Year in Review: Top Stories of 2016

Posted on Thu, Jan 05, 2017
Year in Review: Top Stories of 2016

From finalizing a merger and revealing groundbreaking research to fighting hurricanes and providing top-level care across the country – 2016 was a busy year for the Envision Healthcare family. Our dedicated team worked diligently to improve the health of populations, enhance patient experiences and outcomes as well as manage costs, all while building solutions and partnerships that are shaping the future of healthcare.

As 2016 comes to a close, let’s take a moment to review some of the year’s most inspiring, heart-warming and trendsetting stories.

  1. Envision Healthcare expands its suite of healthcare solutions with the merger of Nashville-based AMSURG. Denver Business Journal
  2. Evolution Health proves it’s possible to reduce avoidable E.D. and inpatient admissions, reduce healthcare costs and improve the patient experience. Journal of Emergency Medical Services
  3. AMR coordinates a cross-country move by ground and air for a patient and her mother. KGW Portland
  4. EmCare physicians care for patients at a Lumberton, N.C. hospital while fighting through Hurricane Matthew. EmCare
  5. AMR/ Rural Metro responds to the tragic nightclub shooting in Orlando. WFTV Orlando
  6. Evolution Health’s Dr. Eric Beck receives Modern Healthcare’s Up and Comers award. Modern Healthcare
  7. AMR’s Dr. Edward Racht delivers the keynote address on the future of EMS at the EMS World Expo. YouTube/EMS World
  8. Envision Healthcare is named one of the World’s Most Admired Companies by Fortune Magazine. Fortune Magazine
  9. EmCare awards Genesis Cup to nerve block collaboration between emergency physicians and anesthesiologists. EmCare
  10. 10. Envision Healthcare joins the S&P 500 after creating the nation’s largest physician staffing organization. Becker’s Hospital Review


How AMR Is Preparing for ASHE

Posted on Thu, Dec 15, 2016
How AMR Is Preparing for ASHE

Paramedics and EMTs face countless potential dangers on a daily basis – car crashes, severe weather, hostile patients and much more. Now, more than ever, they are also having to deal with active shooters, terrorist attacks and other mass causality incidents. The ever-growing threat of an Active Shooter/Hostile Event (ASHE) has American Medical Response (AMR) continually evaluating how it prepares for and responds to such high-threat encounters.

With dangerous incidents on the rise, AMR has implemented an ASHE initiative. It is an evidence-based approach that teaches responders how to prepare for an event, how to respond during an event and what to do after an event to minimize harm to responders and increase the survivability of victims.

“This is the beginning of another new problem,” said Edward Racht, M.D., Chief Medical Officer of AMR, comparing it to other health epidemics like Ebola. “We have to be diligent in our studies and vigilant in our approaches.”

The InterAgency Board for Equipment Standardization and Interoperability (IAB), founded by the Department of Defense and the Department of Justice, describes ASHEs as the intent to cause physical harm or death by a variety of means including the use of weapons.

Some of the more recent domestic events include the San Bernardino terror attack, the Dallas sniper attack on police, the Colorado Springs hostage situation and the Orlando nightclub shooting.

According to Dr. Racht, ASHEs are comparable to an evolving and highly contagious disease that everyone needs to address with urgency.

And, it starts with those who are not in uniform.

Oftentimes, the initial first responders are bystanders, not police or paramedics. ASHE victims can suffer from a variety of injuries that range in severity, but the most common and also preventable cause of death is hemorrhaging. Dr. Racht expressed that anyone can help save a life just by preventing blood loss.

A significant component of AMR’s ASHE initiative is teaching the public tourniquet application and hemorrhage control through the “Stop the Bleed” campaign.

“It is one of the most valuable interventions in the public today,” Dr. Racht explained. “It is life-saving and simple to do.”

Most incidents also require the assistance of multiple first responder disciplines, yet the nature of ASHE presents several operational challenges for all. As a result, research and best practices show that EMS, fire departments, law enforcement, hospitals and other agencies have to enact a unified and coordinated approach that goes beyond each discipline’s traditional responsibilities.

“We have to make the event as predictable as it can be. We don’t want to create confusion and potential harm because we aren’t coordinated.”

