An ongoing test program in Mesa could lead to significant changes in how emergency personnel respond to calls throughout the United States.
As the three-year grant period for a community care response initiative nears its expiration at the end of August, program leaders continue to tout its success. The city received a $12.5 million, three-year grant from the from the Centers for Medicare and Medicaid Services for the test program. The grant was awarded so the city could “test a model that offers new comprehensive delivery systems,” according to the Centers for Medicare and Medicaid Services.
Dr. Gary A. Smith of IASIS Healthcare, which operates four Valley hospitals (including Mountain Vista Medical Center in Mesa), and Tony Lo Giudice, formerly with the Mesa Fire and Medical Department, have overseen the program. Lo Giudice left the Mesa department a few months ago for a job in North Carolina. He worked closely with Deputy Fire Chief Steve Ward who has assumed Lo Giudice’s responsibilities related to the grant.
The purpose of the grant was to implement a program that could discover “new and exciting ways to deliver health care,” Smith said. The program is also designed to decrease costs, provide a higher level of service and comply with the Affordable Care Act. It’s proven effective, Smith said.
The grant let the city establish two-person community care teams who respond to calls for medical service that come into the city’s 911 system. Most calls to fire and medical departments across the country are for medical reasons rather than fires, Lo Giudice and Smith said. The standard protocol has been to send a four-person team to all those calls. Now, once it’s been determined the call is medical and can be handled by a two-person team, a community care team heads out. Those teams consist of either a nurse practitioner or a physician assistant and a firefighter paramedic.
The community care units respond to low-acuity and non-emergent calls, Lo Giudice said. Three units operate in the city and are on duty 24 hours every day, like the rest of the Fire and Medical Department staff. They drive a modified ambulance equipped to allow them to provide services similar to those offered at an urgent care facility.
Before a community care team is sent out, plenty of background work has already occurred, Smith and Lo Giudice said.
Dispatchers in the 911 center first assess the nature of the call and if it’s not life-threatening, a registered nurse, who is now part of the 911 call center staff, gathers more information from the patient. When it’s appropriate, the two-person team is sent out rather than a four-person fire crew.
The idea of sending a two-person crew to medical emergencies isn’t new. But, Mesa’s effort has a new twist. The city and Mountain Vista Medical Center, an IASIS Healthcare hospital in Mesa, are partners in the venture. The nurse practitioners and physician assistants who work as part of the community medical units are from the hospital staff, Smith said.
Mesa has long been a leader in emergency care
This isn’t the first time Mesa leaders instituted a two-person emergency response team to handle emergency calls, Lo Giudice and Smith said.
A decade ago former Mesa Fire Chief Harry Beck created two-person response teams to handle low-acuity calls, Smith said, such as smoke alarms or welfare checks. He took that action to free up the firefighter paramedics to respond to the high volume of influenza calls that were swamping local hospital emergency departments at the time.
Because of that 2007 flu epidemic, people had long waits at emergency rooms, Smith said. In response, Beck added a physician assistant to the two-person team to allow them to handle even more types of calls. The city received a $100,000 grant from the state of Arizona for that program. In 100 days, the teams responded to 978 calls in the 12 hours they worked each day.
“It had a significant impact on what was happening in the community,” Smith said. But, once the grant money ran out, there was no funding to continue it. Meanwhile, the city’s tax base was dropping because of the housing crisis, which resulted in belt-tightening. “So, it ended,” Smith said. “But Harry Beck and I kept talking about it.”
Everybody likes it, no one wants to pay for it
The CEOs of the area hospitals were all in favor of the program, Smith said. But, they didn’t want to pay for it either. Mountain Vista Medical Center did pay to staff a nurse practitioner to accompany a firefighter paramedic on calls.
Smith wrote some policies for that new team to follow, determined what services they could provide and established specific guidelines. It was challenging to figure out how to respond to calls with just two people, instead of four, which is the longstanding protocol in emergency response, Smith said.
Smith still wasn’t ready to give up on the idea and then he and Lo Giudice connected and applied for the federal grant.
Because 80 percent of the Mesa Fire and Medical Department calls are for medical needs, it just made sense for the city to keep exploring the idea, Lo Giudice said. In an average year, Mesa receives 55,000 medical calls and 40 percent are considered low acuity. It doesn’t make sense to take the firefighters off the street for non-emergent calls, he said.
The primary purpose of today’s community response teams, Smith said, is to keep patients out of the ER and “get them to an appropriate follow-up appointment with a doctor.”
Key to the program is what Smith calls “the power of the prescription pad.” The fact that some prescriptions can be given to a patient at his or her home, instead of that person having to visit an ER to get the prescription, is significant, he said.
