Baltimore Helping Baltimore

At 0815 the Baltimore community paramedic and her nurse partner knock on the door of their first patient of the day: a 97-year-old female with significant health needs. Upon entering they note the patient has set up a sleeping cot in the living room, a lit cigarette nearby in a full ashtray.

The CP and RN will complete three more patient visits this day, finishing with an appointment with a 64-year-old female who has taken to sleeping with scissors under her pillow because she’s afraid of her son when he’s not taking his medications. 

Baltimore citizens have significant social and medical needs. These result from lack of access to healthcare, high HIV rates, excessive tobacco use, use of illicit drugs, homelessness, lack of nutrition, and lack of transportation, among other factors.¹ The result is exceptionally high healthcare and EMS utilization. 

Baltimore’s EMS system is among the busiest in the nation. The Baltimore City Fire Department (BCFD) receives more than 154,000 EMS calls for service a year and transports more than 100,000 people to emergency departments.

In addition, Maryland’s ED wait times currently exceed national rates, with EMS transport units often waiting hours to offload patients.² With this demand, the Baltimore EMS system is often taxed beyond its capabilities. The BCFD needed a way to focus on appropriately managing nonemergent patents through alternative mechanisms.

Launching a Program

With these daunting numbers in mind, program leaders conducted extensive research on national and state MIH-CP program models to determine their feasibility in Baltimore. BCFD Deputy Chief Mark Fletcher and David Marcozzi, MD, MHS-CL, FACEP, from the University of Maryland Medical Center (UMMC) agreed to colead a pilot MIH program in West Baltimore. They submitted a proposal to the Maryland Health Services Cost Review Commission.

With the leadership and support of BCFD Chief Niles R. Ford, UMMC Chief Operating Officer Keith Persinger, and Brian Browne, MD, chair of UMMC’s Department of Emergency Medicine, the commission funded the proposal for two years.

The initiative is divided into two components.

Program #1: Transitional Health Support (THS)—THS provides community-based in-home services to high-acuity patients discharged to their homes in an effort to improve health at a lower cost for medically and socially challenged patients. The THS team, consisting of a CP and an RN from the BCFD and an advanced-license practitioner (ALP) from UMMC, works with enrolled patients for 30 days after hospital discharge. It provides the following services and support: 

• Social/functional assessments; 
• Environmental assessments;
• Fall risk assessments; 
• Prescription reconciliation;
• Medical assessments;
• Coordination of resources to meet patients’ needs.

Through the support of an interdisciplinary operations center, a pharmacist, social workers, nurses, physicians, community health workers, and EMTs, the program launched May 15, 2018 and comprehensively addresses barriers to achieving improved health for enrolled patients (e.g., housing issues, social-work needs, and paying for medications).

Program #2: Minor Definitive Care Now (MDCN)—MDCN provides low-acuity 9-1-1 callers the option to receive immediate on-scene care by an ALP and a community paramedic. For all emergency calls BCFD dispatches a normal 9-1-1 response; for certain calls (e.g., ankle injury due to fall, toothache, simple laceration) the MDCN team (a paramedic and an ALP) will also respond and participate in the assessment.

If the patient consents into the program, the team provides a thorough evaluation and definitive outpatient care on scene while other units return to service. The team  arranges follow-up for the patient in coordination with the operations center. The program was launched October 10, 2018.

Benefits and Results

The BCFD identified as its program objectives not only responding to medical, social, and environmental concerns within the 30-day enrollment but also reducing hospital readmissions, ED visits, 9-1-1 calls, and overall healthcare costs.

Upon preliminary analysis the results have shown a 30-day readmission rate among THS patients approximately 2% lower than the expected risk-adjusted readmission rate at UMMC. A robust study has been designed to accurately evaluate the effect of the program on these outcomes with a focus on patient satisfaction. Overall patient satisfaction for the program averaged 9.7 out of 10. 

As of November 2018 MDCN had successfully treated seven nonemergency patients on scene, avoiding the need for ED transport. The success of the MDCN program will be determined by collecting, analyzing, and reporting data on the following outcomes:

• Number of EMS ED transports; 
• Unscheduled re-entry into the healthcare system (associated with original EMS complaint) within a 72-hour period; 
• Total call duration for MDCN calls; 
• Changes in average ED wait times related to implementation of the MDCN pilot program; and
• Patient satisfaction survey results. 

From a funding standpoint, Maryland S.B. 682 was signed into law May 2018. The law provides the opportunity, if value is demonstrated, to allow EMS to bill/receive reimbursement for healthcare services provided in a patient’s home or other location whether or not the patient is transported to a hospital ED, and also for transporting patients to healthcare destinations beyond the ED (e.g., primary care physicians, substance treatment centers, urgent care).

Overcoming Obstacles

To overcome challenges, the BFCD continually evaluates procedures, patient safety and health outcomes, provider feedback, patient satisfaction, and community engagement. The biggest obstacles have arisen from legal issues raised in developing a program between a medical system and a busy municipal government. This public-private partnership has successfully navigated these obstacles to serve the community.

Another obstacle has been documentation. Leaders decided to use the same charting system as the UMMC: Epic. Doing so has ensured accurate and up-to-date data and improved understanding of inpatient and outpatient care plans for optimal management.

