In late 2014, Northwest Physicians Network in Tacoma, Washington – a local independent physician association that is part of DaVita Medical Group – and six Pierce County Fire Districts created the Pierce County Community Paramedicine Collaboration.

THE PROBLEM

The community realized there were a significant number of high utilizers using emergency medical services (EMS). It also realized it needed to identify them and direct them to better care settings.

Many of these patients were relying solely on EMS to fulfill their short-term needs. But they were not getting the support they needed to address their chronic conditions, such as behavioral health conditions or substance use disorder.

“These individuals were using EMS because they didn’t have access to – or knowledge of – other care channels that are better suited to help them,” explained Melissa Haney, communication partnership and behavioral integration manager at Northwest Physicians Network. “Multiple and complex diagnoses can be difficult to manage and without a support system in place, patients with complex conditions are extremely isolated without the means to manage their health.”

PROPOSAL

Supported by a system for real-time notifications for high-risk patients, Northwest Physicians Network developed a Mobile Community Intervention Response Team for its behavioral health patients. The team is designed to provide professional behavioral health resources and support patients in the field.

“We needed a way to identify these high-utilizing patients and to collaborate with other community resources on care plans moving forward,” Haney said. “When these patients used EMS, there wasn’t a way to communicate that with primary care settings. So they were completely unaware that there was a problem.”

By identifying these patients and matching them with the most appropriate care resources for their conditions – ones that were actually equipped and trained to help the patients manage chronic conditions – Northwest Physicians Network could eliminate the strain on EMS.

And this is where health IT technology vendor Collective Medical comes in.

"When you have everything listed in one place, like the platform, you’re able to identify what needs aren’t being met and bring in appropriate settings and providers – all working as one unified care team with one plan of action."

Melissa Haney, Northwest Physicians Network

“The Collective Medical platform connects every member on a patient’s care team so providers can collaborate on care plans and stay up to date with patient histories and encounters,” Haney said. “Basically, it helps us to stay on the same page and coordinate consistent, quality care with community resources.”

If a patient is relying too heavily on EMS, staff know about it. It’s been a lot easier for staff to start a dialogue with these patients about the underlying reasons behind their condition and connect them to the right channels, Haney said.

MEETING THE CHALLENGE

The Pierce County Community Paramedicine Collaboration created a referral process that depends on Northwest Physicians Network to receive, process and refer patients to their health system. Fire districts refer identified individuals to Northwest Physicians Network – these patients usually make at least three EMS calls within three months – and includes any necessary information (such as the reason for the referral, number of 911 calls, number of EMS transports and the reason for each event).

“The Collective platform aggregates and pulls patient information from local EHRs and identifies the patient’s healthcare provider, health plan and hospital utilization in the last 12 months,” Haney explained. “When Northwest Physicians Network connects the patient to their provider, everyone has the necessary information to make the best care decisions for the patient and develop specialized plans around their needs.”

The majority of patients with tendencies of high utilization usually have both medical and behavioral health issues, so it makes treating these patients a lot more complicated.

“But when you have everything listed in one place, like the platform, you’re able to identify what needs aren’t being met and bring in appropriate settings and providers – all working as one unified care team with one plan of action,” Haney stated. “The longer we have used this system to collaborate, the more it’s clear a lot of this utilization is actually preventable, and that patients’ needs can be met long before there’s a problem.”

Patients are usually relieved to be connected with caregivers who can actually provide support. The program has helped patients find in-network mental health and substance use providers, facilitated better communication across multiple providers and care settings, and created access to caregiver support, advance directives and general support for family members that need a caregiver, Haney said.

RESULTS

Northwest Physician Network in collaboration with community providers and EMS services achieved the following: 44% drop in 911 calls; 47% reduction in EMS transport; 36% reduction in ED visits; 42% reduction in hospital admissions; and 31% decrease in observation stays.

“The work of this collaboration has started to produce meaningful results as a result of increasing the accessibility of healthcare resources and care coordination,” Haney said. “This is largely attributed to stronger care coordination for our vulnerable, high-need patients and the increased accessibility to healthcare providers. Patients struggling with chronic conditions like a mental health condition or substance use disorder need a unified system coming together to fully support and coordinate on their needs. The platform is helping us get that clearer picture to better support our patients.”

ADVICE FOR OTHERS

“When you are working with high-utilizing patients, it all comes down to redirecting them to the most appropriate care setting,” Haney advised. “Fire departments and 911 services aren’t equipped – with training or resources – to support patients struggling with mental health conditions or substance use disorder. These patients need consistent care to manage their conditions, not a short-term solution.”

Equally important are the relationships within the medical community.

“It’s great to have this technology to collaborate, but I would encourage people to focus on building relationships with the systems using the platform,” she concluded. “In the behavioral health community in particular, there’s some trepidation to share information with each other. Building trust between organizations creates the ability and willingness to share and truly maximize the impact we can have on patients’ lives.”

Twitter: @SiwickiHealthIT
Email the writer: bill.siwicki@himssmedia.com
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