The sprawling metropolis of South Florida is known for its beautiful beaches and bikini-clad residents. Yet with respect to medical care, the tricounty region (Palm Beach, Broward and Miami-Dade) has been marred by unrelenting Medicare corruption and highly variable healthcare systems. The ultracompetitive environment has left large portions of the vulnerable elderly population exposed to significant gaps in care, along with high rates of hospitalization and readmission.
Take Mildred, for example. The mother of an Army physician, Mildred was recently diagnosed with pancreatic cancer. She was living alone in a small condo in Miami and caring for herself as best she could while her son served in Afghanistan as a field surgeon. When she fell ill, her only choice was a 9-1-1 call and transport to the closest appropriate hospital. Unfortunately the closest facility was not the hospital that was treating her cancer. This geographic dilemma, along with the complexity of her disease, invariably resulted in prolonged ED boarding followed by many days in the hospital. For Mildred the story was always the same: a new doctor (the hospitalist on call), more prescriptions and another ambulance ride back home. “If only my son lived closer,” she whispered under her breath to the transport crew as they drove her back to the crowded third-floor apartment they’d visited several times before.
Stories like Mildred’s are common in South Florida, where readmission statistics continue to climb. Hospital executives admit that while readmissions are problematic, they still like seeing their emergency departments filled with patients. The transition to accountable care organizations (ACOs) has been slow and sparse, and cloudy thinking continues to impact the quality and costs of healthcare in the region.
Consider what happens to the stroke patient brought in by EMS with a debilitating emergency large vessel occlusion (ELVO). Following rapid treatment and more than a week in intensive care, the patient is finally ready to be discharged home with significant deficits and many additional needs. The next 14 days for this patient are the equivalent of taking home a newborn for first-time parents. Counterintuitively, however, these postdischarge days are often poorly addressed by the system, leaving the patient to fight for clarity and help.
It has become clear that most primary care physicians are not set up for this type of “high-maintenance” care. At the time when their stroke patients need them most, many PCPs are not available. They simply do not have the time it takes to reacclimatize patients to the new realities of living following a stroke. And while it’s not anyone’s fault per se, the system currently works against the best interests of these at-risk patients, many of whom are Medicare beneficiaries living with multiple comorbidities.
Collaborative care models are the wave of the future, and one such proven model led by primary care physicians is transforming healthcare for tens of thousands of seniors in six southeastern states. Quietly pioneered in Miami and optimized during the past 30 years, a growing network of ChenMed centers is improving health outcomes affordably for seniors, helping communities exit the aforementioned healthcare spiral. Patients are provided frequent access to both PCP and specialist physicians year-round, including during the critical transitional period immediately following hospital discharge. They also benefit from a broad range of physician-directed in-home services provided by MIH paramedics and nurse case managers. This innovative, decentralized model provides flexibility while retaining a personal touch that reflects on the history of its founders.
The ChenMed Model
When James Chen, MD, PhD, first began practicing medicine in Miami, he quickly focused on serving the needs of seniors living with multiple and major chronic conditions. Driven to improve health outcomes, he convinced health insurance plans to reduce costs of care (heavily weighted in hospital sick days) and financial risk by making his medical practice a full-risk managed services organization (MSO) receiving a per-member per-month stipend from insurance companies for physician-coordinated care.
An ACO pioneer, Chen strategically emphasized nurturing close relationships with each patient; preventative care; and transparency regarding health outcome measures. Successes in care fostered organic growth and the expansion of his medical practice with like-minded physicians, including his cardiologist sons, Christopher and Gordon, and internist daughter-in-law, Jessica.
The Chen family recounts a difficult fight with cancer during which James personally experienced unacceptable access-to-care challenges—even with a family of doctors serving as advocates. Once his road to recovery was completed, the entire Chen family was further inspired to transform healthcare for the nation’s neediest populations. “Everyone deserves timely access to doctors who are true champions for their health,” says Christopher Chen, CEO of ChenMed. “Maintaining the ChenMed culture of care—where love, accountability and passion for service are hallmarks—is of utmost importance.”
The Role of MIH
Recognizing that physicians face real challenges in optimizing patient care, the ChenMed team sought to utilize the mobile integrated healthcare model to extend physician care into homes with the help of highly skilled paramedics.
