Convening a Learning Community To Reduce Nonurgent Use of Emergency Services
Convening a Learning Community To Reduce Nonurgent Use of Emergency Services
In October 2014, the Agency for Health Care Research and Quality (AHRQ) Health Care Innovations Exchange established three learning communities (LCs) to improve the quality of health care delivery by addressing challenges in high-priority areas that AHRQ identified. The Innovations Exchange defined an LC as a select group of potential adopters and stakeholders who engage in a shared learning process to facilitate adaptation and implementation of innovations featured in the Innovations Exchange.
The LC that focused on reducing the use of emergency services for nonurgent conditions (the ES LC) included representatives of nine organizations in the Detroit, MI, metropolitan area. The ES LC’s work built upon a cluster of select innovations from the Innovations Exchange, adapted in the local context. To learn about the collaborative work of the ES LC, the Innovations Exchange interviewed its champions and expert faculty: Herbert Smitherman Jr., MD, MPH, FACP, President and CEO of the Health Centers Detroit Foundation, Detroit, MI, and Innovations Exchange Editorial Board Member; and Matt Zavadsky, MS-HSA, EMT, Director of Public Affairs for MedStar Mobile Healthcare, Fort Worth, TX. The ES LC members modeled their implementation efforts in part on the program that Mr. Zavadsky developed at MedStar Mobile Healthcare.
Innovations Exchange: What factors are driving interest in innovations aimed at reducing nonurgent use of emergency services?
Herbert Smitherman Jr., MD, MPH, FACP: It’s widely recognized that a significant amount of health care is being provided at high cost in emergency departments (EDs). Correcting this means serving people who need care in the right place, at the right time, in the right setting, and at the right level of care. Addressing nonurgent emergency service use requires a transition to more appropriate settings, such as outpatient care, primary care, substance abuse treatment, social services, and senior-based care settings. We’ve got to have more integration of care, which is what our LC was all about.
Matt Zavadsky, MS-HSA, EMT: The reality of Detroit’s experience with high levels of nonurgent use of emergency services is being replicated in every community in the Nation. It’s about the money. Our health care system has been unsustainable because of the lack of alignment of financial incentives. With the Affordable Care Act (ACA), shared-risk contracting, and other efforts to make health care more accountable, payers are no longer willing to accept an ED visit for strep throat. Hospital systems and accountable care organizations are financially on the hook, and so they are developing integrated delivery systems. In Detroit, the LC helped us figure out, given limited resources, how to achieve the triple aim of providing better care and achieving improved health outcomes at lower cost.
What are the main challenges to wider adoption of such innovations?
Smitherman: The two major challenges are poverty and a lack of health care coverage. Prior to the ACA, we were marginalizing large segments of the U.S. population, who as a result were getting care in one of the highest cost settings. With more people covered through the ACA, the next challenge was to expand our health care capacity in outpatient settings and reorganize the delivery system. In Detroit, we’ve been building more federally qualified health centers and primary care capacity, to make sure that when first responders react, and identify acute primary care and mental health needs, they can facilitate access to an appropriate mode of care. But we’ve had a fragmented payment system that leads to health care delivery silos.
Zavadsky: A significant challenge is the need to overcome the long tradition of simply leaving things the way they are. Everyone has benefited from the fee-for-service system—except the patient. Another challenge is the difficult process of bringing together the diverse stakeholders in a community and getting them to work together toward a common goal.
Smitherman: Getting stakeholders to work together in a coordinated way is critical if we’re going to bend the cost curve.
Zavadsky: Despite the challenges, there are reasons to be hopeful. Nationwide, there are about 17,000 licensed EMS agencies. Five years ago, only four agencies had emergency medical services (EMS)-based integrated care program like ours. Today there are about 240 mobile integrated health care and community paramedicine programs, based on data from a 2015 national survey conducted by the National Association of Emergency Medical Technicians, as well as my own contacts with people developing new programs. That’s still a small proportion overall, but the rapid increase in recent years shows that the programs are demonstrating value to community stakeholders.
How did the ES LC go about adopting the innovation?
Smitherman: Using the library of innovations available at the Innovations Exchange, the LC brought together the Nation’s best practices, including Mr. Zavadsky’s program. Then we found ways to scale up and spread these innovations to the Detroit area and other communities. We understood that we needed to reduce response times and connect people to needed services. With input from experts like Mr. Zavadsky and others, we identified our goals and considered how to design a program tailored to the Detroit community. Although every community is different in terms of local priorities, laws, resources, and other factors, the basic problem is the same. And there are a lot of similarities across communities in terms of the value of bringing together the stakeholders to develop solutions.
