Matt Zavadsky, MS-HSA, EMT – The Role of EMS in Value-based Care Pt 1

In this episode, we pay a visit with Matt Zavadsky, EMT and Chief Transformation Officer at MedStar Mobile Healthcare, a high value Emergency Medical Services system that provides advanced clinical care with high economic efficiency.


Tell us a little bit about MedStar, what your organization does, and how it has impacted the communities in which it operates.

Thanks for asking. MedStar is the trade name for a public authority called the Metropolitan Area EMS Authority. We are a regional, governmental administrative agency that is created by 15 member jurisdictions to provide emergency medical services across all 15 of those cities, irrespective of city boundaries. It’s a, again a regional public authority. The challenge was that the Metropolitan Area EMS Authority was way too many letters to try and put on the side of an ambulance. So, we when the, when the Authority was formed the community had a naming contest back in 1986 and MedStar was the name that was chosen. So we are that public authority. We provide 911 and non-emergency medical services, emergency medical services, to about 430 square miles with 1.1 million population. Fort Worth is our largest member jurisdiction. There are 14 others. And we do so without any tax subsidy which is a little bit unusual being a public authority much like you might think about a transportation authority or an airport authority, but we receive no tax dollars. So, it’s a very high-performance EMS system.

What is mobile integrated healthcare and how does it reduce utilization? What are some of the proactive measures being done?

Mobile integrated healthcare is a term that has been used by the EMS profession to categorize services that we are able to provide that may or may not be the result of a 911 response. Most people think of an EMS agency as you know group of experts who hang around a station, wait for a 911 call to occur, and then we respond, mitigate the emergency, and then shlep people off to an emergency department. What we’ve learned over time is that there’s a certain portion of our population who could benefit from some proactive education, medication management, connection with other resources in the community, maybe re-connection with their primary care network, to actually prevent a 911 call. So, the term mobile integrated healthcare is really that umbrella term that refers to all of the things that EMS agencies can really do to improve the health of populations, to reduce the expenditures of the health care system, and to most importantly improve the patients experience of medical care.

What are some of the healthcare roles that EMS has transformed?

So that’s a great question. And if you think about it, one of the major transitions and transformations has been that prevention of the 911 call. We have always been reactive as a profession. EMS agencies, sort of by nature, react to a 911 call. But what we’re doing now, and at MedStar and a number of other agencies across the country, is working with partners, payers, hospital systems, home health agencies, hospice agencies, ACOs, to fill a gap that still exists in our health care system and those gaps are different depending on the population and the partner that we’re working with. So for example, a hospital system has a bunch of frequent flyers that come to the emergency department for ambulatory care sensitive conditions. Those things that really had they seen their PCP or their primary care system, that ER visit would have been avoided. They identify those patients, refer those patients to us, we go visit them with specially trained community paramedics who are trained in things like motivational interviewing and social determinants of health, in addition to doing the typical things that paramedics do, 12-lead EKGs, medication administration, vital signs assessment, following protocols.

So now you’ve got these community paramedics who can reach out to the person who ends up in the emergency department three times last month with congestive heart failure, pulmonary edema, and the ER doc is befuddled as to why. The cardiologist just can’t figure it out. But when the community paramedic goes into the home, finds out that it’s family that eats pepperoni pizza three times a week, or that the patient lives on a second- or third-floor walkup in Texas where it’s 110 degrees in the summertime and when the person gets to their third-floor apartment, they’ve decompensated and are now suffering from pulmonary edema, or their emphysema has flared up. And we work to get that patient, for example, moved to the first-floor apartment instead of a third-floor walkup. The PCP would never know that because they don’t typically go to the patient’s home. The ER doctor certainly wouldn’t know that. Same thing with the diet that we talked about earlier, that menu.

Many times patients get discharged from the hospital with a booklet of discharge instructions. And let’s face it, when they’re being discharged from the hospital and they’re getting their discharge instructions, they are barely listening. But yet, when someone can sit down with them and their family in the kitchen and literally take an hour or two and go through every one of their discharge instructions, explain why it’s important to take their Lasix, explain why it’s important to not eat a high sodium diet, look in their refrigerator, look in their cabinets, help them with that process, we can change the behavior and then give that feedback to the primary care physician, to their primary care network, to say hey here’s what’s going on in the home. And they can change that patient’s whole education level to really keep them out of the hospital. And that high utilizer population is only one. We work with the hospitals on things like readmission prevention, observation discharge avoidance, so they don’t have to be admitted to the hospital under observation status, and then again partnering with payers and ACOs and now a lot with hospital in the home providers, to really be that episodic care for the hospital and home patients as well.

