How To Chart a Course for Survival

If you’re a smart EMS leader, you’ve thought a lot about the future lately. You know times are tough and unprecedented changes are afoot, and you likely wonder how to navigate such perilous passages without running your whole ship aground.

Here’s the rote line that acknowledges no answers are easy and no two systems are the same and nothing we can tell you serves everyone. Now let’s get down to what you should do. 

For one, you should take advantage of resources the EMS industry offers to help forward-thinking leaders puzzle these things out. One is the yearly Pinnacle EMS Leadership & Management Conference, held most recently in Colorado Springs last July. Orchestrated by prominent EMS consultants Fitch & Associates, Pinnacle brings together thought leaders and industry movers to help steer systems through the complex issues of the day. The concepts covered in this article are drawn from this year’s show.

The issues are more complex and imposing than ever.

“No matter what happens with the election and the move toward healthcare reform, the U.S. healthcare system is simply not sustainable in its current form,” says Joseph J. Fitch, PhD, founding partner of the firm that bears his name. “If you study world economics and how healthcare is provided, that’s abundantly clear whether you’re a Republican or Democrat. So it may change and morph along the way, but I think we’re going to see reform continue to move forward.

“But it’s not just that we have federal policy issues and reimbursement changing. We also have changing expectations from customers. In my entire career, I never thought I’d see police officers and firefighters laid off. We’re seeing that, we’re seeing benefits cut, we’re seeing cities go bankrupt. At first people in the rest of the country may have thought, OK, that’s California. But when it’s coming to places like Scranton, PA, people have to wake up and realize, Yeah, this is serious.”

You can’t much control how politicians spend money. But you’ll want to secure your place as budgets are twisted and squeezed. The way to do that is by providing value for your customers. And while patients may be the most important of those, there are others to concern you too—including those lawmakers and regulators, as well as other health and emergency system players. Value is the watchword of the day; figure out how to provide it, and you’ll better position your organization to withstand the inevitable buffeting that, while it may have already begun, seems likely to get worse.

Listen and Understand

The best caregivers are gifted listeners. They can synthesize what a patient says, how they say it, and other clues and contexts into an assessment and direction for action. Organizations require similar skills in discerning the needs and expectations of their communities and determining how to effectively meet them amid prevailing currents and conditions to come.

“Listening means different things for different communities,” says Mike Taigman, general manager at AMR Ventura County/Gold Coast Ambulance in California and a longtime EMS educator and consultant. “I think we’re pretty good at listening to our regulator community. In the fire and private ambulance communities, we’re pretty good at listening to each other. But if you look at a community as all the people who live in a service area and need healthcare and other services, I think historically we’ve not been nearly as good at listening to that community. We’re not as good at listening to our patients within that group as we could be.”

What you’re listening for, in girding for the future, is unmet needs. They’re not hard to find. You can hear them from your patients, in their express words and between the lines. You can hear them from your data, in patterns and clusters and anomalies. You can hear them from hospitals and other colleagues in healthcare and public health and public safety. The system is rife with gaps through which people slip, and that EMS—to the extent it’s not overwhelmed just answering 9-1-1 calls, and to be sure many are—is positioned to help reduce. We’re community-based, mobile, on duty all the time and approach care in a directed, algorithmic manner. That’s a recipe for producing value.

Take Ventura County. Contra any Cali glam-beach image, it has its share of agriculture and poverty. It also has lots of tuberculosis, for which current treatment guidelines call for directly observed therapy (DOT): trained healthcare workers provide the prescribed drugs and witness patients take them. DOT is considered especially important for patients with drug-resistant TB or HIV infections and those on regimens of intermittent treatment.

In Ventura, DOT requires health workers to drive all over the county to deliver medications. AMR already has well-trained clinical professionals scattered about those areas. So leaders have hatched a plan to try having EMS crews do the DOT.

“It’s a whole different slice on things for us,” says Taigman. “We’re meeting a real identified community need for real patients who have a life-threatening disorder. I think it aligns really well with our mission.”

With one more bit of listening, Ventura leaders heard Spanish—many of their patients speak only that or prefer to get their healthcare instructions in it. So AMR brought in an instructor from UCLA to teach its providers TB-specific medical Spanish.

Even if you don’t have TB or language barriers, there’s a lot you can hear with an organizational ear to the ground. Many ED visits are avoidable or inappropriate. Many who seek care in EDs lack access to primary care. And preeminent among current healthcare trends are changes in payment structures to reward things like prevention, disease management, care coordination and prevention of hospital readmissions. For the enterprising EMS system, that’s opportunity for the taking.

Agile Enough to Change

Still, identification is only where change begins, and the history of EMS is littered with opportunities lost to miscalculation, indecision and slow-footedness. Thus a recurrent theme of Pinnacle speakers was agility—how an organization recognizes and reacts to change.
Tradition runs strong in the emergency services. We’re reactive and can be hidebound. Agility hasn’t always been an area of strength.

“From a tactical perspective, we do incredibly well at improvising when there’s a patient-oriented crisis or disaster kind of situation,” says Fitch. “But we really aren’t known for our forward thinking and planning. We tend to wait until things happen. And really, agility can best be defined as the strategic management of uncertainty. Uncertainty can paralyze you. So as a whole we’re not very agile.”

