Maine EMS Community Paramedicine Pilot Program Evaluation

In November 2014, the Muskie School of Public Service at the University of Southern Maine was awarded a contract to evaluate the implementation of the statewide CP Pilot Program in Maine. This report presents process level results from the evaluation. The report includes findings from interviews with the twelve community paramedicine pilot sites in Maine and with the state of Maine EMS office. The layout of the report follows the key themes and categories from our interviews: Staffing Training Stakeholders and Partners CP Services CP Event Data Collection Funding Challenges Successes Sustainability The report concludes with lessons learned which may be helpful for future community paramedicine pilot projects

Evidence-Based Falls Prevention in CAHs (Policy Brief #24)

Inpatient falls are a serious patient safety problem in Critical Access Hospitals (CAHs). Injuries from falls are also costly -- it is estimated that patients injured in a fall sustain upwards of 60% higher total charges than other hospitalized patients. This brief is one in a series of policy briefs identifying and assessing evidence-based patient safety and quality improvement interventions appropriate for use by state Flex Programs and CAHs. Key Findings: Hospital falls are a serious patient safety problem, accounting for nearly 84% of all inpatient incidents. Most falls commonly occur as a result of medication related issues, toileting needs, and hospital environmental conditions. Effective falls interventions target both intrinsic (e.g. physiologic) and extrinsic (e.g. environmental) risk factors. Effective falls prevention teams are interdisciplinary and are embedded in a culture of patient safety. Education for and communication across all staff contributes to successful falls prevention programs

Community Paramedicine in Rural Areas: State and Local Findings and the Role of the State Flex Program (Policy Brief #35)

This study examined the evidence base for community paramedicine in rural communities, the role of community paramedics in rural healthcare delivery systems, the challenges faced by states in implementing community paramedicine programs, and the role of the state Flex programs in supporting development of community paramedicine programs. Additionally, the study provides a snapshot of community paramedicine programs currently being developed and/or implemented in rural areas. Another FMT briefing paper describes these same findings in detail. Highlights: Many rural community paramedicine programs are in pilot stages. Most community paramedics work within an expanded role rather than an expanded scope of practice, the latter requiring legislative or regulatory change. Funding and reimbursement for community paramedicine services are major challenges for the sustainability of community paramedicine programs. Data collection is vital for community paramedicine programs to be able to show value, including shared saving and patient outcomes. Collaboration at local and state levels is essential for buy-in, and partnering with the State Office of Rural Health is especially helpful in the early development and outreach efforts for rural community paramedicine programs

Exploring State Data Sources to Monitor Rural Emergency Medical Services Performance Improvement

In 1981, responsibility for overseeing emergency medical services (EMS) largely shifted to states and localities, contributing to the creation of a fragmented national picture of the state of EMS that is most evident in the resultant data collection and reporting issues that curb the availability of EMS data. These patchwork systems of care disproportionately affect rural areas, where myriad challenges – from a high reliance on a volunteer workforce to low call volumes and inadequate reimbursement – hinder performance. Previous studies by the Flex Monitoring Team (FMT) highlighted how little is known about the administrative, operational, and clinical capacity of rural EMS, which are key to investigate further before considering traditional EMS outcome measures. In this study, the FMT convened an expert panel comprised of representatives from a variety of stakeholders to highlight existing data challenges EMS face, identify data to support rural EMS performance measurement, as well as reassess the FMT’s 2017 rural-relevant EMS performance measures. Among the themes raised by the panel, experts suggested that improved engagement in oversight by state EMS agencies would increase accountability by local EMS; however, they cited a lack of staff capacity and expertise to analyze data in states, as well as disagreement between states on relevant measures. The FMT created EMS capacity measures to monitor and improve rural EMS capacity, along with the National Highway Traffic Safety Administration’s EMS Compass outcome measures to monitor performance. Potential opportunities identified by the panel to source standardized data for those measures include an assessment tool developed through the Joint Committee of Rural Emergency Care, or for the relevant data to be collected by state EMS agencies through their existing EMS service licensure process, many of which already collect some of the relevant data. Electronic patient care records, the typical source of data to calculate EMS clinical and non-clinical performance measures, can be collected and reported to states through the National EMS Information System (NEMSIS). Though not perfect, targeted efforts to improve the collection of local EMS data provides an opportunity for state EMS agencies and State Flex Programs (SFPs) to train local services in data collection, in addition to educating them on how to access and use their own data for performance improvement. This collaboration can also play a role in supporting improved health information exchange between EMS, hospitals, and other providers, which help improve the quality of pre-hospital care and assist in monitoring the quality and outcomes of care across the system of care. The importance of reliable, standardized, and timely data from local and state EMS is underscored by the recently launched Medicare Ground Ambulance Data Collection System, a Centers for Medicare and Medicaid Services study that will collect information to evaluate how ground ambulance costs relate to current payment policies. In turn, this will be used to formulate a report to Congress assessing the adequacy of Medicare ground ambulance payment rates and geographic variations in cost. As the data will be used to assess reimbursement rates across urban, rural, and super rural areas, accurate data collection and reporting is vital. The expert panel also reaffirmed the validity of FMT’s rural-relevant measures and raised questions about monitoring the measures longitudinally or developing measures to assess financial performance and sustainability. Additional work is needed to understand how to best use these measures to track rural EMS capacity over time, as well as identify the relevant financial measures

