1. The Medicine Behind Mobile Integrated Healthcare Practice Jeff Beeson, DO, FACEP, RN, EMT-P Medical Director - MedStar Emergency Physician’s Advisory Board Michael R. Wilcox, M.D. Medical Director Hennepin Technical College Brent Myers, M.D., MPH Medical Director Wake County EMS

2. Role of the Medical Director “These are our patients” “This is my practice of medicine” “I’m calling from Dr. Beeson’s office”

3. The Issue… 5.6 million health care jobs will be created by 2020 Today, 40 million people > 65 – 70 million in next 20 years 2012 - 25,000 docs short – By 2020 = 40,000 short Association of American Medical Colleges

4. We have an answer for this challenge!

5. Scope vs. Role Recall: 37 million house calls already Urban experience – Most “skills” are social, not clinical Rural experience – May be some expanded role? – Perhaps using other inter-professionals?

6. Provider Selection May depend on gap being filled – EMT/paramedic/RN/NP/PA/MD – Mesa, AZ NP and Fire-Medic on fly car Low acuity calls triaged to them May depend on regulatory environment

7. Provider Selection Technician vs. Clinician vs. Practitioner Taking the long view Critical thinking Providers with the longest scene times? Adrenaline Junkie

8. EMTs & Paramedics EMTs/Paramedics already know how to deliver care locally Know how to assess resources and make decisions They could fill gaps in care with enhanced skills through targeted training

9. Provider Training Core curriculum – Disease processes – Patient assessment/education – Community resources Role Specific – EMS Loyalty Program – CHF – Hospice – Primary care

10. Provider Training Involve LOCAL stakeholders – Case managers – Behavioral health – Cardiologists – Hospice RNs Develops relationships/trust

11. Provider Training Clinical Rotations – Community clinics – Homeless shelters – CHF clinics – CVICU’s – Behavioral health – Hospice units – MHP programs Actual home visits

12. Healthcare System Integration Needs determination – Medical interface Cardiology / Specialty – Care plans and protocols Home health – Support – not replace – Focus on transition of care Skilled Nursing – Referrals / coordination – In-house support Wake county fall program

13. Program Development Coalition building – Needs assessment – Relationships! – Gap analysis Filling the gap – What’s missing and how can we help? – Sought out or discovered Expanded scope vs. expanded role – Most valuable ‘interventions’ – Know your regulatory environment

14. Program Development Protocols – Based on gaps to be filled – Eligibility criteria for ECNS v12.1 Code Pri Descriptionv12.1 CAD Code NAED Appr'd KY MedStar Appr'd PSIAM Code Pri ECNS CAD Code 02A013 No difficulty breathing or swallowing (rash, hives or itching may be present) 02A01n-Allergies/Envenomations Y Y02A01O02A01n-Allergies/Envenomations 02A01I3 No difficulty breathing or swallowing (rash, hives or itching may be present) - Injection administered or advised 02A01In-Allergies/Envenomations Y Y02A01IO02A01In-Allergies/Envenomations 12A013Not seizing now and breathing effectively (verified)12A01n-Convulsions/Seizures NN12A01312A01n-Convulsions/Seizures 12A01E3 Not seizing now and breathing effectively (verified) - Epileptic or Previous history of seizures 12A01En-Convulsions/Seizures NY12A01E312A01En-Convulsions/Seizures 12A023FOCAL seizure (alert)12A02n-Convulsions/Seizures NY12A02312A02n-Convulsions/Seizures 12A02E3FOCAL seizure (alert) - Epileptic or Previous history of seizures12A02En-Convulsions/Seizures NY12A02E312A02En-Convulsions/Seizures

16. Quality Assurance Continuing education – Real-time MD/MHP interaction – PCP/Medical Director communication – Programmatic feedback/enhancement Call reviews – ECNS tape reviews – Patient care reviews – Care Coordination Councils Monthly CE meetings – Case reviews

17. Care Coordination Care Coordination Council – Case Managers – Community-based social services – Meet monthly to discuss enrolled patient needs On-line consultation – “Best Option” patient determination – Not a Part-Time job!

18. Electronic Medical Record Key for patient navigation determination

19. Resource Balancing “Mission creep” Alignment of can do and should do

20. Not for the faint of heart?