The Medicine BehindMobile Integrated Healthcare Practice

Jeff Beeson, DO, FACEP, RN, EMT-PMedical Director - MedStar

Emergency Physician’s Advisory Board

Michael R. Wilcox, M.D.Medical Director

Hennepin Technical College

Brent Myers, M.D., MPHMedical Director

Wake County EMS

Role of the Medical Director

“These areour patients”

“This is mypractice of medicine”

“I’m calling fromDr. Beeson’s office”

The Issue…

• 5.6 million health care jobs will be created by 2020

• Today, 40 million people > 65– 70 million in next 20 years

• 2012 - 25,000 docs short – By 2020 = 40,000 short

Association of AmericanMedical Colleges

We have an answer for this

challenge!

Scope vs. Role

• Recall: 37 million house calls already• Urban experience – Most “skills” are social,

not clinical• Rural experience – May be some expanded

role?– Perhaps using other inter-professionals?

Provider Selection

• May depend on gap being filled– EMT/paramedic/RN/NP/PA/MD– Mesa, AZ

• NP and Fire-Medic on fly car• Low acuity calls triaged to them

• May depend on regulatory environment

Provider Selection

• Technician vs. Clinician vs. Practitioner• Taking the long view• Critical thinking• Providers with the longest scene times?

Adrenaline Junkie

EMTs & Paramedics

• EMTs/Paramedics already know how to deliver care locally

• Know how to assess resources and make decisions

• They could fill gaps in care with enhanced skills through targeted training

Provider Training

• Core curriculum– Disease processes– Patient assessment/education– Community resources

• Role Specific– EMS Loyalty Program– CHF– Hospice– Primary care

Provider Training• Involve LOCAL stakeholders

– Case managers– Behavioral health– Cardiologists– Hospice RNs

• Develops relationships/trust

Provider Training• Clinical Rotations

– Community clinics– Homeless shelters– CHF clinics– CVICU’s– Behavioral health– Hospice units– MHP programs

• Actual home visits

Healthcare System Integration• Needs determination

– Medical interface• Cardiology / Specialty

– Care plans and protocols• Home health

– Support – not replace– Focus on transition of care

• Skilled Nursing– Referrals / coordination– In-house support

• Wake county fall program

Program Development

• Coalition building– Needs assessment– Relationships!– Gap analysis

• Filling the gap– What’s missing and how can we help?– Sought out or discovered

• Expanded scope vs. expanded role– Most valuable ‘interventions’– Know your regulatory environment

Program Development

• Protocols– Based on gaps to be filled– Eligibility criteria for ECNS

v12.1 Code

Pri Description v12.1 CAD Code NAED Appr'd

KYMedStar Appr'd

PSIAM Code

Pri ECNS CAD Code

02A01 3 No difficulty breathing or swallowing (rash, hives or itching may be present)

02A01n-Allergies/Envenomations   Y Y 02A01 O 02A01n-Allergies/Envenomations

02A01I 3No difficulty breathing or swallowing (rash, hives or itching may be present) - Injection administered or advised 02A01In-Allergies/Envenomations   Y Y 02A01I O 02A01In-Allergies/Envenomations

12A01 3 Not seizing now and breathing effectively (verified) 12A01n-Convulsions/Seizures   N N 12A01 3 12A01n-Convulsions/Seizures

12A01E 3Not seizing now and breathing effectively (verified) - Epileptic or Previous history of seizures 12A01En-Convulsions/Seizures   N Y 12A01E 3 12A01En-Convulsions/Seizures

12A02 3 FOCAL seizure (alert) 12A02n-Convulsions/Seizures   N Y 12A02 3 12A02n-Convulsions/Seizures

12A02E 3 FOCAL seizure (alert) - Epileptic or Previous history of seizures 12A02En-Convulsions/Seizures   N Y 12A02E 3 12A02En-Convulsions/Seizures

Quality Assurance• Continuing education

– Real-time MD/MHP interaction– PCP/Medical Director communication– Programmatic feedback/enhancement

• Call reviews– ECNS tape reviews– Patient care reviews– Care Coordination Councils

• Monthly CE meetings– Case reviews

Care Coordination

• Care Coordination Council– Case Managers– Community-based social services– Meet monthly to discuss enrolled patient

needs• On-line consultation

– “Best Option” patient determination– Not a Part-Time job!

Electronic Medical Record

Key for patient navigation

determination

Resource Balancing

• “Mission creep”• Alignment of can do and should do

Not for the faint of heart?