Fire-Based EMS The Next Generation Fire Chief Harry Beck Mesa Fire and Medical Department Gary Smith, MD Medical Director, Mesa Fire and Medical Department

Purpose Describe a model of Fire-Based EMS for proven performance and efficiencies under the Affordable Care Act.

City of Mesa, Arizona 137 square miles 75,000+ > 62 years of age 440,000 residents (2010) 85,000 winter visitors (2010) 75,000+ > 62 years of age Diverse Population

Mesa Fire and Medical Department 21 ALS Engines 5 ALS Ladders Community Paramedics Private Ambulance 2 Community Care Units 20 Fire Stations 55,938 Total Calls 80 % Fire Based EMS

Mesa Fire and Medical Dispatch Analysis 2013 Mesa 911 Calls 55,938 Medical Emergency Calls 45,854 Low Acuity Calls 10,061

Community Care Initiative

Low Emergency Response Model Features Improves Availability for Response to High Emergencies Improves Availability of Ambulances and ERs 911 Based Operated from Fire and Medical Response Model Integrates Partnerships

Low Emergency Response Model Features Allows Partner Billing No City Billing at This Time No change in PM Scope of Practice Tiered Triage and Deployment Alternate Destination/Admission Avoidance PCP Referral

Community Paramedic Unit (TRV) Captain Paramedic & Firefighter Two Response Units Low Acuity Patients Peak Time Deployment Priority Dispatch Triage Treat and Refer

Community Care Nurse Practitioner Unit Captain Paramedic & Nurse Practitioner Nurse Practitioner Provided by Mountain Vista Hospital Treat and Refer to PCP CLIA Waived Laboratory Tests Provide Alternative Destination Patient Follow-up Peak Time Deployment Provide Support to Law Enforcement

Community Care Behavioral Health Unit Captain Paramedic and Behavioral Health Specialist Dispatch to Definitive Care in 1-Hour 45-Minutes Alternate Destination Video

Proven Model Air Date: January 2013, KSAZ-TV

Emergency Room Costs 2013 Cost Comparison Source: Kliff,S. An Average Emergency Department Visit Costs More Than an Average Month’s Rent. The Washington Post. 2 March 2013

Emergency Care Charges Low Acuity Medical Patients Past Model New Model Savings Transport to ER $1,000 $0 $1,000 Registration $525 $0 $525 Physician Assessment $325 $150 $175 Decision Making $950 $0 $950 MFMD Cost $375 $375 $0 $2,650 Total Savings per Patient

Emergency Care Charges Behavioral Health Patients Past Model New Model Savings Transport to ER $1,000 $0 $1,000 Initial Evaluation $3,500 $150 $3,350 3-Day ER Hold $6,000 $0 $6,000 Inter-Facility Transport $1,000 $0 $1,000 MFMD Cost $375 $375 $0 $11,350 Total Savings per Patient

Unit Insurance Coverage 2013 Community Care Response Behavioral Health Community Care Response Behavioral Health Medicare 28% 44% Medicaid 37% 36% Private 15% 19% None 20% 1%

Projected Cost vs. Benefit Detail

EMS Prevention Model Features Reduces EMS Calls Supported by Call Center RN Tiered Triage Coordinates with Providers Integrates Partnerships

EMS Prevention Model Features Incorporates City Billing Assists with Sustainability Provides Post-Hospital Services Provides “GAP” Services Reduces Hospital Admissions

Loyalty Customer Program Proactive Service Reduction of EMS Calls Partnership with ACO

Transitional Care Program 72-Hour Post-Discharge Contact Partnership with Physician (PCP/Specialist) Proactive Service Reduces Readmissions Transition to Home Health Sustainable

Hospice Comfort Pack Program Coordinated with Hospice Provider Maintains Patient Qualification Improves/Maintains Care Eliminates Transport Sustainable

Crisis Prevention Outreach Programs Target Populations Facilitates Access to Appropriate Service Facilitates Intervention Behavioral Health Partnership

