CMS recently announced the Emergency Triage, Treat, and Transport (ET3) model. As a voluntary, five-year payment it provides greater flexibility to ambulance care teams to address emergency health care needs of Medicare Fee-for-Service (FFS) beneficiaries following a 911 call.

Under the ET3 model, CMS will pay participating ambulance suppliers and providers to:

  1. transport an individual to a hospital emergency department (ED) or other destination covered under the regulations,
  2. transport to an alternative destination partner (such as a primary care doctor’s office or an urgent care clinic), or
  3. provide treatment in place with a qualified health care partner, either on the scene or connected using telehealth.

The model will allow beneficiaries to access the most appropriate emergency services at the right time and place. 205 ambulance providers and suppliers have been selected to participate in its new payment model

Case Study: Integrated Community Partners Coupled With A Paramedic Program Redefines In-Home Interventions  

TANDEM365 is a complex medical case management program coupled with a robust community paramedicine program that offers rapid response and in-home intervention capabilities. Blending population health management with community paramedicine, the goal of TANDEM365 is to connect all providers across the healthcare continuum to effectively coordinate care and prevent gaps.

Tandem365’s Vision

To become the new health architecture by:

  • empowering the self-management of preventative health.
  • helping those who have few options for better health.
  • collaborating resources to reduce the costs of care.
  • organizing the complexities of healthcare for each individual.

How TANDEM365 Got Started

TANDEM365 ownership consists of four retirement communities and an ambulance company that when working together created a model which cares for individuals in advanced stages of illness. The primary focus is serving older adults with medically and/or behaviorally complex illnesses. They are identified as super utilizers of the health system and many are affected by social determinants of health. These individuals are highly affected by the fragmented health delivery system in our country.

One of the most amazing things that has been accomplished, outside of developing the model, is to bring four competitors in the community together to create a new solution for at risk individuals. Four of the owners are very successful in providing retirement community services and together serve over 10,000 individuals across the state of Michigan. The services include independent and assisted living communities, skilled nursing, memory care, home health, hospice, private duty, and two of the owners run very successful PACE (Programs for All-Inclusive Care) programs. We utilized the experts from PACE to design a similar concept but avoided restrictions attached to PACE programs. With eyes wide open, each organization entered into a business agreement that would most definitely impact many of their own service offerings and encourage and support the concept of aging in place.

Beginning in 2013, a team of individuals, representing the owner organizations, participated in many months of discussion and mapping of the issues within a fragmented healthcare system. An imaginary older adult named “Henry” was created and placed in every scenario in which an older adult would fail. He depicted many of the older adults that we all know today. Henry lived alone, family members were out of town, he could no longer drive, he missed physician appointments, mismanaged medications, experienced repeat emergency department (ED) visits and preventable hospitalizations, and most of all remained isolated and unaware of resources that could potentially assist him.

There are several key components of the program that have assisted TANDEM365 in achieving positive outcomes. During determining Henry’s success, the idea of community paramedicine was considered. Not much was known about community paramedicine in 2013, but what was known was the skillset and availability of EMS. How would paramedics fit within the interdisciplinary team and how could they be deployed? A large provider of EMS services was invited to our mapping sessions and the answer became clear. An integrated care model utilizing paramedics would provide the best outcomes. Consequently, the State of Michigan was requesting proposals to be submitted for agencies interested in exploring community paramedicine. A proposal was submitted outlining the program and approval was granted. Under this study a paramedic could provide interventions in the home setting and if effective at stabilizing the patient, collaborate with TANDEM365 to keep the patient at home and out of the emergency department.

Community Paramedicine As An Integrated Partner

The “integrated care paramedic” (ICP) is a member of the interdisciplinary team who not only responds to urgent needs 24/7 but also carries a caseload of participants that require case management and consistent follow up. TANDEM365 consists of three tiers in which we identify acuity. The acuity level dictates who oversees the participant’s care plan. ICP’s are utilized once the participant graduates to needing less nursing and social work involvement. Participants may tier up and down throughout their time on service. This method was developed over the first couple of years of our program so that all staff operate at the top of their scope of practice while also ensuring that our resources are deployed effectively.

