A year and a half ago the Mesa (AZ) Fire and Medical Department (MFMD) received a $12.5 million CMS grant to fund a three-year trial dedicated to improving care and lowering costs by more effectively managing low-acuity calls.
The Mesa Community Care Response Initiative sends a nurse practitioner or physician assistant—along with a captain/paramedic—to examine and treat patients in the field without transporting them to the emergency department. The call center flow chart illustrates how calls are processed. The program aims to increase patient satisfaction, decrease ED and EMS transport costs, make more efficient use of MFMD resources and lessen ED overcrowding.
I recently met with the architect of this innovative approach, MFMD medical director Gary Smith, MD—who constructed the business plan that eventually won the grant—along with Fire Chief Harry Beck, who is tasked to implement the program.
High- or Low-Acuity?
The first question asked when a call comes in is, “Is this a high-acuity call?” If yes, MFMD sends out a four-person ALS company. If no, the call transfers to an RN employed by MFMD to triage. Both Smith and Beck believe this RN triage component will be the cornerstone of a future telemedicine rollout. That program would involve a partnership with local physician groups to provide after-hour physician calls.
“One of the things we picked up on pretty quickly,” says Beck, is that “anything we can do to interrupt or prevent a 9-1-1 call is a process we should be involved in.” An effective nurse triage line will reduce frequent callers and improve patient care.
Transitional response vehicles—four units staffed with an EMT captain and ALS firefighter—manage the low-acuity calls and keep ALS units available for bigger emergencies.
The community care unit (CCU) is staffed by a NP or PA, while the community care specialists (CCS) unit is staffed by a licensed social worker and captain/paramedic.
The CCUs are reporting a 64% diversion rate from the ED, and those of the CCS behavioral units are even higher. Both the CCU and CCS are a result of non-FD community partnerships: Mountain Vista Medical Center supplies the nurse practitioners and physician assistants, while a local firm called CPR (Crisis Preparation and Recovery, Inc.) supplies the licensed clinical social worker who delivers the patient with a full psychological workup at the time of delivery to the psych center.
“By sending an advanced practice PA/NP, you now have the ‘power of a prescription pad’ because they can take care of the individual right then,” says Smith.
MFMD has also added i-STAT handheld blood analyzers to the advanced-practice ambulance, so practitioners can get an outpatient basic metabolic panel. “We get an H&H (hemoglobin and hematocrit) to determine if the patient is anemic. We are adding lactate to that so we can go out on sepsis calls. Sepsis is now a core measure for CMS because of the high readmission rate,” notes Smith.
The CCS unit allows more efficient treatment of behavioral patients, including investigation into what triggered their episode. In the past such patients were typically just treated with Versed and taken to the ED, where they were managed and released without much understanding gained. Local police are now even starting to summon the unit directly for appropriate patients.
The Power of Partnerships
Though only about 60% of the business plan has been implemented to date, it’s already drawing interest from elsewhere. Representatives of Kaiser Permanente visited and concluded a similar program could potentially save half a billion dollars in California; they’re now working with Smith on a version in Anaheim. In Arizona, Sierra Vista (outside Tucson) is also using a nurse practitioner model, and Rio Verde is operating a PA clinic at a fire station. Texas mobile healthcare pioneer MedStar has shared expertise in identifying care-intensive hotspots and budgeting.
Smith credits partnerships between healthcare entities as critical to the success of the program. His ultimate goal is to create a model that can be reproduced throughout the healthcare system.
“It makes perfect sense to have public and private come together,” says Smith, “but I can’t stress enough that the fire agency has to own their dispatch. Whoever owns the communication center is the one who owns the outcomes.”
An added bonus to the integration is the opportunity for current paramedics to grow into some of the advanced healthcare roles.
Revenue sources for sustaining the program could potentially include the nurse triage/physician telemedicine call center, which could also function as a transfer center and manage beds inside the hospital, as well as postdischarge services provided for local hospitals.
In Mesa, though, they’re beating financial expectations so far and have a goal of returning half of what CMS gave them.