Integrated provider teams take 24/7 approach to preventing ER visits

In medical emergencies, patients have few alternatives to calling 911 or rushing to the emergency department for costly care. That's the status quo, but a growing number of providers, payers and agencies are testing care approaches that help patients in novel and proactive ways.

One of these approaches is mobile, integrated healthcare. Teams made up of a mix of clinicians are available 24/7 to attend to patients' needs—outside the hospital and in person or by video chat, phone or text message, whether there's an emergency or not. Evidence suggests this approach can improve patient outcomes and lower costs, although putting it into practice presents considerable challenges.

“There is significant, potentially avoidable cost in most populations, and it can be identified if you choose to look for it,” said Dr. Eric Beck, CEO and president of Evolution Health, a population health management company that managed such a program in Florida. A preliminary study of that program, carried out among members of a Medicare Advantage PPO, was recently published by Beck and other researchers in the Journal of Health Economics and Outcomes Research.

The study showed a 19% decrease in monthly emergency room costs per patient and a 21% decrease in emergency department utilization among the roughly 1,000 patients enrolled in the model, compared to a control group. Patients also appeared to be more engaged and active in managing their health. A larger, forthcoming study will include 60,000 patients.

The program in Florida began with specifying high-risk, high-cost patients for whom interventions would most likely have an impact. The patients in the study represented between 9% and 12% of the entire Medicare Advantage membership and more than half of its costs.

Those patients received planned and unplanned care from physicians, nurses, paramedics, pharmacists, social workers and other providers. A patient with a chronic illness, for instance, would have a care plan that included coaching, appointment follow-ups and medication adherence through home visits and weekly phone calls.

Such regular contact is supposed to help patients manage chronic diseases by ensuring they receive timely preventive care. And if they do have emergencies, they can call the team.

Previous studies have suggested that as many as 27% of all emergency department visits could be handled safely at sites such as urgent-care centers, with annual savings estimated at $4.4 billion. From 2009 to 2010, people over the age of 65 made 19.6 million visits to emergency departments, or 15% of all such visits, despite making up 13% of the overall population.

The National Association of Emergency Medical Technicians has described mobile integrated healthcare and community paramedicine as an innovation with “the potential to transform EMS” into “a value-based mobile healthcare provider that is fully integrated” with healthcare and social services. The association estimated in 2014 that 103 EMS agencies had such programs with more agencies developing them.

For hospitals and health systems, these programs require considerable amounts of time, resources and energy to build. Having the right financial incentives and revenue models are key. For the growing number of providers moving into bundled payment programs and other CMS demonstration projects that hold them financially accountable for patient outcomes, a mobile, integrated program might prove particularly appealing.

“It's not for organizations that aren't strategically interested in making an investment to do that at scale,” Beck said.

Another challenge is preparing personnel and training clinicians.

“How do you bring together a team?” Beck said. “How do you take paramedics and nurses and physicians, and how do you prepare them for virtual, mobile, 24/7 delivery? It's a new mental model that needs to be familiar to the patient but to the clinician as well.”