One of the great things about EMS is that the communities that we are in, and we’re in almost every community right because you’ve got your local EMS agency, is they are a trusted group of people. And even the most suspicious patient, who might be afraid that someone’s going to come and take their kids away, or make them go into a nursing home or do something like that, when someone comes to their door in an EMS uniform, and knocks on the door, they let us in. Because we’ve been in their home at 2 o’clock in the morning when they can’t breathe, or when they’ve crashed their car, or when their kid has fallen. So that trusted resource really lends itself well to patients listening to the recommendations and the instructions given by the paramedic.

Talk about the utilization outcomes for the home health partnerships you have in place?

One of the gaps that we help fill is with home health agencies. Patients want home health generally are relatively medically fragile, and they activate 911 quite a bit, they may have needs literally 24 hours a day, 7 days a week. And the goal of the home health agency is to prevent those patients from going to the emergency department. Because if their contracted with the payer, if they’re contracted with the hospital, and they have a high ER utilization rate in their cohort, the payers is going to stop using them or the hospital going to stop using them. Because that’s against what they’re using home health for.

So, we have several partnerships with home health agencies that do two important things. The home health agency registers their patients on service with us. Every time they do an intake on a new patient, one of the intake process is they notify us that this patient, Patient A, is now on their service. We register that patient in our 911 computer aided dispatch system and if, and what we find more often than not, when that home health patient calls 911, they’re flagged. And we take the call just like we would any other 911 call. But we also dispatch a community paramedic to co-respond with our ambulance. And then, simultaneously, our 911 center calls that home health agency and says “Hey ABC home health to MedStar listen. I want to let you know Patient A just called 911 for difficulty breathing. Tim, our on-duty community paramedic, is on the way to the scene. He’ll call you in about 15 minutes once he does an assessment.”

So now the home health agency can contact their on-call nurse who brings up Patient A’s medical records on their homecare homebase system, or Kinnser, or whatever they’re using. So that when Tim calls the on-call nurse at 2 o’clock in the morning and says “Yeah. You know what. He’s got you know 2 pillow orthopnea and he’s got rales at the bases. You know, blah blah blah. 12-lead looks good, his vital signs are relatively stable. We’re going to start IV. Give him so Lasix. Stay here for about half an hour with the ambulance or so, or however long we need to. Measure urine output and can you come see him tomorrow. And we don’t take him to the hospital. So, the home health agency benefits from avoiding an avoidable ER visit. Good care coordination I’m seeing and now they can follow up with that patient the next morning to make sure that they’re stable. Maybe they need to adjust Lasix. Maybe there was some educational gap. Work with the cardiologist, whatever the case might be. So, that brings huge value to a home health agency, and they pay us for that type of on-scene care coordination from a 911 call.

But then there’s a second service that’s part of that expanded role and the home health agency can call us on a 10-digit hotline into our 24-hour 911 center and say “Hey Patient A just called here it’s 2 o’clock in the morning. They’re complaining about a little bit of difficulty breathing. They didn’t call 911 but they called us because they didn’t know what to do. It’s going to take us 2 hours to get a nurse out to the house or quite frankly it’s too expensive for us to pay a nurse overtime for 4 hours minimum pay to go out and assess this patient. Will you guys please send the on-duty community paramedic to do an assessment and call me?” And we do that. And to give an example of how often that is used so far, we’ve had about 3,700 home health patients registered in our system. 72% of those 3,700 patients have activated the 911 system, which is not surprising but when you start putting the numbers to it you can really say wow that’s a lot of activations and that makes a lot of sense. So, those are the calls that we’re sending this community paramedic to along with the ambulance and doing the on-scene care coordination. And when we do that, only about 51% of the time are we actually transporting someone to the hospital. Because the rest of the time we’re able to mitigate it on-scene, care coordinate with the home health agency, and not take him to the emergency room.

In addition to that, the home health agencies have asked us about 600 times to go see an episodic case. Middle of the night, weekends, even during the day if they’re super busy. And when we go to those calls, only about 6% of those patients end up needing to go to the emergency department. We mitigate in on-scene and really just become that service level extension of the home health agency.

So huge value to the home health agencies. We do the same thing with Hospice agencies for the same reason. We do it almost the exact same type of program for multiple Hospice agencies to prevent patients from going to an emergency department who were on Hospice, and it works really well. The patients benefit, the home health agency benefits, and certainly we benefit because we’ve changed our model and we’re getting revenue by bringing more value to the rest of the health care system.