Prior to going live, the team needed to be sure this technology existed within a secure infrastructure. UMMC Information Systems and Technology personnel built a “community paramedicine” department within Epic that includes individualized schedule templates for both THS and MDCN, reflecting each unique workflow. After gaining security approval for each defined role (EMT, paramedic, registered nurse), BCFD MIH-CP personnel completed training and created specific “smart phrases” to standardize documentation. 

Access to Epic allows the CP team to view admission information, follow-up care guidelines, and discharge instructions from the inpatient team. If a patient’s primary care provider utilizes Epic, that documentation is also visible, and so is the work performed by the MIH team, as well as pharmacologic recommendations routed via the EMR by the MIH pharmacist.

Furthermore, if a patient is referred to a UMMC site (emergency department, urgent care, intensive ambulatory care clinic, heart failure clinic) for immediate medical evaluation, the receiving provider can see the most recent vital signs, care provided in the home and/or on scene, and any information related to treatment.

Additional challenges arose with the coordination of resources and communication between the operations center and the rest of the MIH team. Teams meet in person with patients roughly five times over 30 days. Due to staffing constraints, the same team members are not always able to visit the same patient. It is essential that patients develop a strong trusting relationship with our program as a whole. The team has added thorough QA review systems to ensure delivery of all requested resources. Adjusting program schedules as well as the layout and workflow of visits has helped support overall operational capacity. 

Finally, the team identified that patient care plans are dynamic and need to be reevaluated at multiple points. Some resources initially expected to be easy to obtain have in fact proven nearly impossible (e.g., furniture, home maintenance and repairs, nutrition education). Identifying patients’ needs is easy, but resolving them can take time and patience. Some patient needs cannot be met within their enrolled 30-day time frame. 

Next Steps

Currently we can provide effective health support to the patients we reach within the THS and MDCN programs by helping them identify how best to manage their own care. To increase our effectiveness, however, it is imperative that we reach more patients. 

A long-term goal is to partner with other city institutions. Inclusion of additional facilities will expand not only our geographical area but also our access to resources. 

A short-term goal for expanding resources includes discontinuation of an ALP in the patient’s home. Instead we’d like to have them join the team via Zoom video call technology. The eventual goal is to provide a two-paramedic model also utilizing Zoom, which would enable collaboration of multiple hospitals and the fire department.

Our next step for MDCN is to expand the service area both east and west. Additionally we will have to increase the call types to which MDCN responds. Currently we respond only to alpha-level calls (e.g., earaches, dental issues, simple lacerations). We rely on the accuracy of the caller as well as the call-taker. It’s not uncommon for callers to inadvertently provide inaccurate information, necessitating a change in the level of service at the scene. 

MDCN crews have the required knowledge to read available call information (via CAD) and decide whether the patient meets designated criteria. Allowing paramedics who have responded emergently to a scene to refer patients into the MDCN program is another option. 

We are working with the Maryland Institute for Emergency Medical Services Systems (MIEMSS) to improve our operations to further ensure safety, improved health, and value of our efforts. An area of discussion with MIEMSS, and actually a goal for our program, is the use of telemedicine to assist in the evaluation of patients in the THS program. Lastly, as the safety and effectiveness of the program is confirmed, our goal is to operate with teams of paramedics instead of our current RN/PM model. Another option for MDCN is to enable paramedics responding to a scene to refer patients into the MDCN program.

Lessons Learned

EMS is evolving rapidly as evidence-based data establish new pathways to more appropriately manage high- and low-acuity patients. Through a joint partnership Baltimore initiated a modular, scalable, and robust community paramedicine program. We hope it can serve as a model for other programs across the nation.

The operational construct for our model is a result of a firm link between providers and a supporting operational center, the emphasis on interprofessional expertise, and linkage to a contiguous EHR. This model can be used by other jurisdictions en bloc or through analysis of their patients’ needs and applying relevant parts to their community.

In time and with supporting evidence, we believe this program can serve as a funding source for EMS, supported by hospitals and insurers who are interested in maintaining the health of individuals beyond the hospital. Ultimately this isn’t about EMS making people healthy—it’s about EMS keeping people healthy.

References

1. Baltimore City Health Department. Community Health Assessment: Baltimore City, https://health.baltimorecity.govhttps://s3.amazonaws.com/HMP/hmp_ln/imported/health/attachments/Baltimore%20City%20CHA%20-%20Final%209.20.17.pdf.

2. Medicare.gov. Hospital Compare, www.medicare.gov/hospitalcompare/search.html.

Erinn Harris, NRP, is a lieutenant at the Baltimore City Fire Department.  

Mark Fletcher, NRP, is deputy chief of EMS at the Baltimore City Fire Department.

James Matz, NRP, is a battalion chief for the Baltimore City Fire Department.

Colleen Landi, MS, CRNP, is lead nurse practitioner at the University of Maryland Medical Center and clinical program manager for the Baltimore City MIH program.

Anita Hagley, NRP, RN, is a registered nurse and a paramedic and captain for the Baltimore City Fire Department.

Jessica Thomas, CRT, is a paramedic with the Baltimore City Fire Department.

Benoit Stryckman, MA, is a health economist at the University of Maryland School of Medicine.

Rudy Dinglas, MPA, is an operations specialist for the Baltimore City Fire Department.

David Marcozzi, MD, MHS-CL, FACEP, is associate professor and director of population health in the Department of Emergency Medicine at the University of Maryland School of Medicine. He is assistant chief medical officer for acute care at the University of Maryland Medical Center.