Building Bridges Between EMS, Public Health, and the Healthcare Community

By Ed Mund

Healthcare as we have known it is changing rapidly and dramatically. The National Volunteer Fire Council (NVFC) has been representing its members’ interests in three concurrent and in many respects complementary national efforts that hope to influence how we transition into tomorrow’s healthcare systems. All three tackle the issue from the first responder community’s point of view yet offer a means for all to embrace a collaborative, population-centered future.

This article will detail recommendations from these projects and offer examples of positive results already being realized in the U.S. Use this information to be an agent of positive change in your community.

Where We’ve Been

Community preparedness, population health, and resilience activities have historically centered around traditional providers or payers, driving how healthcare was delivered under financial and regulatory constraints. Care was provided by those who had traditionally done it, or by those who would be paid for the service. Broader collaboration was limited at best, with little to no overlap. Local public health may have known little about EMS operations. Likewise, the only real awareness in hospitals of how EMS operates may have been limited to emergency department staff.

 

Where We Are

Today providers, payers, and residents are experimenting with a range of unconventional models to see how they might better meet their communities’ needs through collaboration and expanding into non-traditional roles. The focus is more on the patient than the provider.

Model for the Future

In light of efforts underway today, community healthcare likely will look very different in the future. Efforts will be centered around who can do the best job in the most cost-effective manner, regardless of historic roles. Everyone, including regulators and payers, will become partners in creating new community healthcare programs.

In this population-centered model, processes, protocols, technology, policies and practices are designed to keep people well. Collaboration on wellness care and acute care will provide the best possible outcome for individuals and communities day-to-day and during disasters.

This approach is so new that a consistent name for this collaborative process has yet to be settled. Some terms being used include:

  • Community paramedicine
  • Mobile integrated healthcare
  • Community healthcare programs

Whatever it is called, the expectation will be to achieve better outcomes on a population level than we are reaching today.

These new healthcare models are being driven for the most part by a traditional cause – funding. What is different, however, is now we are not asking how can we do more with less so much as we are asking, “How can we do better?”

Payers have turned to the value-based purchasing funding model as their path to better healthcare. Value-based purchasing is structured around the “Triple Aim” – an approach to optimizing health system performance. The Triple Aim proposes that healthcare institutions simultaneously pursue three performance goals: improving the health of populations, enhancing the patient experience of care, and reducing the per capita cost of health care. The primary Triple Aim goal is to improve the health of the population, with its two secondary goals – improving patient experience and reducing costs – contributing to the achievement of the primary goal.

Some are suggesting making it a Quadruple Aim, which adds improved clinician experience as a fourth component to the Triple Aim goals. In other words, can we improve the working life for care providers and staff at all levels as well? As with patients, satisfaction would be measured in improved processes and outcomes. It would also include team approaches to certain tasks, better scheduling, staffing levels, and working environments. More information on the Triple Aim and Quadruple Aim can be found at: http://www.annfammed.org/content/12/6/573.full

Paths to the Future

The NVFC is participating in three national projects related to these efforts:

  • Promoting Innovations in EMS, a two-year examination of what EMS and the healthcare system could look like if innovation drove processes and outcomes
  • EMS Agenda 2050, a two-year project to update the original 1996 EMS Agenda for the Future
  • NFPA 451: Guide for Community Healthcare Programs, a new reference guide from the National Fire Protection Association (NFPA) on how to conduct community assessments and work collaboratively within communities to improve healthcare access and outcomes.

Of these three, Promoting Innovations in EMS (PIE) is the nearest to completion. A final draft has been submitted for approval to the National Highway Traffic Safety Administration (NHTSA) which funded the project. EMS Agenda 2050 and NFPA 451 are in the drafting and comment stages, with completion expected sometime later this year.

Seven Themes in PIE

The final draft of the PIE document contains more than 40 actionable recommendations categorized into seven themes:

1) Legal & Regulatory
As we all know, regulation by nature is preventive: Do no harm; . . . I don’t understand so I won’t let you . . . ; I don’t trust you, so no, you can’t do it; . . . Somebody did something wrong, so let’s not let it happen again. Therefore, can an innovation be designed and implemented under existing laws and rules? If so, then go for it. If not, how do we change the rules?

Example:
See how Pennsylvania made it possible for paramedics to distribute vaccines on page 51 of the current PIE draft at http://emsinnovations.org.

2) Financial Sustainability
If funding is not sufficient, can you access alternative funding methods or implement new funding models? Secondly, how can you achieve funding priority among competing interests for funding and stability that funding will always be accessible?

Examples:
Read about Anthem Insurance’s new payment models at
https://www.emsworld.com/news/218925/moment-weve-been-waiting-anthem-compensate-ems-care-without-transport.