Community Based EMS Programs Direct Community Involvement Partnership with Good Samaritans Awareness/Education/Training MICR/CPR Training First Aid Training Hospital Partnerships Immunizations School Partnerships

What… When… Where… Why…

The Reason We Are Still Needed

…and Needed Less

The Fire Service is Getting More Expensive…

Mobile Integrated Healthcare Programs Pilot programs focus on Patient Navigation 9-1-1 Nurse Triage “EMS Loyalty” Programs Readmission Avoidance Hospice Revocation Avoidance 23-hour Observation Avoidance Require Agility

Core Reform Strategies Public Reporting: engaging consumers and other stakeholders Health Information Technology: enabling improvement Value-Based Payment: rewarding achievement Clinically Integrated Delivery Systems: achieving patient centered care

A Future System Affordable Accessible – to care and to information Seamless and Coordinated High Quality – timely, equitable, safe Person and Family-Centered Supportive of Clinicians in serving their patients’ needs Engaged with the community and fulfilling its population’s unique needs

Developmental Needs Cost Recovery Shared Savings Pay-For-Performance Capitation ACO Involvement Fire Station Based Clinics 72 hr. Patient Follow-Ups Research Evidenced-Based Quality Assurance

To view a copy of this presentation… www.mesaaz.gov/fire www.evwellness.com Find us: mesafiredept East Valley Wellness AZ

Mountain Vista Medical Center Public-Private Partnership Mountain Vista Medical Center IASIS Healthcare (One of the largest healthcare organizations in the US) 176 Beds 15 Bed Emergency Department 55,000 ED visits a year Level 3 Trauma, Stroke Center, Cardiac Center

Mesa Fire and Medical Model Evolving Issues National Health Care Major Issue Cost of Health Care - 17.9% GDP Impact of Affordable Care Act Resulting Changes to CMS Creation of Accountable Care Organizations CMS Grant Opportunity

Community Care Initiative: Aims and Drivers Affordable Care Act Community Care Initiative: Aims and Drivers

Dispatch to Definitive Care Behavioral Health Dispatch to Definitive Care in 1 hr 45 min Video

Citywide BLS Calls 2013

Behavioral Health/Substance Abuse 2013

Behavioral Health/Suicide Threat 2013

2012/13 Community Care Response Pilot Community Care Response Unit 2012/13 Community Care Response Pilot 2012/13 CCR Responses 1,250 Directed to Appropriate Care 500 (40%) 2012/13 Low Acuity Response Analysis (based on current dispatch protocols) Medicaid 3,723 Medicare 2,817 Private 1,509 Uninsured 2,012 Directed to Appropriate Care (potential) 4,024

Cost Average Per Patient Total $375 Human Resource Supplies/Equipment Community Care Response Unit Cost Human Resource Captain Paramedic and Nurse Practitioner or Behavioral Specialist) $310 Supplies/Equipment $20 Response Apparatus $45 Average Per Patient Total $375

Medicare 18% Medicaid 15% Private 8% None 1% No Information 59% Behavioral Health Unit Insurance Coverage Including Patients with no Insurance Information 2013 Medicare 18% Medicaid 15% Private 8% None 1% No Information 59%

Behavioral Health Unit Insurance Coverage 2013 Medicare 44% Medicaid 36% Private 19% None 1%

Private 23% Medicare 3% Uninsured 29% Billing Information for Behavioral Health Unit Information Provided by the Mental Health Provider 2013 Private 23% Medicare 3% Uninsured 29% Medicaid/Medicare/Magellan 45%

Community Care Response Unit Expansion of the model Public-Private Partnerships Higher Education for Members Enhance public access Fire Station Based Clinics Determine demographics

The Next Generation Public School Partnerships Communication Center Centralized Medical Direction On site medical direction Telemedicine Business/Special Events Integrate into health care systems

The Next Generation Post Surgical Checks Injury Prevention Community Based EMS Behavioral Health Intervention Sustainability Healthcare Information Exchange

Primary Care Physician Not to replace the Primary Care Physician