Mildred is a classic example of a senior who could benefit from the MIH model, directed by physicians who serve as champions for their patients. When Mildred’s 11 p.m. call for vomiting and diarrhea could not be triaged by the on-call physician, it ultimately forced a call to 9-1-1, followed by transport to the closest and most appropriate ED and an inevitable hospital admission.
Had she been a Chen Medical Center patient at the time of the call (she later became one), Mildred’s experience almost certainly would have improved. She would have first called to speak with her PCP or an after-hours physician colleague empowered by electronic medical records, who would have been able to immediately dispatch the MIH paramedic to her home for physician-directed care. She would have avoided the time and stress of a trip to the hospital, followed by a probable admission. (The average South Florida ED visit costs $3,000, the average hospital admission $8,000.)
The combined program allows physicians to treat at-risk patients at home with paramedics accustomed to treating “any patient” at “any time” in “any location.” Unlike home health agencies, which send nurses out during daytime hours, PCP-directed paramedics work both day and night, and are able to navigate austere (urban) environments.
In 2015 American Ambulance, a subsidiary of Falck, collaborated with ChenMed to establish a mobile integrated health (MIH) entity named Transitional Health Solutions (THS). Years earlier American’s CEO, Charlie Maymon, had the vision to initiate a MIH program and applied for a CMS Innovation grant. He didn’t get it, and the item fell dormant, but the conversation never did, and ultimately it led American’s director of business development, Stacey Patasnik, to make an important discovery.
Patasnik recognized that hospitals were not the ideal MIH partner due to their continued interest in keeping their EDs full. Instead, “full-risk” organizations like ChenMed had numerous reasons to be interested. Full-risk entities bear the full financial burden of patient care and therefore have patient wellness in their best interest. ChenMed was the perfect partner, Patasnik thought, and she quickly moved to connect the stakeholders from each side. The 10-page CMS grant application was dusted off, Transitional Health Solutions was born, and Maymon’s dream finally became a reality.
Not Your Typical MIH Program
While MIH programs are on the rise nationally, the THS-ChenMed pilot was different in several key areas. First, the model was one of fiscal sustainability rather than grant funding. CMS has funded numerous pilot projects over the past few years, several of which have shown promise, yet sustainable payment models are the exception, not the rule. Currently a fee-for-service (FFS) model is being employed, but future collaboration will utilize a capitation model.
Second, THS paramedics, all critical care-certified, act as the “eyes, ears and hands” of the patient’s physician. Prior to initiation of the pilot, an intensive program was conducted for all team members with the assistance of national experts such as Chris Cebollero, who was flown in from St. Louis. Paramedics were taught to switch their focus away from the speed of the 9-1-1 service to the slow, methodical approach to the MIH patient. Protocols were then established and operational decisions formalized. A critical operational concept that has proven to be of great value is the requirement that MIH calls be “bookended” by the patient’s PCP via telephone or secure, HIPAA-compliant text or video chat. This policy ensures that physicians familiar with the patient are in direct contact with field providers who can carry out their clinical requests.
Third, the THS providers carry a comprehensive diagnostic and treatment cache. Every unit is equipped with an i-STAT, PT/INR and urine dipsticks, along with the standard EMS equipment and monitors. CLIA-waived point-of-care (POC) tests are rapidly performed in the patient’s home and transmitted securely to the Chen physician.
Gianni Neil, MD, a Chen Senior Medical Center medical director, has seen tremendous value to her patients due to the comprehensive information obtained by the on-site THS paramedics. One of the biggest advantages she has realized is “the ability to learn more about the patient’s living conditions and determine methods to further help patients stay healthy and out of the hospital.”
Every MIH paramedic addresses specific PCP requests, and each in-home visit includes checking vitals; formalized social review; evaluation for fall risk; and medication reconciliation. Finally, the program is data-driven and transparent to all stakeholders. Call types, labs or treatments administered, and outcomes are tracked continuously to help create a lean process that maintains efficiency.
Collaboration Yields Success
Remember Mildred? She became a Chen Senior Medical Center patient in 2015. Immediately prior to a weekend when her Army surgeon son was scheduled to visit her, she fell ill and became dehydrated. “I knew where this was going,” Mildred remembered thinking as she called the Chen Senior Medical Center on-call physician line. Neil answered the page and, after speaking to Mildred for five minutes, requested she “hang tight.”
