Walkabout Medical Homes with Mary Takach: A 10-month Study of Australia
Reducing inappropriate utilization of the emergency department (ED) is a very common focus of health systems, payers, and practices seeking to improve health care quality and reduce costs. To help break the cycle of non-emergency ED use lists of “superutilizers” are generated from a variety of data sources and care managers are assigned to work with these patients.
In my fellowship research project that is comparing publicly funded primary health care organizations (PHCO) in the U.S. and Australia, I have come across two PHCOs, one from each country, that are working with their local fire departments or ambulance services to capitalize on the skills of paramedics to deter non-emergency transports. CEOs Carol Bruce Fritz of Community Care of Central Colorado and Learne Durrington of Perth Central & East Metro Medicare Local have both identified these programs as one of the proudest accomplishments of their tenure. Using data to analyze where to focus limited resources, pilot programs were launched in target areas.
Each pilot uncovered the need to train paramedics “to work at the top of their license” and integrate them as a member of the larger care team that includes primary care, mental health, and social services. The pilot programs were successful in providing a new tool to approach the complex issue of ED overutilization and lessen the burden on public emergency service resources.
Community Care of Central Colorado, of Colorado Springs, partnered with Colorado Springs Fire Department (CSFD), and two local hospitals to launch a pilot program that focuses on Medicaid patients that have six or more ED visits, plus 30 or more prescriptions filled (exclusions for cancer, end stage renal disease, etc.) in the past 12 months. CSFD reported that greater than 70% of 911 calls were for non-emergent medical reasons.
Medicaid patients enrolled in the program are offered a direct phone number to speak to a paramedic when they need non-life threatening assistance rather than to call for an ambulance. Paramedics are also involved in improving care transitions, meeting with the Medicaid patient within five days of the patient’s discharge from one of the two participating hospitals to do a care transition evaluation.
This evaluation includes a medication reconciliation process, review of the hospital discharge plan with member/family, intervention for primary care provider follow-up visit within seven days of discharge, home safety evaluation, and a patient activation assessment. A standardized checklist adapted from the Coleman Model is used for communication to Community Care of Central Colorado and the primary care provider. The organization plans to expand this pilot program to include strategies that addresses social determinants of health including housing, transportation, and food assistance to name a few.
In Perth, Western Australia, like many other areas, “paramedics are schooled to transport, and ambulances are paid to transport,” explained Durrington. “That’s part of the challenge in reducing non urgent emergency demand.” Despite this fact, Durrington found that the local ambulance service was open to the pilot and wanted to explore options whereby paramedics felt comfortable not transporting to ED.
Apparently, ambulances spend so much time “ramping” or sitting in a bay outside the EDs waiting to get in, that participating in the pilot may save money in the end and patients may get a better outcome. The Perth Central & East Metro Medicare Local, in partnership with St. John Ambulance and the area ‘afterhours medical service’, developed an afterhours primary care referral pathway—and the ambulance service took on training the paramedics on the pathway. The Perth Central & East Metro Medicare Local, like many other Medicare Locals in Australia, uses HealthPathways, based on a model pioneered in New Zealand, to establish formal processes or clinical guidelines for care.
After a paramedic arrives at a home and makes the initial assessment that emergency transportation may not be necessary, he or she then reaches out to the afterhours call services to speak to the primary care physician on call to confirm the approach. This phone call is regarded as a “warm” transfer to the primary care physician and guidance is then given about next steps.
This usually involves the physician-on-call making a home visit. It also may involve the physician recommending that an appointment be arranged with the patient’s primary care provider to be seen the next day or that the paramedic provide some kind of intervention at the home. The project was started in a community where ambulance calls were very high. Durrington believes that when scaled in her catchment area, the new care pathway has the potential to save about 5000 ambulance transports a year.
Fritz summed it up, “If you have complex issues you have to have complex solutions and there has to be a variety of solutions not just one.” Fritz described one frail diabetic woman who called 911 for transport to the ED regularly, who is now getting a peanut butter and jelly sandwich delivered each day at lunch through the pilot. She has stopped calling 911.
Australia Cuisine, Part II. What exactly is vegemite and is it good?
Vegemite was developed almost 100 years ago as a way to use the yeast being dumped by breweries. Concentrate the liquid, add salt (a lot), some celery and onion flavorings and you get a thick black paste that is loved by many Australians who call it their “comfort food”. To be honest, a thin layer on toast with “avo” (avocado) is quite tasty, but straight from the jar is very unpleasant! The best way I’ve enjoyed Vegemite was in ice cream form. A scoop of this gives your taste buds a thrill ride—sweet, savory, and salty, all at once! But comfort food? I’ll stick with the peanut butter and jelly sandwich.