Dr. Racht compared the approach to understanding the emergence of these new challenges to other circumstances EMS and healthcare personnel face such as the initial identification of HIV/AIDS. During that era, “the ‘new’ and emerging threat forced everyone to better understand the disease, our response and how to best take care of our patients and ourselves.”

Development of the concept and practice of universal precautions was a milestone in the healthcare industry’s approach to all patients. Similarly, the Sept. 11 attacks led to the development of the National Incident Management System that now enables everyone to communicate and integrate much more effectively.

He also believes that studying past events will help responders prepare as much as possible for future ones. As part of its ASHE strategy, AMR is analyzing previous incidents, performing training exercises and evaluating equipment needs so responders can assess a situation quickly and respond appropriately.

Responders’ first priority, no matter the situation, is to ensure their safety.

EMS personnel have traditionally stayed and provided treatment in the cold zone – an area that theoretically does not pose a significant danger. Dr. Racht explained that this is still the safest and most effective place for paramedics and EMTs. EMS evaluation and management in the warm zone is an evolving area of discussion and one that requires careful thought, analysis and a focused approach to providing care that may not necessarily be delivered in the same way as it has been in secure environments.

Once the responders are safe, they identify the injured and assess the scope and magnitude of the event. They can then focus on providing immediate life-saving intervention which typically includes hemorrhage control and airway management.

“It’s part of what communities expect EMS responders to do – produce order out of chaos.”

Dr. Racht stressed that this is an international learning process and, while AMR is dedicated to ensuring it is fully equipped to handle such events, it is important enough and critical enough that it requires everyone’s attention and participation.


MIH – A Key Component to Achieving the Triple Aim

Posted on Mon, Nov 28, 2016
MIH – A Key Component to Achieving the Triple Aim

A patient-centered care model that is cost-effective, improves population health and leaves patients satisfied seems too good to be true. However, Evolution Health, an Envision Healthcare company, can do just that. Based on a recent evaluation of a Medicare Advantage population in Florida, its Mobile Integrated Healthcare (MIH) model demonstrated the ability to reduce avoidable Emergency Department (E.D.) and inpatient utilization, lower healthcare costs and, most importantly, improve the patient experience.

“The patient’s health and satisfaction are our top priority,” said Daniel Castillo, M.D., MBA, Chief Strategy and Quality Officer and Executive Vice President of Population Health at Evolution Health. “Our approach to providing individualized, needs based care and our ability to improve population health can significantly impact the future of healthcare.”

MIH provides integrated post-acute care, chronic care and prevention services on a 24 hours a day, seven days a week basis to patients when and where they need it. That accessibility is in part why MIH is so successful.

“We meet patients where they are – both physically and mentally – tailor our care to their specific needs and make patients and their family members an active part of the care team.”

Results from the peer-reviewed published article titled, “Mobile Integrated Healthcare: Preliminary Experience and Impact Analysis with a Medicare Advantage Population,” reveal that patients were receptive to MIH and responded positively to the experience. The patient satisfaction survey shows:

  • 97% said their providers sought their opinions, listened carefully and clearly communicated their options
  • 97% said their providers were knowledgeable
  • 96% said they would recommend their providers to family and friends
  • 95.8% net promoter score

He says he is particularly proud of the communication satisfaction score because “it shows that we can communicate effectively across providers and to our patients.”

Dr. Castillo, along with Eric Beck, D.O., MPH, EMT-P, FACEP, Chief Executive Officer for Evolution Health, Brent Myers, M.D., MPH, Chief Medical Officer, and Jonathan Mocko, Evolution’s actuary, led the MIH evaluation.

They leveraged the services of an interprofessional care team that consisted of nurses, social workers, advanced practice providers, emergency medical responders, pharmacists and more to address the Triple Aim — improving population health, enhancing patient experience and outcomes and reducing care costs.

Dr. Castillo says that the patient-centered approach has far-reaching effects on population health, healthcare costs and use of the E.D.

“When we focus on improving patients’ health and providing high-quality, safe and accessible care – through both planned and unplanned interventions – E.D. and inpatient utilization and costs are naturally reduced.”

