It Takes a Team of Teams to Transform Healthcare

With contributions from Karen Abrashkin, MD, Kashif Baqai, MBA, EMT-P, Michael Guttenberg, MD, Karin Rhodes, MD, MS, Alan Schwalberg, EMT-P, & Kris Smith, MD

On October 31, 2013, the Northwell Health (formerly North Shore–LIJ) Center for Emergency Medical Services (CEMS) set out on a ground-breaking community paramedic pilot program that would meet the goals of the Triple Aim for a population of chronically ill homebound patients at high risk for ED and hospital utilization.

We undertook the Advanced Illness Management project in integrated partnership with two of Northwell Health’s population health management services: House Calls, the organization’s home-based primary care program, and the Nurse Clinical Call Center, consisting of nurses credentialed in the International Academies of Emergency Dispatch’s Emergency Communication Nurse System (ECNS).

This project was conceived to facilitate an understanding of the underlying leadership, structural, clinical and operational designs necessary to successfully meet the Institute for Healthcare Improvement’s Triple Aim: improvement of population health, improvement of patient experience and reduction of the per-capita cost of care.

Over the two-year-plus pilot, a cross-functional and highly integrated care team of community paramedics, emergency medical dispatchers, emergency communication nurses, EMS-credentialed physicians, house call nurses, social workers, care coordinators and support staff worked to set up a structure that has exceeded expectations.

Working with the House Calls patient population, the team developed a 24/7 on-demand in-home clinical response program and capability to supplement physician-led home-based primary care teams by providing on-demand clinical care alternatives for acute exacerbations of chronic conditions and urgent care issues that would have traditionally been referred to 9-1-1 or the emergency department.

Utilizing the existing scope of practice and formulary of a New York paramedic, a community paramedic can provide a high-fidelity clinical assessment and advanced treatment options when a nurse or physician is unable to help the patient or caretaker in crisis via telephonic advice. Using these assets, the physicians have sent these patients to the ED at a rate much lower than typical 9-1-1 calls. Patients can remain safely at home, receiving the care they need when and where they want it.

Additionally, the patients, caretakers and physician providers have all indicated incredible satisfaction with the program. The community paramedics are equally engaged and see the potential for new career paths to extend the clinical careers of EMS providers. In addition to these successes, the program has had a zero clinical defect rate (that is, zero reported adverse clinical errors or poor outcomes), a very low ED recidivism rate post-CP visit, and estimated financial savings of $7,267,081 in avoided payments at an extremely low cost point, with the potential to provide triple-digit returns on investment in a risk-based reimbursement environment.

This article outlines the program’s path to success, reviews challenges and lessons learned, and shares its most recent value-based metrics in an effort to provide other agencies with the knowledge and tools they need to prepare for the transformation to value-based reimbursement that lies ahead.

Program Formation: A Shared Consciousness

Our shared consciousness of what was needed started with team-visioning sessions where everyone involved in the healthcare continuum came together to create a common vision, mission and aim.
Everyone understood the problem, was invested in finding solutions and understood how their various roles fit together. This has been extremely important; given our team’s dissimilar contributors, clinical programs and backgrounds, at times it felt as if we were in different boats rowing toward a common destination.

More important, the team collectively understood the strengths and weaknesses of the other boats in our armada, so we could instinctively adapt and help each other when barriers arose. For this project the shared goal was achieving the Triple Aim for our House Calls population: mostly homebound seniors with multiple chronic health conditions, multiple comorbidities and typically 5–6 dependencies in activities of daily living (bathing, transferring, walking, feeding, dressing, toileting, etc.). This population is representative of the 5% of high utilizers in the United States who account for 50% of Medicare spending. The needs of this population set the foundation for the community paramedicine program in its launch form, but it has remained structurally similar since, as it was designed for constant change.

From Ideation to Blueprinting

Once we achieved a shared consciousness, teams began the work of designing the actual program and clinical and operational workflows through an approach that allowed for constant change (known as resilience engineering), as we were entering unknown waters. With all hands working in collaboration, the team laid out a framework document that touched and defined every domain and element necessary for a comprehensive program. This included:

• A primer on why change was needed and acceptance of the need to shift from a mental model based on risk avoidance—where we try to convince everyone to go to the hospital because of the unknowns—to one that’s risk-tolerant, with shared decision-making between the patient, paramedic and physician;
• The development of a clinical sandbox (a term from software engineering that indicates clear inclusion/exclusion boundaries) that defined what could be clinically done in home without transport to an ED;
• Communications policies and procedures including call-taking and dispatch workflows; operational guidelines and workflows; documentation guidelines and workflows; clinical, operational and financial quality review guidelines and metrics; physician oversight/involvement; clinical protocols and workflows; and addressing regulatory/legal/compliance concerns;
• Metrics and sources for data collection including value-based metrics, measurement development and reporting;
• Training that transmitted a common understanding of our group’s mission and aim and individual roles in the system, as well as filled gaps and refreshed identified clinical content and experiences.