The concept has “caught fire around the country,” Smith said. He’s spoken to emergency officials from many places who want to learn more. The California cities of Los Angeles and Anaheim and Los Angeles County, along with the North Denver department, are all running model programs of Mesa’s plan, he said.
Officials in the emergency service business around the United States have reached out to Mesa officials seeking information, guidance and a better understanding of the program because they are interested in implementing similar programs in their communities. They’ve visited Mesa and Lo Giudice and Smith have gone to their communities to explain the program.
Getting insurers on board
Smith has met with Valley insurers about the program and has been greeted with excitement about it mostly because of the lower costs that come when patients don’t have to be taken to emergency rooms by ambulance. But, he said, those companies aren’t yet ready to reimburse the costs of the community care team calls in the fashion they handle ambulance calls. That means he and others will keep working with insurance companies to reach some sort of agreement, Smith said.
“It’s a new program so we have to go to insurers and see if there are ways to cost-share it,” Ward said.
“We have really good data,” to share with insurers, Ward said. “The (Centers for Medicare and Medicaid Services) has provided third-party resources to review that data and we review it.”
Lo Giudice describes the record-keeping part of the project as utilizing “quite a robust data methodology.” Data is reviewed by the Mesa department to help identify patterns and trends so delivery methods can be adjusted, he said.
“We can pull any data we want out to try to predict what could happen. We’re continuing to evolve and adapt along the way,” Lo Giudice said.
Sustainability is the issue that must be resolved, Lo Giudice said. Once the grant expires, “how do we get reimbursed from insurance companies?”
Everyone is on board with the concept of providing high-quality care and making a difference in the lives of people, Smith said.
Positive scores from patients
The department has conducted patient surveys since the program was implemented. Those show that 98 percent of respondents were satisfied with their treatment and said they were treated with respect, Lo Giudice said.
Even more important to him was the fact that 96 percent of patients said they understood what they were supposed to do after the response team left – whether it be schedule a medical appointment or get a prescription refilled or anything between.
“There are a lot of problems with people not knowing how to do self-care,” Lo Giudice said.
The community care program “fills a gap in the community for people with no access to a primary care provider who would be going to an ER otherwise,” Ward said. Among the key results is the fact that patient outcomes are improved.
The work done by the community care teams with the grant funds have resulted in significant impacts, Smith said. “It has been a phenomenal experience.”
The teams responded to 49,000 calls in 2010 and to 66,000 in 2016. The teams have caused a 76 percent diversion rate from emergency room visits for Mesa Fire and Medical Department calls, including 60 percent on the medical side alone. Other calls are mostly related to the behavioral health unit which was added mid-way through the grant program after officials saw a real need for it.
Besides the initial call, the community care teams make follow-up calls to patients who had to be admitted to a hospital, Smith said. They help review the patient’s medications, conduct an EKG and a home safety inspection and talk to the patient “to make certain of their safety.” They also help set up follow-up medical appointments.
In addition to administering care to patients, the community care unit can give people a ride to a pharmacy to pick up a prescription, if they don’t have a vehicle. They give patients rides to places like Community Bridges “to get them plugged into the system,” Mesa Fire Capt. Paramedic Seth Johnson said. They’ll also help set people up with hospice or other transitional services. They can even help with calls to insurance companies for their patients, Johnson said.
The mission of the teams is to provide more efficient service, deliver care in a better setting and save money, Lo Giudice said.
“We want to provide the best responses to whatever the call is,” he said. “We continue to learn how to best respond.” Fire departments traditionally have over-responded to calls to err on the side of safety, and learning how to respond with fewer personnel and pieces of equipment has been a small challenge, he said.
Everyone involved in the program has a “great sense of the positive benefits this provides to the community,” Lo Giudice said.
Money, money, money
The big question now is how to get money to keep the program operating, Lo Giudice said. “The problem is we’re taking an innovative program and part of it is in an existing medical payment system. It’s almost impossible to modify the system.”
But, he said, accountable care is important to everyone involved in the system – doctors, hospitals, insurance companies, the fire department, the patients, so it’s not impossible to create a cost-sharing system and create methods for alternate payments. It will take time to do any of that, though, Lo Giudice said.
Lo Giudice “anticipates community para-medicine and mobile integrated health care will become the new normal” around the country.
Getting additional grant money to extend the program is not an option. It was a one-time grant and isn’t renewable. But, the money that’s been saved across the board and the revenues generated by the community care teams could be funneled to pay for its continuation, he said. That decision hasn’t been made, though.
– Shelley Ridenour is a freelance reporter for MyNewsMesa.com.