The Kansas Emergency Medical Services Association analyzed the effectiveness of three alternate funding streams. Its conclusions can be found at
https://kemsa.org/resources/Documents/funding/EMS%20Revenue%20Maximization%20Initiative%20Recommendations%20Report_12.30.16.pdf.

3) Education
Prehospital care providers should be trained with evidence- and competency-based educational materials. Providers at all levels of the patient care continuum should train together to better understand what happens to the patient at every step before and after each individual interacts with the patient. Some argue that college degrees should be required at certain (or all) licensure levels.

Example:
The Center for Domestic Preparedness in Anniston, AL, provides multi-disciplinary training that is evidence and team based and – best of all – available at no cost. Find details and course descriptions at https://cdp.dhs.gov.

4) Regional Coordination
Find ways to create regional centers of excellence to improve care and cost-effectiveness. Change regional boundaries that hinder coordination and collaboration.

Examples:
Multiple states are already using regionalization for specialized care that incorporates in-field recognition, hospital bypass, real-time diagnostic data transmission, and earlier hospital team activations for trauma, cardiac, burn, or stroke patients.

ODMap is used by law enforcement, first responders, and public health agencies in 27 states to track opioid overdoses. Learn more at http://chronicle.augusta.com/news/2017-11-18/new-app-maps-overdose-epidemic-real-time.

5) Interdisciplinary Collaboration
Everyone at every level and in every healthcare setting should know what the capabilities of each other are, both inside and outside their respective work areas. With this knowledge, organizations can enable optimal use of all community-based resources.

Examples:
One collaboration example is from Prosser, WA, where the local hospital reduced patient readmissions by using its in-house EMS agency to conduct post-discharge follow-up visits. Details are at http://www.emsworld.com/article/10932227/prosser-washington-community-paramedic-program-yields-results.

In San Francisco, a consortium of social agencies and the fire department collaborated to reduce overuse of EMS and hospital emergency departments by a small cohort of patients. Details are at http://www.emsworld.com/article/10319160/san-francisco-fire-departments-home-program.

6) Medical Direction
The local public health officer, EMS medical director, and hospital administration look for ways to coordinate and collaborate. Engage multi-disciplinary teams to learn with and from leaders in other discipline. Share best practices. Design and test novel care pathways.

Example:
In its 2014 Clinical Policy on Medical Direction, the American College of Emergency Physicians (ACEP) called collaborative medical oversight and care coordination essential elements of any community paramedicine or mobile-integrated healthcare program.

7) Data & Telecommunications
Patient information needs to be secure yet shared in real time along the entire care continuum:

  • Per patient event
  • Among all care providers
  • Per patient life
  • Across geo-political boundaries

Example:
Authorized by Congress in 2012, the First Responder Network Authority (FirstNet) is a national program to improve broadband access for first responders to communicate and transmit patient data. Currently urban areas have the broadband equivalent of 12-lane superhighways available, both in terms of speed and bandwidth. Many rural areas by comparison have two-lane dirt roads, if that. Sticking with the road analogy, FirstNet intends to have the minimum level of service anywhere in the country be a four-lane highway. Government oversight agencies can learn more at https://firstnet.gov. The site for AT&T, the commercial system vendor, is www.firstnet.com.

What can you do?

Participate in EMS Agenda 2050 by learning more at www.emsagenda2050.org. After a year of input from across the country, the first draft of the document is due out for public review and comment by May 2018. The authors are casting the widest possible net, seeking input from every part of the healthcare industry and the general public it serves.

Learn about the Guide for Community Healthcare Programs at www.nfpa.org/451. Among other elements, it describes how to do a community assessment to find the low-hanging fruit that can be fixed quickly and inexpensively. It also offers a step-by-step planning model for collaborating with healthcare community partners to achieve success, starting with local fire and EMS agencies.

Download the PIE report at www.emsinnovations.org and study its recommendations. Consider viable solutions for your area. Talk to others in the healthcare community, starting with your own internal partners. Expand conversations to groups you have not typically worked with before. Convene stakeholders to conduct a community needs assessment. You’ll likely find many of you are fighting the same battles. Band together and collaborate to collectively overcome them.

Once you have an overarching need identified, develop a pilot project to address it. Seek funding if the pilot won’t fund itself through project savings. Launch when ready, then evaluate, modify as needed, succeed, then move on to the next community need.

Look for every opportunity to innovate. Advocate to create a culture of innovation among your colleagues and community partners. What is at stake? Nothing less than the healthcare environment our successors will work in, and the healthcare our children and grandchildren will receive.

Ed Mund is a volunteer firefighter/EMT with Riverside Fire Authority in Centralia, WA. He is an NVFC EMS/Rescue Section Director-at-Large, representing the NVFC on PIE, NFPA 451, and EMS Agenda 2050, and is Treasurer of the Washington State Fire Fighters’ Association.