That’s borne out by data Fitch & Associates is collecting as part of an ongoing agility survey (see https://fitchassoc.com/agility). In findings presented at Pinnacle, just 3% of respondents rated their organizations as extraordinarily agile, while another 17% said they were “aware and improving.” Ominously, 37% thought their services were at substantial risk, and 14% feared they were in danger of extinction. Just 4 in 10 thought their organizations were much good at anticipating customer expectations.

Fitch outlined four dimensions of organizational agility:

1) Awareness and alertness to change—Can you gauge what change is coming and how it might affect you?

2) Leadership orientation—Do you face the future rather than dwell on past experiences and failures?

3) Process, tools and structure—Can you measure your delivery and ensure excellence?

4) Performance-based culture—Are the right visions and values guiding your priorities, decisions and behaviors?

“There’s a lot of room within each of those areas to look at where we can improve,” says Fitch. “We think we’re fairly sophisticated; we have CADs and ePCRs and that kind of stuff. But at the end of the day, we don’t know how to use technology to improve our ability to perform our jobs. There are certainly pockets of excellence out there, and I think people are looking more at how they do things and can make intelligent and timely decisions. Does something like response times make a difference? It takes tools to know that. It takes being able to measure and understand outcomes.”

Without those tools in place, you could be on the extinction watchlist. With them, you can measure needs, quantify changes and demonstrate that what you do matters—i.e., adds value.

Change What Matters

There are two main ways EMS can add value to its community and healthcare system, noted another Pinnacle speaker, Gregg Margolis, PhD, EMT-P, director of the Division of Health Systems and Health Care Policy within the Department of Health and Human Services’ Office of the Assistant Secretary for Preparedness and Response (ASPR): It can do what it does, but better; and it can assume new and expanded roles.

What can we do better? Imagine dispositions centered around the best interests of the patient (e.g., transport to urgent care, referral to a primary doc or other resources), not how we have to get paid. Imagine helping tailor holistic care plans for the heaviest system users, as many big-city systems have for their most frequent callers. At the least services can commit themselves to collecting data and helping to bolster the evidence base lacking for so many prehospital practices.

What else can we do? This could mean “community paramedic”-type things; mobile health services; wellness, prevention and elements of primary care; care coordination; and helping reduce unnecessary hospital visits/readmissions and preventable use of the 9-1-1 system.

“The big opportunity for EMS is in developing relationships with their communities’ public health and healthcare systems and trying to figure out how to address unmet healthcare needs,” Margolis says. “Needs may be different in different communities—for example, in an inner-city urban environment vs. a rural environment. Some of the things EMS might be doing in one community may be well handled in another community with existing infrastructure. But I would really encourage chiefs and local EMS leaders to reach out to their local public health departments.”

“When people start talking about things like community paramedicine, it seems like they take two different approaches,” says Taigman. “One is, ‘We’re gonna build a cool medic and then look around and find problems to point them at.’ Then there’s the more epidemiologic approach of asking, ‘What does this community need?’ I’ve had good results with the kind of grassroots health-oriented community groups—the people working on things like diabetes, asthma, homelessness, school health, clean air—and the public health departments and groups around those. Keep plugging in to those conversations, and it’s a window into your world like you won’t have access to any other way.”

The recent emphasis of ASPR’s Hospital Preparedness Program has been to support the development of healthcare coalitions (involving hospitals, trauma centers, EMS and other players) as an essential component of preparedness for disasters and public health emergencies. Such coalitions can also represent frameworks for increased EMS involvement.

“They were initially intended to help in preparedness by building cooperative relationships healthcare organizations could use during emergencies,” says Margolis. “But I expect these coalitions will also be a place where otherwise-competing organizations can come together to identify common healthcare challenges they all face. Healthcare coalitions may start out as emergency preparedness entities, but can be used to address many other things. And getting EMS involved in healthcare coalitions is a major goal of the revised hospital preparedness grant guidance ASPR recently released [see www.phe.gov/Preparedness/planning/hpp/reports/Documents/capabilities.pdf].”

The catch, of course, is getting paid differently. It’s a circular dilemma: Without funding, we can’t conduct the programs that might show cost savings and improved outcomes from expanded EMS activities. Consequently there’s limited data to demonstrate benefit, which we need to entice such funding.

That’s why this is such a pivotal time. Current financial pressures demand leaner ways of doing things, and the Affordable Care Act provides some potential footholds. It’s a time for pilot projects, beta tests and proofs of concept—small-scale efforts to test big new ideas.

Three EMS systems recently received funding from the Center for Medicare & Medicaid Innovation to test such projects (see sidebar). In Maine a dozen community paramedic pilot projects are commencing under the guidance of the state. Other examples proliferate, increasingly with emphases on collecting data to evaluate impact. If these are, as we suspect, ways we can help patients and provide value to healthcare systems, we’ll be showing it soon enough.

Conclusion

Not every EMS system may have the opportunity, inclination or need to move into expanded roles in its community. Some will be fine just answering 9-1-1 calls; that need certainly isn’t going away. But know, if that’s you, that the time may never be so ripe to try something different and broaden the notion of what out-of-hospital EMS can be.

“Emergency response is the core of what emergency medical services is and in my estimation always will be,” says Margolis. “But EMS professionals and the mobile healthcare resources EMS offers could add great value to healthcare systems in many ways. EMS can really do a lot more for community health with a modest increase in staffing and equipment. I don’t think it’s about doing more with the same resources, but doing a lot more with a little more.”