Our LC set out as a community of stakeholders to establish protocols to allow EMS to refer patients with nonurgent problems to primary care and social support services. We gave special attention to the top 25 individuals who were placing 911 calls, and to hot-spot locations in our community where many nonurgent EMS calls originated. We implemented our protocols using our SafetyPAD EMS information system and our electronic medical record system. When we made an EMS run, we could identify patients with nonurgent problems, refer them in real time, and make appointments for them to receive the community outpatient services they needed. By doing that, in many cases we eliminated the need for the next EMS call.
What have been some of the successes and challenges in implementing the innovation?
Smitherman: We’ve come a long way. We have more vehicles and staffing and a new emergency medical dispatch system. We’ve reduced the average EMS run time for urgent calls from 18 minutes to 9 minutes, in part because our EMS system is not busy with nonurgent runs. One ongoing challenge is keeping all of the stakeholders at the table and continuing to moving forward. But people are excited about the progress we’ve made. Foundations like what they see and are willing to fund this approach. Our program can serve as a model to help other communities solve these problems and make real progress.
What was your experience with using the ES LC as a mechanism to support adoption of the innovation?
Zavadsky: Any health care provider or emergency care provider has a responsibility to share best practices. Through the LC, we were given the opportunity to do that, and Detroit has had amazing success, due in large part to the collaboration by the participants in the LC. Two key factors made our model a logical fit for Detroit and the LC. First, as in Detroit, our model is an urban model, with an EMS system serving a large population, and with many patients who can’t find the resources they need. Second, we had figured out how to make the program financially sustainable, which is very appealing for communities that need to convince organizations to fund such an initiative. Many efforts to develop such programs have failed because they were not able to show value. Working with Detroit’s sophisticated health care system, Dr. Smitherman and his team were able to make rapid progress in adopting the innovation. People in the LC were cautiously enthusiastic during our first meetings, but a lot of relationship and trust building occurred after that. Through honest dialog and collaboration, the LC was able to get the process started and achieve impressive results.
What lessons can you share about using an LC as a dissemination and implementation strategy?
Zavadsky: A key lesson of the Detroit process was the value of having a respected health care research organization such as AHRQ serve in a convener role and convince people to participate in the effort. If the individual players tried to do the same thing, half of the stakeholders might not agree to participate. The LC offered a way to bring outside experts into the community and address the underlying problems directly and frankly. Outsiders can say things that people who live in the community can’t say, like, “You’re doing what? Why? Here’s how we’ve done that.” In South Florida, for example, they’ve had marginal success, because the hospitals were not willing to collaborate, or people didn’t want to acknowledge the extent of the problem. Given such resistance, it’s more effective to have an outside organization lead the process.
Another important success factor was having a technology infrastructure for the LC that promotes collaboration and knowledge sharing through an online platform, webinars, and other tools for interaction. As the field continues to move forward and more communities establish such programs, it would be great to establish a clearinghouse for sharing protocols and other resources that other communities can use to develop such programs and achieve similar results.
Our experience In Fort Worth shows that EMS organizations in many communities would like to implement these kinds of programs. We’ve had inperson visits from EMS providers and other professionals from 190 communities seeking to address the same problem. We’ve also received hundreds of e-mails and phone calls asking about our program, and many of those people learned about our program by reading our profile on the Innovations Exchange. So there’s huge interest in replicating best practices. People would love to have something like the LC available to serve as a “scar-avoidance mechanism” that lets them benefit from previous efforts that have proven successful.
About Herbert Smitherman Jr., MD, MPH, FACP: Dr. Smitherman is President and CEO of Health Centers Detroit Foundation, a federally qualified health center look-alike that serves the underserved and uninsured in Detroit and surrounding Wayne County. He is also the Assistant Dean of Community and Urban Health, and Associate Professor of Internal Medicine at Karmanos Cancer Institute, Wayne State University School of Medicine. His research focuses on health issues in underserved populations and their access to appropriate health care. Dr. Smitherman serves as a member of the Editorial Board of the AHRQ Health Care Innovations Exchange.
About Matt Zavadsky, MS-HSA, EMT: Mr. Zavadsky is Director of Public Affairs for MedStar Mobile Healthcare, the exclusive emergency and nonemergency ambulance service provider for Fort Worth and 14 other cities in North Texas. With 37 years of experience in EMS, he has helped develop health care partnerships that have enabled MedStar to serve as a mobile integrated health care provider. He is a frequent speaker at national conferences and has done consulting on EMS issues. Mr. Zavadsky is adjunct faculty for the University of North Texas Health Science Center.
Dr. Smitherman reported having no financial interests or business/professional affiliations relevant to the work described in this article.
Mr. Zavadsky reported that MedStar Mobile Healthcare received payment from the AHRQ Health Care Innovations Exchange for providing consultation services to the learning community, and that the Innovations Exchange reimbursed his travel expenses for attending learning community meetings.
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