How to Build Better Systems of Care

Last May, Brent Myers, MD, joined Evolution Health, a Dallas-based, national integrated medical practice, as the chief medical officer and executive vice president for medical operations, and AMR, the nation’s largest ambulance service, as an associate chief medical officer.

Before making this move, Myers worked at Wake County EMS in Raleigh, NC, for more than a decade. He has been widely recognized for his work to build a mobile integrated healthcare program there to offer in-home care, care referrals and a better system for treating people with mental illness.

His experience trying to get patients mental healthcare and being faced with regulations that he describes as “truly frustrating and not patient-centered” was the impetus for him to try to build better systems of care.

“In the emergency department in the area I was responsible for we had 14 beds,” Myers says. “I would go in on a Saturday or Sunday morning, eight to 10 of those beds would be occupied by patients with mental health conditions.”

The hospital did not offer psychiatric care, but under the Emergency Medical Treatment & Active Labor Act (EMTALA), it was legally required to screen the patients. Myers went on to explain that the hospital was located across the street from a university-based, well-funded psychiatric facility that had psychiatrists, psychologists and social workers. The psychiatric facility, however, was not covered by EMTALA and could not accept the mental health patients waiting in the emergency room for psychiatric treatment.

“We were literally boarding these patients in the ED, waiting on a bed at an appropriate facility to open up,” says Myers. “It was absurd to me to be standing across the street from help these patients needed and not be able to send them there. I said to myself, there has to be a better way to do this.”

Building a Mobile Integrated Healthcare (MIH) Program

Myers went on to launch a successful MIH program at Wake Country EMS. Using 14 advanced practice paramedics, the program offers treatment and patient navigation to patients with mental illness as well as the elderly, and people living in assisted living facilities or with chronic illnesses, often without a trip to the emergency room.

When asked what advice he has for other EMS services looking to launch an MIH program Myers encourages them to:

• Do a community needs assessment and aim first to fix problems that are low-hanging fruit;
• Ensure all the stakeholders are at the table when creating the program; and
• Consider sustainability of the program from the start.

Myers points out that Wake County’s MIH program is largely funded by taxpayers. “It doesn’t generate a lot of revenue, but it is the single most popular service provided by Wake County. Period. The advanced practice paramedic program ranks at 85% positive community score,” says Myers. “But in other communities, this might not be the same and so you’re going to need a hospital funding or funding from Aetna, Blue Cross Blue Shield or some other source.”

Models for Alternative Destinations and Assisted Living Facilities

Myers is now working to apply his experiences in Wake County nationwide through Evolution Health and AMR.

Evolution Health is an integrated medical practice that oversees 2,400 team members who provide approximately 2 million patient touches annually. The organization specializes in working with patients with complex medical problems, including offering care in the home or other alternative settings.

Evolution Health is a subsidiary organization of Envision Healthcare, a national provider of hospital physician services and emergency and non-emergency medical transportation, as is American Medical Response, which offers ambulance transports and mobile integrated healthcare programs.

The team at Evolution Health works on a variety of projects, including working with insurance companies and hospital groups to manage the care of specific populations such as people living with chronic disease or in need of end-of-life hospice care.

Myers sees his efforts deploying MIH providers, including advanced practice paramedics, to deliver care in alternative settings and destinations as among the valuable experiences he brings to Evolution Health.

“One of my goals at Evolution Health is to focus on the structure of patient care treatment pathways,” says Myers. “We want to ensure that we bring high reliability to the care at the population health level. We want to absolutely ensure it is evidence-based.

“We’ve got great clinicians across the country, regional medical directors who are just outstanding, wonderful clinicians,” he continues. “Each of them is caring for patients. Our goal is to bring all of that learning together and make sure we are giving that same, consistent care from Florida to California and everywhere in between.

“Part of the reason the Evolution Health team wanted me to come on board is they were interested in work I have done in creating a reliable patient-centered approach to evaluate patient concerns and then determine, ‘Do you need to go to the emergency room? Can you go to an urgent care clinic? Can you wait in your home?’” says Myers.

Myers points out that with elderly patients, for example, seeking care in the emergency room can be particularly problematic, particularly if the person has experienced a fall.