During the 90-day evaluation period, the interprofessional care team achieved:

  • 40% decreased inpatient utilization
  • 21% decreased E.D. utilization
  • 37% decreased inpatient per member per month (PMPM) cost
  • 19% decreased E.D. PMPM cost

Evolution Health’s Medical Command Centers (MCCs) are the heart of the MIH operation. Through the MCCs, patients have 24/7/365 access to clinical professionals such as physicians, advanced practice providers and pharmacists who can provide care over the phone and in-person. Call takers are responsible for assessing patients’ needs and for coordinating and disbursing the appropriate resources.

Part of the multidisciplinary team includes paramedics from Evolution Health’s sister company, American Medical Response (AMR). Merlin Underwood is an MIH paramedic in Broward County and he has been an integral part of the MIH team.

“We get to make sure they get care when they need it, how they need and with whomever they need it – always with quality and safety as our focus,” Underwood said.

As an MIH paramedic, Underwood responds to calls through the MCC. He evaluates patients on-site and determines if it is appropriate to treat them in their current location, in an alternative care setting or if it is best to transport them to the E.D.

As practicing clinicians, paramedics like Underwood can care for patients in the comfort of their homes at 2:00 in the afternoon or at 2:00 in the morning. In doing so, they help save patients long waits in the E.D. and expensive bills.

“You can just see the relief come over their face when you tell them they don’t have to be transported to the E.D.”

The interprofessional care team implements appropriate care programs and scheduled interventions to manage patients’ health. The team is also dedicated to improving patient education and working with patients to understand their needs and become more engaged in their care.

Dr. Castillo says the Evolution Health team is at the forefront of mobile healthcare. He believes that “as we continue to work towards patient-centered care and focus on patient engagement, we can, in fact, improve population health and the current inefficiencies in our healthcare system.”

He says he looks forward to working with his colleagues to create a better experience for both patients and physicians.


Emergency Medicine’s Expanding Role in Population Health

Posted on Wed, Mar 23, 2016
Emergency Medicine’s Expanding Role in Population Health

By Nick Zenarosa, M.D., FACEP

Traditionally, population health management has fallen to primary care providers (PCPs), but as more patients opt for the ED instead of a PCP, the responsibility of population health management is shifting.

Becker’s Hospital Review reports that nearly 80 percent of adults ages 18 to 64 visited the ED due to lack of access to other providers. An estimated 56 percent of primary care delivered in EDs is based on preventable, non-urgent visits, according to the Network for Excellence in Health Innovation (NEHI). And, the American College of Emergency Physicians finds that more than 33 percent of all primary care is performed by emergency medicine providers, yet they make up less than 5 percent of the primary care workforce.

An NEHI study identified the following five causes for patient use of the ED for primary care:

  • Patients have limited access to timely care services
  • The ED provides convenient after-hours and weekend care
  • The ED offers patients immediate reassurance about their medical conditions
  • Primary care providers refer patients to the ED
  • Hospitals have financial and legal obligations to treat all ED patients

The NEHI study further shows that increased insurance coverage under the Affordable Care Act will not drive patients to primary care. Findings indicate that the belief that ED overuse is the result of poor and uninsured seeking non-urgent care may be spurious – these populations were found to be a small subset of the overall population who were using EDs inappropriately. However, the Agency for Healthcare Research & Quality (AHRQ) indicates that if the ED staff encourages patients to an initial primary care visit, they will likely continue to see a PCP.

Disease Management Growing More Difficult, But There’s Hope

Particularly of concern for population health management is the management of chronic disease – especially the growth of Type 2 diabetes mellitus. It can lead to devastating complications such as renal disease, blindness, heart disease, stroke and impaired peripheral circulation. Blood glucose control, particularly decreased glycosylated hemoglobin, is associated with the delay or prevention of these complications. This type of control is achieved by close monitoring of diabetics’ blood glucose results, lifestyle management, diet and medication.
This close monitoring requires consistent, comprehensive care that is best offered in a primary care setting. However, access to primary care may be an issue for these patients.

If the trend of growing ED volumes continues, it could fall on emergency physicians to handle the proliferation of diabetes. Managing the disease requires knowing about it – screening high-risk individuals, actively looking for chronic conditions instead of passively finding out, discharging patients with long-acting insulin, oral hypoglycemic agents and diabetes education to get them started on a treatment plan. If the patient is not stable enough to go home, placement in the observation unit for medication initiation, including insulin and diabetes education, is a reality. He or she can follow up with a PCP, and return to the ED if unable to see PCP within the prescribed time. This approach could be applied to other chronic diseases.