Our primary approach to resilience engineering (our program’s built-in design for change) revolved around an all-hazards clinical and operational approach that could constantly transform based on programmatic needs. Instead of focusing specifically on one type of disease process or population, the team wanted a design that could easily handle growth to new populations in response to clinical and market needs. This design for change was threefold: operational, clinical and financial.

Operationally, the program wanted to be able to provide 24/7 coverage, have reasonable response-time reliability, not have excessive mission times, and be “fault tolerant” (an engineering term used to mean never shut down or go out of service, ever).  

Clinically, the program wanted to achieve as much flexibility as possible to be able to handle the needs of any clinical population. We achieved this through designing a clinical sandbox combined with live and online physician-led decision-making, turning the paramedics into agile physician extenders. Combined with secure video technology, this allowed the program to provide for a clinical experience that’s something between a PCP’s office and an ED, but in the comfort of the patient’s own home.

Some may consider this approach less community paramedicine than a sort of telemedicine-assisted EMS—a throwback to the Johnny-and-Roy days of direct physician-led clinical decision-making via online medical control without protocols.  However, without cycling back to EMS’ heritage, the ability of the program to accomplish a risk-tolerant model could not have been achieved.  

Financially, we wanted to build something that would cost much less than care in other settings. We achieved this through sound operations management design and using concepts borrowed from system status management and high-performance EMS that leverage the concepts of marginal costing, predictive modeling and a flexible deployment strategy. Using this approach, the program has been able to match supply and demand for needed services without the inefficiency and overhead of idle time. Our CP units and supervisors are not dedicated to this specific function, but rather wear many hats and perform many roles that also generate revenue or help CEMS manage risk for downstream savings. These additional hats include critical care transport, echo/delta response assists, 9-1-1 response, treatment and transport, and pretransport behavioral health safety screenings.

Given this approach, the program’s costs are based on a fixed per-visit fee that covers indirect expenses and overheads, coupled with a fee to cover the variable costs for our staff’s time and other direct expenses. The program’s experience has shown that these expenses are not too far off from what it costs CEMS to perform a typical EMS transport. That makes sense, as CEMS’ time on task for a community paramedicine response is similar to that of a traditional EMS transport to the emergency department.

Since the program is just emerging out of its pilot state, efforts to obtain reimbursement directly from insurance companies are just beginning. We have prepared our value-based metrics for these discussions. Additionally, given that the program is part of an integrated delivery network (IDN)-based system of care that includes risk-based reimbursement strategies and mechanisms, we are able to get paid internally for these services at a direct-cost fee-for-service level of reimbursement. While this does not cover overheads or margin for recapitalization and expansion, it is a tremendous start, as the program’s contribution to healthcare savings is anticipated to be high, driving a significant value-based return.  

Project Management and Empowered Execution

Once the operational and clinical framework was nearly complete, the team took the blueprints and placed them into a project management structure.

We used Basecamp and Smartsheet, cloud-based tools that enable real-time collaboration and information sharing. These gave the individual teams access to a shared workspace and communications platform (the program’s version of an integrated neural communications network, which enables immediate and documented communication and collaboration). The plan was then segmented into digestible chunks, assignments made, deadlines set, task/process interdependencies defined that could limit us to sequential or allow for parallel processing, and finally the team optimized a plan to the most expeditious path for implementation.

Leadership enabled staff to make decisions in moving the project forward (empowered execution) by allowing each team to rely on its own specific experiences, wisdom and judgment (based on the program’s shared vision). The team kept things on track and on time for the planned rollout.

Finally we announced a program start date, developed and completed training and credentialing programs for all team members, and made patients aware of the program with an option to opt out if they didn’t want to participate.

A System Designed for Adaptive Learning

As part of an existing workflow with the House Calls program, patients who experience a change in clinical condition are directed to call the seven-digit House Calls physician number 24/7. In the past, an answering service would take these calls and page the on-call physician, who would call the patient back. With our community paramedic program, these calls are forwarded to our 9-1-1 center, which also houses our ECNS-based, RN-staffed Clinical Call Center. This approach centralizes these service requests, enabling us to directly manage the care in an integrated fashion and allowing recording of all interactions for quality improvement.