“If you take them to the ED, you get a physician who has likely never seen them before. You might have a note from the facility that says the patient has mild dementia,” Myers says. “If they come in and they don’t know what day of the week it is, I have no way of knowing if that’s baseline or not. I have to presume there is trauma from the fall, and they get a head CT, the labs and the whole deal.”

The better system, he says, is to connect the assisted living facility with a provider who knows the patient and his or her baseline. Often, he points out, it is possible to provide safe, appropriate care for these patients without taking them to the hospital.

“The patients and their families would much prefer not running back and forth to the hospital all the time,” Myers says. At Wake County EMS, “We had that problem in play for about three years and we were able to reduce transports by 60%.”

The Transition to Value-Based Care

However, Myers is quick to point out that reducing the number of transports isn’t the primary goal. As the nation moves toward value-based purchasing, the focus is increasingly improving quality of care and patient experience.

“Some predict that by 2025, 40% or more of all healthcare will be paid for on a value-based proposition as opposed to a volume-based proposition,” Myers says.

Part of the role Myers envisions for Evolution Health is creating “fee-for-service bridges” to help healthcare systems and hospitals make the transition from fee-for-service models to value-based models. A critical first step in crossing this bridge and moving toward value-based care is realigning reimbursement with incentives.

“Right now, the incentives are to do more procedures, but often that’s not the desired outcome,” says Myers. “People are getting paid on a fee-for-service basis to prevent readmission. That is less than ideal because some patients only need one visit or one phone call. Yet, another patient may require daily visits for a week. You have to tailor it to the patient.”

When it comes to caring for larger populations, Myers and the team at Evolution Health are taking a different approach.

“Things work better when we recognize there is a science to readmission prevention and care management,” says Myers. “When you take on the care of thousands of patients and say, ‘They’re yours for the following things,’ then it falls on the provider to be responsible for offering the best care and achieving patient satisfaction.”

But, he says, the healthcare system isn’t quite there yet.

“In some markets, we’re on this fee-for-service grid,” says Myers. “We might have to send a PA because a nurse can’t go. Across the state line, you have to send the nurse because the PA can’t go. Yet, what the patient really needed was a pharmacist.

“Once we can get to the point of being responsible for populations, then you can send what the patient needs rather than what can be coded,” he continues. “To me, that’s the thrilling part: We are starting to create systems and teams that are patient-appropriate and patient-centric.”

Patient-Centered Care Through Provider-Focused Management

Part of Myers’ previous work at Wake County EMS and his ongoing work at Evolution Health is focused on creating patient-centered care by building provider-centered systems. Myers says it is one of the career accomplishments of which he is most proud, that he was able to “do the right thing for patients in a way that truly valued the provider.”

When reflecting on his time at Wake County EMS and what he plans to carry forward in his career at Evolution Health, he says, “To the extent that we had success, what I am most proud of is we were provider-centric. We did not look at the bottom lines. We did not treat our people as though they were just dispensable employees. We truly sought their input, and let them run the place. My job was to tear down the roadblocks that kept my team from doing what they needed to do to take care of people.”

When asked where he hopes to be in five years, Myers plans to take his work in the prehospital system and apply it to interprofessional teams.

“The question and the challenge is, ‘Can we create better care delivery systems with the same provider-centric focus with nurse and pharmacists and EMS providers and physicians?’” he says. “Five years from now, I want to look back at the Evolution team and see us solving problems at the provider level, which means people working at the top of their license. When you get good providers, they know how to take care of patients.”

EMS World Expo 2015 Keynote

Next month, Myers will deliver the opening keynote at EMS World Expo, September 15–19 in Las Vegas, NV. He will focus his talk on how EMS fits into the changing healthcare landscape. Myers says he believes the healthcare and EMS industries are on the cusp of creating truly evidence-based, patient-centered care systems.
When it comes to EMS he says, “whether it’s private or it’s public; whether it’s governmental or fire-based; none of that matters. What matters is what value are we bringing to the table. We’ve got to get past seeing our value as focused on cardiac resuscitation and taking care of heart attacks and strokes. That is vital to what we do, but we’ve got to move beyond that.”

Register today at EMSWorldExpo.com.