Monday, March 18, 2019

Using Community Paramedicine, mHealth for Care Coordination at Home


Community paramedicine programs give health systems an mHealth platform upon which to improve care management and coordination at home for high-need patients.
Community paramedicine programs offer hospitals and health systems an opportunity to leverage mHealth to reduce emergency department costs and improve care management for patients with complex chronic diseases.
Mobile Integrated Health Community Paramedic (MIH-CP) programs are often rooted in partnerships with local EMS and ambulance companies. They deploy specially trained paramedics to the homes of selected residents, often targeting frequent users of the 911 system.
These programs have two primary goals.
The first is to reduce unnecessary ED transports by visiting “frequent flyers” . This, in turn, reduces the strain on crowded EDs and, in the long run, reduces the number of non-emergency 911 calls.
Secondly, community paramedics aim to help those with complex chronic conditions improve their health and wellness at home, thereby improving care coordination and  the relationship between patient and primary care doctor.
“Community paramedicine is not a new field, but it is a growing one in the era of innovative care delivery models that emphasize integration across disciplines, a comprehensive approach to care coordination, and a commitment to reducing health disparities,” Carol Backstrom and Jennifer Ryan, both of Harbage Consulting, wrote in a 2017 Health Affairs article.
Developing an impactful, cost-effective CP program requires communities and healthcare providers to collaborate on implementing technologies and care strategies that harness all the resources at their disposal.
BUILDING UPON THE MIH-CP PROGRAM FRAMEWORK
The MIH-CP movement got its start in 1996, when the National Association of Emergency Medical Technicians (NAEMT) unveiled an EMS Agenda for the Future that shifted some of the focus to community health services. The NAEMT now offers a mission statement for MIH-CP programs.
“Recent changes in the healthcare finance system have created an unprecedented opportunity for EMS to evolve from a transportation service to a fully integrated component of our nation’s healthcare system,” the document states.
“Aligned financial incentives now focus stakeholder awareness on the value of EMS in providing either “patient navigation” throughout the healthcare system, efficiently and effectively directing each patient to the right care, in the right setting at the right time, or providing primary care in medically underserved areas.”
According to this mission statement, an effective MIH-CP program should be:
  • Fully integrated – acts as a vital component of the existing healthcare system, with efficient bidirectional sharing of patient health information.
  • Goal directed – is predicated on meeting a defined need of a specific patient population in a local community articulated by local stakeholders and supported by formal community health needs assessments (HNAs).
  • Patient-centered – incorporates a holistic approach focused on the improvement of patient outcomes.
  • Collaborative – works together with existing healthcare systems or resources and fills resource gaps within the local community.
  • Consistent with the Triple Aim - improves the patient experience of care, improves the health of populations; and reduces the per capita cost of healthcare.
  • Data-driven – leverages data to develop evidence-based performance measures, research and benchmarking opportunities.
  • Physician-led – is overseen by engaged physicians and other practitioners, as well as the patient’s primary care network/patient-centered medical home, using telemedicine technology when appropriate and feasible.
  • Team-based – integrates multiple providers, both clinical and non-clinical, in meeting the holistic needs of patients who are either enrolled in or referred to MIH-CP programs.
  • Educationally appropriate – includes more specialized education of MIH-CP practitioners, with the approval of regulators or local stakeholders.
  • Financially sustainable – includes proactive discussion and financial planning with federal payers, health systems, managed care organizations,, legislatures, ACOs, and other stakeholders to establish MIH-CP programs and component services as an element of Triple Aim approach.
  • Legally compliant – meets all legal criteria through strong, legislated enablement of MIH-CP component services and programs at the federal, state and local levels
In a January 2019 blog  post on Health Affairs, Caitlin Thomas-Henkel, a senior program officer at the Center for HealthCare Strategies (CHCS), and Sandi Groenewold, a family physician with ThedaCare, note that such a CP program can put specially trained paramedics right into the home, “where they may discover unexpected barriers and underlying factors that affect health outcomes.”
“A community paramedic can investigate these issues firsthand and seek ways to solve them through patient education (such as needing to take food with certain medications, developing reminders for medication schedules, or special packaging), connecting the patient with community resources, or both,” they wrote. “This approach is a paradigm shift that differs from the traditional one-way model of medication prescribing and dispensing to a patient-centered approach.”
In this model, Thomas-Henkel and Groenewold suggest using a telehealth platform to keep the primary care provider, pharmacist, specialists and other care team members in the loop, letting them know when home visits are conducted, allowing them to communicate with the patient and even looping them in for a virtual visit when needed.

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