Instead of these calls going directly to the PCP, the ECNS RN uses IAED’s nurse triage system to determine the patient’s clinical needs and navigate them to the appropriate locus of care, which can include self-directed care; scheduluing a follow-up appointment; an MD phone consult; a community paramedicine visit; an emergency EMS response; follow-up care; or some combination thereof.

Once launched, the Clinical Call Center was quickly answering calls, and community paramedic requests started within an hour of the system going live.

Given the comprehensive system design and an adaptive root cause analysis-based learning system put into practice through a rigorous retrospective quality review processes, problems were quickly identified, solved and fixed as they arose. What we thought would be the biggest challenge—potential bad clinical outcomes or clinical risk—has never been a cause for alarm. Rather, the most significant challenge was getting misunderstandings ironed out between EMS operations, 9-1-1 communications, nursing and physicians, mostly dealing with program familiarity, further workflow optimization and change management. This was all rectified through continual tweaks in our systems and processes coupled with continuous team learning and computer-based training.

An unforeseen challenge and learning point was that given the advanced illnesses of the population the program was serving, deaths were to be expected. In the program, if a patient passed at home from an anticipated death, law enforcement would be contacted as part of local protocols. However, the team did not include law enforcement in its initial educational populations for the new program, so law enforcement was unaware of our efforts and aims.

That created some initial confusion and adverse family interactions. The team had not anticipated negative reaction from law enforcement agencies when these patients passed peacefully at home as desired (and legally documented in DNR and other orders) because these patients’ families didn’t follow traditional 9-1-1 workflows but rather called the House Calls program directly.

Ultimately the team met with law enforcement partners and built collaborations and a customized workflow for each jurisdiction served in a manner that honored the policies of the different jurisdictions as well as our patients’ desires to pass at home with their families.

Measuring Value-Based Outcomes

One of the bigger tasks for our team during the planning and execution phase was developing the metrics necessary to prove our operational, clinical and financial worth (the program’s value-based metrics).

We knew the information EMS typically collected—volume, response time, time on task, IV starts, meds pushed, etc.—would be of some value when describing the program, but what the team really needed to understand was the true value the program could bring to the table and how to measure its outcomes (improved health, improved satisfaction, lower costs).

To solve this, the team developed a series of customized data points that are collected across our data continuum throughout the patient encounter. Sources include computer-aided dispatch, electronic patient care reporting, nurse advice information (from ECNS) and electronic medical record systems, as well as through direct-to-patient and -clinician surveys for every community paramedic encounter.

We aggregated these data sources into a single database for review, research and outcome reporting. In fact, the team intentionally built the metrics and data systems around an academic research structure so it could ultimately withstand the rigors of peer review and an IRB process.

While not completely necessary for all EMS agencies, understanding this level of data granularity and structure is an important tool in academia that also has great utility in the business world when it comes to negotiations with payers and collaborative partners.

The results from the program’s various metrics and outcomes can be found in Table 1. The important thing to notice about the structure and variables presented is that they paint a quick picture, no matter your perspective in the healthcare continuum, of the scope and value of the program.

From Pilot to Sustainability: How to Build a Bridge

As with many other community paramedic programs, our program is currently moving from pilot to permanence and sustainability. There is much discussion in healthcare about the chasm we must all cross in transitioning from fee-for-service to value-based reimbursement. In this analogy, programs must erode one form of payment as it shifts to another, and often the loss from fee-for-service revenue is greater than the revenues from value-based reimbursements until they’re properly scaled, thus creating a financial gap that has to be bridged.

If you are a small EMS agency, have a small profit margin or have little to no financial reserves, crossing this chasm could be fatal, especially without appropriate EMS payment reform at the federal and state levels. One of the main reasons healthcare is seeing significant mergers, acquisitions and joint ventures is the economies of scale needed to provide the financial cushion to cross this gap. This is happening in EMS too, with many small to medium-size EMS agencies consolidating or regionalizing for sustainability.

Luckily there are other financial mechanisms available to help cross the chasm. Many community paramedic programs are currently built on grants and subsidies that buy time to learn how to clinically and operationally meet their program’s aims, while working toward financial sustainability. Our program has been fortunate to receive several grants that are being used as part of its “bridge”—one from the Verizon Foundation that helped implement telemedicine and a second from the Samuels Foundation that has allowed for expansion into new populations (new hospice and home-care initiatives are underway). That said, CEMS and our population health management group are still covering a large portion of program costs.