“I’ll have a paramedic come to your house within 30 minutes,” Neil said. A quick call to the THS dispatch center, and Neil was immediately connected with Kirk, an MIH provider who’s a trained critical care paramedic. Neil explained Mildred’s history and current condition and requested a full evaluation including a BGL and basic metabolic panel as well as ondansetron IV and a liter of normal saline. Adhering to a set protocol, Kirk followed through and called Neil back to update her on Mildred’s progress.
Before he left Kirk heard a knock at the door and was greeted by Mildred’s son, the Army physician. When he heard what had just transpired, the doctor was extremely grateful for what Kirk had done for his mother. Mildred’s cancer would ultimately beat her, months later, but this one hour of hand-holding, targeted treatment and a little humor from Kirk made a lasting impact on Mildred’s son.
To date THS has made more than 1,300 house calls for a dozen Chen Senior Medical Center locations in Miami-Dade and Broward counties, and THS now has two units active around the clock.
At the 2017 NAEMSP conference in January, data was presented on the first 506 patients. Remarkably, 84% of these acutely ill patients remained at home after a PCP-directed MIH visit, and only 2% required 9-1-1 transport. Fourteen percent of patients who required transport reached the appropriate destination (clinic or hospital) using the THS-affiliated ambulance service. Regarding interventions, 42% of the at-risk patients received either an oral or parenteral medication; 33% received an EKG; 14% received POC lab testing; and 11% received fluids by IV. A total of 64 patients required transport to the ED, with cardiac diagnoses being the most common etiology. Overall savings have been estimated at $1.4 million, but the overriding reason for PCP-directed extended paramedic care is achieving better health outcomes for patients.
The Future of Chronic and Acute Care
The THS model has now expanded to offer clients chronic disease management and remote monitoring using wearables connected to a data center with customized vital sign triggers. Certain patients are also outfitted with a tablet that allows direct videoconferencing with dispatch. An EMR was created for this process, tailored to interact agnostically with other entities. Dashboards are in place to provide transparency to all stakeholders.
Payers have taken notice and realized the great benefit of THS programs similar to that being orchestrated by Chen Senior Medical Center. They are attempting to find the balance where MIH programs can provide a clinical benefit while also saving the system money. Focusing on the sickest 20% of the Medicare population may have greater value than utilizing MIH for the 80% who are generally in good health. Allowing patient-centered physician groups, such as ChenMed, which bear the financial risk, to participate in sophisticated MIH programs represents an everybody-wins scenario. Not only can well-equipped MIH programs fill gaps post-hospital discharge, they also can limit interruption of physicians’ daily practices while reducing unnecessary readmissions. Plus, at-risk patients can enjoy better health outcomes.
Mobile integrated health is undoubtedly the future of medical care for communities around the country. Collaboration, innovation and data collection, combined with focused patient selection, are vital to the success of this healthcare modality.
Dispensary on Site
The integrated ChenMed model addresses several other key issues as well. Patients, on average, see their PCPs once a month, and they are asked to bring all their medications to each visit. This way compliance is easily measured, with the PCP frequently reviewing and reconciling medications to improve health outcomes and avoid adverse drug reactions (the nation's fourth-leading cause of death, according to the FDA).
When new drugs are required, ChenMed provides them onsite so the physician can discuss the directions, side effects and pertinent nuances of each medication with each patient. It is well known that many patients delay their trips to the pharmacy after medical appointments or skip them altogether. Having a dispensary on site is invaluable for ChenMed patients.
Peter Antevy, MD, is the medical director for Transitional Health Solutions. He also serves as an EMS medical director for the Coral Springs Fire Department, Davie Fire Rescue, Southwest Ranches Fire-Rescue and American Ambulance in Florida. He is the associate EMS medical director for Palm Beach County Fire Rescue and the Seminole Tribe of Florida's Fire Rescue Department. Antevy serves as medical director at the Coral Springs Fire Academy and for Broward College's EMS program and is a pediatric emergency medicine physician at Joe DiMaggio Children's Hospital in Hollywood, FL. He is founder and chief medical officer of Pediatric Emergency Standards, Inc. Reach him at Peter@Handtevy.com.