Promoting a Culture of Safety: Use of the Hospital Survey on Patient Safety Culture in CAHs (Briefing Paper #30)

The Institute of Medicine has emphasized the importance of establishing a culture of safety to improve patient care, specifically: developing clear, highly visible patient safety programs that focus organizational attention on safety; using non-punitive systems for reporting and analyzing errors; incorporating well-established safety principles such as standardized and simplified equipment, supplies, and work processes; and establishing proven interdisciplinary team training programs for providers. We sought to investigate the degree to which these elements are present or absent in Critical Access Hospitals. This report presents the results of a literature review and a rural patient safety expert panel comprised of representatives from federal and state government and academia. There is another policy brief that summarizes these same findings

Addressing Opioid Use in Rural Communities: Examples from Critical Access Hospitals

The opioid epidemic continues to have a devastating impact in rural areas disproportionately affected by a lack of infrastructure to provide treatment for opioid use disorders (OUDs). Critical Access Hospitals (CAHs), often the hubs of local systems of care, can play an important role in addressing OUDs. Using a substance use framework developed for the Flex Monitoring Team’s earlier study of CAH substance use strategies, this brief highlights strategies adopted by CAHs to combat opioid use in their communities. It also identifies resources that State Flex Programs can use to support CAHs with this challenging population health issue

Community Paramedicine Pilot Programs: Lessons from Maine

Community paramedicine programs are beginning to flourish across the nation, and the need to provide demonstration or pilot programs is essential to providing a consistent and high-level standard for this model of care. While the overarching goals are to align with the Triple Aim, piloting a community paramedicine program also allows each community to develop and implement a program tailored to the healthcare needs of their specific community. A successful program builds the evidence base that can then be used to create legislative change necessary to financially sustain this model of care across the healthcare delivery system. This article provides a discussion of the healthcare needs of people living in rural areas and of the ways in which community paramedicine can address some of those needs. This article begins with a discussion of legislative authorization and characteristics of the Maine community paramedicine pilot program, the general strategies for implementation, and lessons learned from these programs. A case study of a Maine community paramedicine program provides an example of key implementation strategies along with structural and operation functions of the program that may be useful for other community paramedicine pilot sites looking to implement a community-based health care program. Included as one of four articles in the Symposium on Community-Based Health Care, edited by Alexander Henderson. The purpose of this symposium is to provide a venue for the exploration of central issues in community-based care, including program implementation, interorganizational relationships, and clinical provider education. The articles in this symposium contribute to the ongoing conversation on Community Paramedicine/Mobile Integrated Health emerging in clinical medicine, operations research, and practitioner-based publications

Improving Rural Systems of Care for Time Critical Diagnoses (Briefing Paper #41)

This paper examines the efforts of state Flex programs to support the development of Emergency Medical Services (EMS) time critical diagnoses (TCD) systems of care, which includes stroke, ST-Elevation Myocardial Infarction (STEMI), and trauma. The severity of these conditions necessitate a coordinated regionalized approach to transportation, diagnosis, and treatment to meet recommended treatment windows (e.g., the golden hour in trauma or a door to balloon time of 90 minutes for patients with STEMI) to maximize patient outcomes. These efforts to support the engagement of rural EMS agencies in TCD systems of care are an optional but important area of Flex Program activity under Program Area 3 - Population Health Management and Emergency Medical Services Integration. Through a review of state Flex grants and progress reports as well as interviews with state Flex coordinators and EMS stakeholders, we examined state Flex program initiatives to improve TCD system capacity and integrate EMS into local/regional systems of care, particularly those served by Critical Access Hospital (CAHs). Highlights: Collaboration between state Flex programs and the time critical diagnoses (TCD) stakeholders encourages a consistent focus on rural TCD issues and improves system-level communication. Flex funds can be used to leverage other state EMS resources to improve rural TCD performance and undertake projects for which there may be no other source of funding. Data collection at the local, regional, state, and program level remains challenging, impacting the ability to improve EMS TCD system performance and monitor Flex Program impact. Training is a significant area of state Flex program TCD activity, but states struggle to directly connect participation in the trainings to changes in local EMS operations and/or performance. State Flex programs must move beyond training and partnership activities to engage EMS, CAHs, and other stakeholders in making local/regional system changes to improve TCD services

Emergency Transfers of the Elderly from Nursing Facilities to CAHs (Policy Brief #32)

Research has shown that essential information is often missing during transfer of nursing residents to the Emergency Department (ED), and communication problems between nursing facilities and EDs are one of the most cited barriers to providing quality patient care. Tools, such as transfer forms and checklists, that improve communication between settings of care help improve patient safety and quality of care. This Flex Monitoring Team study assesses the evidence base and best practices for improving the nursing facility-to-hospital transitions of care. Key Findings: Transfers to the hospital emergency department (ED) are common for many nursing facility (NF) residents, with over 25% experiencing at least one ED visit annually, and many encountering repeat visits. Communication issues, including incomplete information during transfer, impact clinical care of the elderly NF resident transferred to the ED. Several studies strongly recommend the use of standardized transfer forms as a way of improving communication, which ultimately improves patient safety and quality of care. However, standardized transfer forms, in and of themselves, are not sufficient to solve communication issues between the sites of care (NF, EMS, ED). The establishment of ongoing relationships between hospital, EMS, and nursing facility staff help facilitate effective communication regarding patient needs during the transfer process and encourage the development of a systems approach to the transition of care