderson, Spectrum Health, Tandem 365, and Priority Health.