1. Anaheim Fire & Rescue Community Care Response Unit (CCRU) Permission to utilize Mesa Fire and Medical Department’s TRV-PA201 Pilot Program information has been granted to Anaheim Fire and Rescue by the Mesa Fire and Medical Department’s Research Team

2. Current EMS Care Model Since the inception of emergency medical services (EMS), 911 responders have transported patients of all acuity levels to emergency departments for definitive medical care Paramedic and EMT care provisions are followed at the local-county level. Local and state mandates require EMS disposition of patients to the emergency departments Medicare and most private insurers utilize a “fee for service” payment model for both advanced life support and basic life support ambulance transports

3. Patient Protection and Affordable Care Act Employer based healthcare insurance is the leading source of healthcare coverage in CA and in the U.S The US Census Bureau estimates that ~16% (50 million) of Americans are without health insurance today* Anaheim’s insured population may increase by ~55,000 people due to Health Insurance Exchanges taking effect 1/1/14 While small groups will initially move into the healthcare exchanges, it is unknown if larger corporations will drop coverage and also move into the exchanges Us *C US Census Bureau 2010, Quick Facts http://www.census.gov/http://www.census.gov/ The Kaiser Family Foundation, http://healthreform.kff.org/faq/what-is-a-health-insurance-exchange.aspxhttp://healthreform.kff.org/faq/what-is-a-health-insurance-exchange.aspx

4. Realities The healthcare climate is in a state of change and reform Declining reimbursements is our new reality Medi-Cal and Medicare reimbursement levels are already low Most hospitals count on commercial PPO and HMO reimbursements to make up the difference – soon this will not be the case

5. Realities Reimbursement through the insurance exchanges will be significantly less than commercial rates. This will impact healthcare providers throughout the state While healthcare providers may experience higher volumes due to more individuals being insured, the reduced reimbursement will require hospitals to find innovative ways to reduce expenses Many hospitals are being asked to save in budgets over the next several years

6. Future EMS Care Model Accountable Care Organizations (ACOs) are future delivery models that the federal government hopes will help improve the health of individuals and communities by linking payments to outcomes The concept requires healthcare organizations, led by hospitals, physician groups, insurance companies and EMS to integrate and share responsibility for providing patient care Instead of the existing fee-for-service currently employed by both Medicare and most private insurers, the ACO system rewards providers for outcomes, not procedures. Providers get paid more for keeping patients healthy and out of the hospital* It will take legislative change at the state EMSA and local OCEMSA level in order for our current EMS providers to transport to alternative care sites or to provide an advanced level of care * http://innovation.cms.gov/initiatives/index.html#_Expandhttp://innovation.cms.gov/initiatives/index.html#_Expand

7. Population Health Management Managing the care of its members and making demonstrative improvements in wellness CMS – Value Based Purchasing Program Process Measures HCAHPS Mortality Hospital Acquired Conditions

8. New Opportunities The Fire based EMS system has tremendous emergency care capacity as we interface with unscheduled care - the 911 caller We need to identify our community needs and provide alternative solutions to the way we provide care instead of continuing to send patients of all acuity levels to one place….the overcrowded emergency department

9. EMS Transitional Response Vehicle (TRV) Model in Action: The Mesa Fire & Medical Department Mesa, Arizona

10. History of Mesa EMS TRV Pilot Program Development The Transitional Response Vehicle (TRV) Program Pilot was created to better align medical response efforts with call severity. An alternative and innovative response model that would deploy a single vehicle utilizing the capabilities of a mid level provider and a paramedic captain to non-emergent, low level call requests in place of a standard response of a paramedic engine/truck and ambulance unit.

11. Mesa’s TRV Program Today The current mid-level provider concept has evolved into a public/private partnership with local hospital; Mountain Vista Medical Center providing a nurse practitioner (NP) This latest pilot study, utilizing the NP/Mountain Vista Medical Center partnership, was initiated in August of 2012 and will operate a unit 40 hours a week. http://www.youtube.com/watch?v=tS80XOI1G9E http://www.myfoxphoenix.com/category/233272/localox 10 news

12. Calls would be screened by emergency medical dispatch to identify patients who may need definitive care within the scope of practice of an NP, redirecting non-emergency patients out of 911 response system. Definitive care would then be provided on scene by the Community Care crew instead of an unnecessary or inappropriate BLS transports to an overcrowded emergency department. Anaheim Community Care Phase 1: Anaheim Fire and Rescue’s Alternative Response Model: Community Care Response Unit (CCRU)

13. The objectives of the CCRU Pilot are to: Study the effectiveness of definitive care delivery on- scene in place of an unnecessary BLS transport to an emergency department (ED). Potentially “medically clear” patients who could benefit from services within the nurse practitioner scope of practice and decompress the current ED. The program will examine response protocols, operating procedures and cost effective model for the future Improve efficiency and effectiveness of Fire/EMS service delivery for the community in partnership with (local hospital) in a manner that would be sustainable

14. Operating procedures within the scope of practice of the NP and treated by CCRU 1. Back pain 2. Wound care – suturing/skin tears 3. Falls 4. Infectious disease: Otitis Media Sinusitis Pharyngitis Bronchitis Asthma 5. Jail responses 6. Social service calls

15. 2012 Anaheim Fire & Rescue’s Specific Provider Impressions in Relation to Mesa Fire & Medical’s TRV Responses

16. The highest Alpha call volume is located in Anaheim’s west side. An effort will be made to place the CCRU at the busiest station during the appropriate peak times for maximum productivity. Responses by AF&R in 2012 - - - Current population transferred to Kaiser

17. Re-thinking deployment Value- Added Patient Care Increase Market Awareness Cost Effectiveness /Recovery Hospital/Fire Department Partnership Improve Community Relations Innovative Leadership Recognition Benefits of Implementing CCRU Pilot Program

18. Phase 2: To Address Population Health Management: The Future Partnership Model Combining EMS and Hospital Community Health The CCRU will respond to medically appropriate responses and also manage medically complex patients to stay healthy and reduce unplanned hospital visits, including: primary care preventative care transitional care chronic care

19. What questions do you have?