That sounds like a major shift in utilization reduction

Yeah absolutely, and we see that across all of our programs. You know, for years, EMS agencies were only reimbursed if we transported someone to the hospital from a 911 call. And what we’ve been able to do over the last decade is really, really explain to the payers, Medicare, Medicaid, commercial insurers, anybody who will listen, that all you’re really doing is incentivizing us to spend your money. Because we know that only about 10% of the 911 calls that we respond to are truly life threatening. Another 20% probably need acute care right now at an emergency department. But 70% of the calls that we respond to can probably, and we’re showing more and more, can be mitigated on scene, referred to another health care resource, whether it’s urgent care, or primary care, self-care at home, follow up with your doctor, and that navigation as opposed to transportation is what is starting to be reimbursed. And really bringing more value to not only the payers but care management organizations, ACOs, IPAs who are in a shared risk arrangement with payers, and that’s really the transformation that’s occurring with EMS.

What do patients seem to want when they call 911?

What do patients seem to want when they call 911? That is the gold ring question, and it probably falls into two types of calls. The type of call where the patient truly feels or knows that there is a life-threatening medical emergency occurring. Dad is unconscious and nonresponsive. The kid is unconscious, unresponsive. Toddler fell out the window. Motor vehicle crash with a rollover and ejection. You know, those types of calls fall into that 10 to maybe 30 percent bucket where yep, this is a true emergency, we need somebody here to stop bleeding, start breathing, start pressing on the chest, you know, whatever it’s going to take to sustain life until they can get definitive care in the hospital. And that’s great. Some patients really need that, they want that, that’s why they call.

What we’re finding, especially during the pandemic, it was really accented through that process, is a lot of patients called 911 to see if they needed to call 911. Because they don’t what’s going on. So, you know, a little bit of difficulty breathing, or their vomiting, or they just don’t feel well, or is it a kid with a fever, and you know they want someone to come to their house, who they trust, who wears a stethoscope around their neck, who has an EKG machine, who can check blood sugar, who can you know check oxygen level, to see do I really need to go to the emergency room or not. Or can you do something for me now that A, reassures me, B, maybe fixes the problem that I’m having so that I can go to my own doctor. The classic case in that is a diabetic, where you know somebody goes into insulin shock, and we get there, and they’re stuporous, or they’re unresponsive, and we check their blood sugar, and it’s 30, and we start an IV, and we give them D50, the wonder drug, they wake up. We, you know, have the family make them a peanut butter and jelly sandwich with, you know, marshmallows or whatever, and that patient does not need to go to the emergency room. And we checked their blood sugar rates now, you know, 110. They need to see their endocrinologist because maybe they need to have some adjustments with their insulin or whatever the case might be, or their diet, but we don’t need to bring those people to the ER. And they wanted to know that. But we fixed their problems. Same thing with asthmatic. Same thing with a number of things that we can correct in the field so that they can now go see their normal care provider.

We had a case recently that just typified this where we had a diabetic who the family called because his blood sugar was showing high, and we found that, in fact, his blood sugar was like you know 300 and normally we would take that person to the hospital. Hydrate him. There’s not a lot we can do. Where the hospital is going to see him. An ER doctor who doesn’t know that patients are going to run a while bunch of tests, and be concerned about DKA, and doing all sorts of stuff. But what we do instead, is now we call this endocrinologist and say “Hey. We’re here. We started IV and we’re hydrating them. His blood sugars 300. What do you want us to do? Do you want us …” And he says “Oh. His blood sugar is only 300? Yesterday when he was in the office it was 450. So, he’s doing better.” It’s just when you connect the person with their PCP, who knows that patient, you get better decisions that are patient centric. So that, you know, patients want to know that they’re going be OK and there you go. And I think that more and more that’s the role that we’re starting to fill.

Matt, this is very reminiscent of an era when Providers would make house call visits to their patients.

And we facilitate the doctor doing the house call. Especially today with telemedicine and all sorts of different things, we can be in the home, whether it’s on a 911 call or an episodic request by the payer or by the physician practice or whomever, and telemedicine the doctor in. And say OK, here’s the vital signs, here’s the 12-lead, here’s the blood sugar, here’s the SA02. And we can be that extension of the physician where he or she can still be in their office, they can still be at home if it’s on the weekends, or whatever. They don’t have to go out, we can help facilitate that and just again bridge that gap between the patient and their physician.