This program was designed to be financially sustainable from inception based on an all-hazards clinical and operational approach and the ability to leverage existing resources when needed. This way costs are based on a marginal per-visit and time-of-use basis, and throughput and utilization are nonissues. The program has reached direct-cost sustainability at this point through internal fee-for-service reimbursements from our population health management group, as well as through matching grants that are allowing expansion into new populations.

Caution Moving Forward

While the program has had tremendous success and the team is confident it can expand and scale sustainably for many other populations, we must maintain caution. The financial gap created as an organization shifts from volume to value can erode its financial foundation. Because of this, our team must carefully plan and execute its growth and align with the organization’s acquisition of risk-based reimbursed populations as it forgoes fee-for-service revenues. This alignment is a key success pillar that’s challenging but necessary to achieve within an integrated health system. Trying to align these forces and systems in a nonintegrated fashion will be even more challenging, especially for EMS that’s not part of a health system or is in a competitive marketplace. It doesn’t mean it can’t be achieved; it will just be that much harder.

As market forces, payment reform and the changing fundamental economic structures of healthcare reshape our future, community paramedicine will likely be a powerful tool in serving patients when and where they need healthcare. Success will involve patience, timing and working as part of an integrated team of teams.

Creating a Team of Teams

Our entire integrated care team was asked to read Team of Teams by Gen. Stanley McChrystal. The book reviews how our military, intelligence community, various federal agencies and their stovepiped independent operations and layered bureaucracy could not keep pace with new and nimble foes in Iraq and Afghanistan.

Our military was designed to defeat armies, not small groups of independently empowered, yet somehow coordinated teams that could hit high-value targets and inflict maximum damage before our troops on the ground could react, even though our intelligence community often knew where and when their attacks were planned. The book describes how the military and other federal agencies had to transform themselves to adapt to the changing environment and new enemy.

The concepts of shared consciousness, resilience engineering, mental models, integrated neural communications networks and empowered execution are all described in the book—we highlight these terms and concepts throughout the article in italics. While we were developing our community paramedicine pilot, we used many of these concepts without actually knowing it until we later read this book.

Team of Teams draws parallels and many examples to our current situation in healthcare and our battle against ourselves in trying to reform to sustainability. Thanks to Gen. McChrystal, we now have a vocabulary to apply to the key transformational concepts we have utilized. We highly encourage every EMS and healthcare leader attempting to transform their organization to read this book. For more information, see https://mcchrystalgroup.com/.

About Northwell Health’s Center for Emergency Medical Services

The Center for Emergency Medical Services (CEMS) was established in 1993 to fill a market void in critical care medical transportation for pediatric and neonatal patients.

Since its inception CEMS has grown to become one of the largest health system-based integrated EMS providers in the U.S., providing all levels of quality-driven, value-based medical transportation, emergency medical services, critical care transportation and mobile healthcare services, including both ground and rotor-wing capabilities.

CEMS provides these services across New York City and Long Island under two operational models:

• 1) Through a contract with FDNY to provide 9-1-1 EMS services to New York City;
• 2) A high-performance-based EMS system that enables CEMS to provide all levels of services across NYC and Long Island through an unrestricted Certificate of Need issued by the state department of health.

CEMS employs more than 700 dedicated staff who respond to approximately 135,000 calls a year in its FDNY and HPEMS operations, and is currently the largest hospital-based provider to the NYC 9-1-1 EMS system. CEMS is known for its patient-focused approach and culture that yields high-quality services, advanced clinical practice, innovative delivery systems, superior satisfaction and a sustainable financial model that drives its value proposition.

Published Research

Northwell Health and its integrated community paramedicine team recently published their preliminary pilot findings in the Journal of American Geriatrics Society. Find their article “Providing Acute Care at Home: Community Paramedics Enhance an Advanced Illness Management Program—Preliminary Data” at https://onlinelibrary.wiley.com/doi/10.1111/jgs.14484/full.

The authors would like to recognize Craig Smith, EMT-P, and David Kugler, MD, for their program contributions.

Jonathan D. Washko, MBA, NREMT-P, AEMD, currently serves as the assistant vice president of operations with Northwell Health Center for EMS. He has been involved in EMS for over 30 years, holding progressive leadership positions with small, medium and large EMS systems in government, private, for-profit and not-for-profit entities. Considered a leading industry expert on EMS system design, high-performance EMS concepts, industry best practices, EMS deployment, lean business processes, system status management and EMS finance, he  is often called upon by EMS systems in crisis—as well as those considered at the top of their game—in order to help transform these organizations to become the best they can be. Reach him by e-mail at jwashko@northwell.edu, on Twitter at @jonathanwashko and on LinkedIn at www.linkedin.com/in/jonathanwashko.