Cultivating Stakeholder Relationships Part 1: Healthcare Partners

Matt Zavadsky is a featured speaker at EMS World Expo 2013 in Las Vegas, NV, September 8–12, and will lead the 1-day Mobile Integrated Healthcare Summit scheduled for September 11. Click here for more information.

The healthcare environment we currently find ourselves in is creating the perfect conditions for cultivating new relationships with healthcare partners such as payers, hospitals, physicians, skilled nursing facilities and even home care agencies. This is primarily due to the alignment of financial incentives being created in the healthcare market. 

The recent Supreme Court of the United States (SCOTUS) decision on the Affordable Care Act doesn't really affect changes seen in our healthcare world. Things like accountable care organizations (ACOs), bundled payments, and reimbursements based on quality and patient satisfaction, have already been implemented and are being driven by market forces and not politics.

Visionary EMS leaders have wished for this environment for years. But before we begin our journey down this new road, there are a few statements we must ban from our vocabulary:

• "We've always done it that way …"
• "There's no money to be made in that …"
• "It's what our community expects …"
• "We're an ambulance service …"
• "We don't have the money …"
• "There are regulatory 'issues' …"

So how can we position ourselves as a valuable partner in the rapidly changing healthcare system? Over the next few Public Affairs columns, we will look at the 'then' and 'now' expectations of our healthcare partners; the challenge it creates for the partner; and our opportunity to add valuable services for these partners. For this column, let’s look at hospitals, skilled nursing facilities and hospice agencies.

Hospitals

Then = "Come when we call you and it better be easy to request your service."

Now = "Do we really need you?"

Transportation Challenge—Waning are the days of being able to bill fee-for-service for the individual services provided to patients. Hospitals and other providers are more often being paid a global or "bundled" payment for an entire episode of care. Consequently, more and more hospitals who are "on the hook" for the cost of caring for patients are looking for the safest and most cost effective way to move patients throughout their system. 

Transportation Opportunity—Call centers that determine the most appropriate and cost effective level of transportation will be crucial. Some healthcare systems may have already created these for themselves. If they have, find a way to offer them an outsourced opportunity to replace their center. If they have not created one, offer to do it for them. Create an infrastructure that can screen the patient's medical need and match the need with the right resource. This may mean creating arrangements with other types of providers such as wheel chair van and medical livery services, or even consider providing these services yourself. If you can do this effectively, you can not only demonstrate ease of facilitation for the customer, but also significant cost savings.

Readmission Challenge—Hospitals are now being penalized for patients who re-admit to the hospital or even re-admit to the emergency department within 30 days after discharge. The penalty in most cases is no reimbursement for the care delivered upon readmission.

Readmission Opportunity—There are several value-added services you can provide to help hospitals with this challenge. The first is data. In many cases, you may be the only agency who actually knows how often patients are being readmitted. You can generate reports on patients transferred more than once in 30 days, then mine it further to weed out logical repetitive patients such as radiation or dialysis. The patients remaining may be of interest to the hospitals for target intervention to prevent readmissions. 

Another service you can provide is a follow-up program. The hospitals can determine patients they feel are at risk for readmission, such as CHF, COPD or recurrent falls, and you can offer to have a crew or an individual visit the patient at home to see what the risk are that may lead to a readmission. You can educate the patient on how to effectively manage their care and other sources for care, such as their primary care physician.

Yet a third service you can offer is a follow-up phone call. For example, if the patient frequently forgets to fill prescriptions or forgets to take their meds, your communications center can call to remind them.

Skilled Nursing Facilities

Then = "Come when we call you and it better be easy to request your service."

Now = "Do we really need you?"

Readmission Challenge—Much like hospitals, SNFs and long-term acute care centers (LTAC) are under increased pressure to not send patients back to hospitals after discharge. In fact, in some cases, hospitals have threatened SNFs and LTACs with removal from the "A-List" for admission referrals if the SNF or LTAC sends too many patients back for readmission. 

Readmission Opportunity—Like hospitals, you can provide call volume data to the SNFs/LTACs on transports from their facility. It's interesting that often they cannot see their own trends unless it is provided by an outside source. Most interesting to the facilities will be patients you transport twice or more in 30 days when the original call was NOT from the facility; this would identify for the facility patients brought back to the hospital within 30 days. Another innovative service you can provide for the facility is either secondary assessments or treatments at the facility. This may have more applicability for the SNFs than LTACs due to the variability of caregiver experience at the SNFs. Imagine that a patient at the SNF needs D50 or other drug therapy that perhaps the staff at the SNF are unable or unwilling to provide. You could send a unit to the facility to administer that care in the SNF to prevent the patient from going to the hospital. Sound odd? An innovative Ohio-based EMS agency is actually doing this in their service area to help a SNF manage ventilator-dependent patients who are having difficulty with the ventilator. With the approval of their medical director and the facility medical director, crews go to the facility, assess the patient, adjust ventilator settings and occasionally administer Versed at the facility to assist patients when necessary. These patients are not transported to the hospital.

Hospice Agencies

Then = "Don't come when the family of a home hospice patient calls 9-1-1."

Now = "Can you help prevent the family from calling 9-1-1?"

Hospice Revocation Challenge—Hospice agencies invest a great deal of time educating families on what to do when the at-home hospice patient is at the end of life. Ultimately, the 7^th cousin twice removed is the one at home with the patient, or the family just freaks out when the end arrives. This often results in a call to 9-1-1 with most likely a subsequent transfer to the hospital. This is a major expense to the hospice agency and can create significant angst for the family.

Hospice Revocation Opportunity—Consider partnering with your local hospice agency on a program to "enroll" patients (really patient families) who are at risk for last moment revocation in a specialized intervention program. The address can be flagged in your computer dispatch system with the name of the hospice nurse and instructions to notify the nurse pronto if a 9-1-1 call for the hospice patient is received. You can also proactively discuss with the family options other than calling 9-1-1 when they get scared. Perhaps a back-office number to your agency could result in a non-emergency response from a crew or supervisor to be with the family until the hospice nurse arrives as the patient takes their last breaths. If your medical director allows and the hospice agency is agreeable, you might be able to have your staff assist the patient with administration of the medications in their in-home "comfort pack" to make them more comfortable. 

The most important concept in thriving in our new environment is building relationships with these key stakeholders to help identify needs they have, and how you might be able to meet that need. In our next column, we will explore ways you can work with home care agencies, doctors and payers. In the meantime, if you have any questions about these ideas, or if you would like assistance putting these types of programs together, please feel free to contact me at MZavadsky@medstar911.org

Matt Zavadsky, MHA, is director of public affairs for MedStar EMS, the public utility model system in Fort Worth and 14 surrounding cities in North Texas. He holds a master’s degree in Health Service Administration and has 30 years' experience in EMS, including volunteer, fire-based, public and private-sector EMS agencies. He is a former paramedic and has managed private sector ambulance services in four states, as well as serving as a regulator. Matt is a frequent speaker at national conferences and has done consulting on numerous EMS issues, specializing in high-performance system operations, public/media relations, public policy, employee recruitment and retention, data analysis, costing strategies and EMS research. He has served as chair of the American Ambulance Association's Industry Image Committee and as a member of its Professional Standards, Strategic Development and Management Training Institute Committees. He is adjunct faculty for the University of Central Florida's College of Health and Public Affairs, teaching courses in healthcare economics and policy, healthcare finance, ethics, managed care and U.S. healthcare systems.