Transitional care clinics, such as acute episodic care clinics, also offer a solution to chronic disease management. These clinics can be open seven days a week for 16 hours or 24 hours with the same triage processes as the ED. Between non-emergent patients and PCP patients looking for urgent care, this approach could save millions of dollars.

Coordinating Care through Established ED Demand Management Techniques

Emergency medicine professionals excel at demand management. Triaging, surge control and vertical flow are all tools that could have wider applications for population health and chronic disease management. ED staffs could improve clinical outcomes by coordinating patient care between the ED and primary care.

Emergency physicians can improve effectiveness and efficiency by coordinating care across the care team:
  • Communication with ED providers, ED nurses and others outside of the ED
  • ED flow rounds once a shift to ensure everyone on the multidisciplinary team is on the same page
  • Ensure successful transitions from the ED and plan for patients’ next steps
  • Engage patients as active participants in their care. Without patient and family involvement, the patient is unlikely to be able to manage their disease

A county-owned hospital with a Level-1 trauma center recently implemented some of these population health management techniques in its ED. The results aren’t scientific, just anecdotal, but they are promising:
  • A decrease of 28 to 49 hospital bed days per day
  • 3 percent decrease in inappropriate inpatient admissions related to diabetes
  • $158,000,000 in estimated expenses mitigated annually in aggregate
  • Tens of millions of estimated dollars at risk for Medicaid 1115 funding relative to ED process and access to primary care

Moving forward, the ED could use the following proposed metrics to measure success with Type 2 diabetes mellitus patients:
  • Number of patients initially diagnosed with Type 2 diabetes mellitus
  • Number of patients started on treatment plan
  • Number of patients transitioned to primary care clinics
  • Number of T2DM patients connected to a clinic who come to the ED for care before and three months after initiation of process
  • Decreased number of patients seen for medication refill

In this value-based purchasing environment, it’s more important than ever to keep the frequent ED visitors from doing what they’re used to doing – going straight to the ED when they don’t need emergency care. Getting out in front of population health by tapping the ED to help these “frequent flyers” formulate a more effective care plan could be the key to proactive, preventive care, less ED gridlock and fewer readmissions.

Nick Zenarosa

Nick Zenarosa, M.D., FACEP, is President of Integrative Emergency Services, an affiliate of EmCare. He currently serves as the System Medical Director of Emergency Services for Baylor Scott & White North Division. He also is Chairman of Emergency Medicine at John Peter Smith Hospital in Fort Worth, where he oversees the emergency department, the clinical decision unit, urgent care emergency department, and the emergency medicine residency program.

Dr. Zenarosa received his medical degree from the University of Illinois at Chicago College of Medicine. He completed an internal medicine residency at Parkland Memorial Hospital in Dallas and an emergency medicine residency at Carolinas Medical Center in Charlotte, N.C., where he was chief resident.



Trauma Designation and the Resulting Bottom-Line Benefits

Posted on Fri, Jan 08, 2016

The Wide-Reaching ROI of Trauma Care

By John Josephs, MD
CEO, EmCare Acute Care Surgery

As CEO of an acute care subsidiary of the nation’s largest physician services company, my primary goal is taking hospitals through trauma designation and recertification. And, despite the fact that I work with many different hospitals of various ages, sizes and situations, I have consistently seen certain positive results stem from the designation.

Achieving trauma center designation or recertification is a complicated process that can seem overwhelming to many hospital administrators. However, completing the processes is well worth the effort. There are both operational and financial benefits outside the trauma department that act as "ripple effect" improvements that stem directly from trauma service implementation.

Trauma surgery is a natural and important offshoot of the broader realm of acute care surgery (sometimes referred to as emergency surgery). While acute care surgery is a less recognizable term to those outside of the healthcare industry, trauma designations have become a widely known, quantifiable benchmark that hospitals nationwide use to demonstrate quality of care.

Meaningful financial advantages
Medicare offers disproportionate funding to hospitals with trauma centers. Additionally, the Patient Protection and Affordable Care Act reinstituted the trauma stabilization act, which will unlock government funding for the development of trauma programs. On top of that, as a designated trauma center, hospitals can actually bill and collect for certain activation fees that are paid by both Medicare and private insurance companies. Those fees can be very meaningful, sometimes more than funding the trauma program itself.

