Alternatives to the ED

The Regional EMS Authority (REMSA) of Reno, NV, has received a $9.9 million grant from the Center for Medicare & Medicaid Innovation to develop new care pathways for patients beyond going to hospital emergency departments. Once these are developed, this project will create a template for reimbursement of ambulance services by Medicare/Medicaid that does not necessarily involve transport of patients to EDs.

“There are three elements to this grant,” explains Mike Williams, REMSA’s vice president of operations. “One involves an alternative phone number to 9-1-1 to call and access medical care. The caller will get a nurse advice-type line, and through a call triage system, the call-taker will be able to direct the caller either back into the 9-1-1 system for complaints of an urgent/emergent nature or, in the second part, into our community paramedic program, which will allow an advanced practice paramedic (APP) to be sent to determine the third part: if they need transport to a hospital, an urgent care center or their physician’s office, or perhaps don’t require transport at all.”

The program will also encompass the local CMS-approved medical home program for chronically ill patients. Under the medical home program, patients have a primary care “home” physician and a team of nurses, social workers and now APPs to coordinate their care through that physician. It will take about a year to add the alternative pathway system to REMSA’s communications center.

“We are going to start with patients who have physicians so there will be closer control over who calls and under what circumstances,” says Williams. “Then it will spread to the general public as we do public education on the project. People who might typically call 9-1-1 will now have alternatives. We believe this will be the new wave of healthcare, giving patients options that allow for a more appropriate care response, if needed, and a lower-cost, more convenient medical approach.”

The second part of the program is sending an APP to evaluate the patient’s condition and determine what pathway the patient should follow to receive care. The APP could be sent after a call to the alternative phone number or as scheduled by the patient’s physician, medical home or hospital system referral. The training curriculum used for the APP will be the one developed by several universities currently used in Eagle County, CO. It will be taught through the REMSA education department in partnership with the University of Nevada, Reno School of Community Health Sciences.

This part also involves APPs monitoring and following up with patients who have been discharged from hospitals. They will help these patients with new medications, making sure they take them in the right amounts at the right times, etc. They can also ensure patients comply with other discharge instructions, hopefully preventing the need for return visits.

“Decreasing the readmission rate has gotten us support from the local hospital community,” Williams says. “This grant will create partnerships between REMSA and all the hospital systems in the Reno area. One of the aims of the program is also to reduce the number of unnecessary ED visits that can delay care for all ED patients.”

The Reimbursement Connection

One of the things that makes this program different from other community paramedic programs is its connection to the Centers for Medicare and Medicaid Services (CMS) and reimbursement. One part of the grant is a study to see how costs can be decreased and savings accrued for the medical centers, CMS and REMSA. This is part of the incentive to cooperate in the process. CMS is looking at this as an experiment, and there will be a lot of data sharing to make sure that what we believe will happen actually does. The university is also assisting with data analysis.