The "halo effect"
"The halo effect" is a term that's used to describe the increase of throughput in the emergency department after a trauma program is developed. What we've found, and it's been well documented in the medical literature, is that when a hospital becomes a designated trauma facility, it receives increased traffic from the emergency medical services agencies that already come there. Additionally, the facility also starts receiving traffic from EMS agencies that traditionally went to other facilities. Once emergency medical technicians and paramedics get comfortable with a certain emergency department, they start going there more and more frequently. The emergency medical services provider no longer comes to the trauma-designated hospital just for trauma, they start bringing chest pain patients, stroke patients and patients with a wide array of conditions. Trauma-designated hospitals simply have busier EDs.

The "halo effect" also impacts the remainder of the hospital simply because the ED gets busier — the inpatient beds are filled more quickly and regularly, there are more higher-acuity patients so there are more X-rays, more laboratory tests and more patients who need the rehab facilities. The general surgery referrals get busier, the orthopedic referrals grow. The volume in the operating rooms tends to grow as well.

A built-in process improvement program
Another key reason for wanting to become trauma-designated is that the trauma program itself can serve as a process improvement program. Trauma designation has been shown to raise the bar throughout a hospital. On the back end of the trauma verification process, I have had many hospital administrators tell me that their hospital just performs better after receiving trauma designation.

Improved surgeon satisfaction
Acute-care surgery programs usually require an on call surgeon for trauma. That surgeon can also be on call for the emergency general surgery. In many cases, this allows practicing general surgeons to take call only if they want to, which makes that hospital the desired location in the community for surgeons to bring their patients. Sometimes surgeons view call as a burden. If a hospital can take call service off the table for the other practicing surgeons, many times that hospital becomes the preferred location for their practice. Not being on call can allow surgeons to run a much more efficient elective general surgery practice. These surgeons also appreciate knowing that the trauma-designated hospital will have a surgeon dedicated to seeing those trauma patients in a timely fashion.

A trauma surgeon taking the general surgery call can also see patients sooner in the emergency department, get them out of the emergency department and on the OR schedule at a time when there's a gap in the schedule. It decreases the after-hours burden of cases and improves the efficiency of utilization of the personnel that hospitals are already paying for during the day.

These benefits for general surgeons and sub-specialists also tend to be duplicated with primary care physicians. When PCPs are aware of the trauma designation and the enhanced surgical coverage and resultant process improvement that comes from trauma designation, they increase their referrals to that location.

Enhanced surgeon recruiting
Allowing general surgeons to avoid being on call can also be a great recruiting advantage. Hospitals often struggle to recruit surgical sub-specialists because being on the medical staff usually means spending time on call. If they know that all the general surgery calls are already taken, or they don't have to participate, it allows the hospital to better recruit subspecialty surgeons.

Additional prestige
Trauma is the first Center of Excellence Designation. It's verified by the American College of Surgeons and can go a long way towards elevating the reputation of a hospital. Each level of trauma designation comes with an implied level of capability. The most prestigious trauma centers in the country are American College of Surgeon verified Level 1 trauma centers. Typically Level 1 trauma centers are major teaching institutions, facilities affiliated with large universities and medical schools. So the idea of taking a community hospital and making it a Level 1 trauma center just conveys that same level of stature within the community and within the trauma region. It can also serve as a beneficial marketing tool.

Improved overall service
Perhaps the most important reason for a hospital to become trauma-designated is it allows that hospital to better serve its community. The mission of every hospital is to provide comprehensive care to the people in its community. Offering trauma care is an added service for the area the hospital serves.

Patients who arrive at a hospital in need of trauma surgery are treated by a surgeon who is on-site and dedicated to that hospital. That surgeon can help speed the patient through their course of care so that the patient gets seen sooner, evaluated sooner and operated on sooner, if surgery is needed. And that means that they're going to recover sooner. Patient satisfaction scores tend to go up when patients are treated quickly.

The Results
I have seen hospitals that were struggling prior to trauma designation — newer facilities in a saturated area or older hospitals unsuccessfully competing with shiny new high-tech sites — go on to become the most robust, well-regarded facilities in their communities. Trauma designation allows challenged hospitals to build strong, positive reputations of quality that can help recapture patients. Becoming a trauma facility truly can help breathe new life into a hospital.


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