The ability for an ICP to respond to urgent needs of a participant has successfully reduced emergency room visits and unnecessary hospitalizations. When an ICP can respond to an urgent need within 90 minutes, we avoid transports 85% of the time. An ICP operates with standing protocols approved by each county that we operate. We also incorporate standing orders signed by the participant’s PCP to initiate care in a timelier manner.

TANDEM365 has served over 2000 participants today and continues to grow in expertise as well as numbers. Criteria for eligibility is determined at the payer level through advanced analytics. Assessments are performed by nursing and social work on enrollment where the information is utilized to create a plan of care and a rapid response plan which is used for after-hours interventions. A thorough triage process occurs when participants call the office 24 hours/7 days per week. After hours calls are triaged through the dispatch center by EMS (Emergency Medical Services).

Blending Population Health Management With Paramedicine

The TANDEM365 model of care is unique because it blends population health management with community paramedicine, creating a truly integrated approach to care. Our team consists of registered nurses, social workers, paramedics, medical assistants, TANDEM365 medical director and most importantly, the participants primary care physician. Our goal is to connect all providers across the healthcare continuum to effectively coordinate care and prevent gaps. TANDEM365 does not look to reinvent the wheel of service providers but rather focus on engaging all providers in the plan of care.

In addition to experienced professionals, it was important that additional services/support be provided in order to keep Henry safely at home. It was decided that a personal emergency response device was mandatory for participants. his device would provide notification of falls and provide easy access to the participant needing urgent attention. All alerts come through our dispatch triage center. Participants are identified by their phone number as a member of TANDEM365 and the triage process is individualized.

The participant is often eligible for community provided services but is unaware or unable to apply. Nurses and social workers perform various assessments and determine the need and eligibility for additional services. TANDEM365 may also provide transportation to physician appointments, chore worker and personal care services, monitored medication dispensers/medication management, and telehealth. Services are individualized and, in some instances, unique in nature. For example, a dumpster has been provided and teams organized to assist with severe cases of hoarding. TANDEM365 social workers enjoy the ability to be creative when searching for solutions that improve a living environment or social situation.

Improving quality of life for participants is one measure of success. The first goal after enrollment, is to create a trusting relationship with the individual and all care providers. TANDEM365 understands that meeting participants “where they are” is essential in providing a meaningful impact. Staff are taught to treat the person with respect, dignity, and holistically; understanding that the journey includes unraveling a long history before getting to the root of a situation. Teaching the participant to CALL US FIRST is key. A quick and consistent response builds a trusting relationship that allows us to have in depth discussions, such as, advanced care planning and end of life decisions.

Care coordination between providers is essential in order to stay engaged with care delivery, treatment changes, discharge planning, medication reconciliation, etc. Fragmentation in this area continues to be challenging. Receiving up to date information and sharing information among all providers takes a great deal of time and energy for staff. Some improvement has occurred over the past five years, due to utilization of the state HIE and health system portals, such as EpicCare Link.

Despite the difficulty, TANDEM365 has made communication and care coordination a part of our culture. It must be intentional and timely. Connecting with physicians, case managers, home health agencies, community services providers, pharmacies, discharge planners, skilled nursing staff, personal care workers, family members, is all a part of what our staff must do in order to achieve the best outcome. Staff exhibit the commitment by making in person visits to the hospital, skilled nursing facilities, and accompany participants to physician appointments when necessary. TANDEM365 works with over 700 physicians, several hospital systems, and dozens of nursing/rehab facilities.

Target Population

TANDEM365 manages enrollments from a targeted list based on an algorithm developed by the insurance company. Criteria varies from payer to payer. Most of our participants are in advanced stages of their illness and usually in the last two years of their life. The model has been tested over the past five years and TANDEM365 participants experience <5% ED utilization and <5% hospitalizations month to month. Preliminary outcomes indicate that when utilizing a matched cohort, participants enrolled in TANDEM365 reduce the total cost of care by up to 33%. Referrals to Hospice are increased by >10%.

What’s Next?

Strategic direction is an active topic at TANDEM365. Our partner payers are interested in continued organic growth in their respective footprints. Other discussions include unbundling our services to other healthcare providers that could benefit most from the 24/7 rapid response team. TANDEM365 intends to remain a disruptor in the current healthcare system. Seeking new opportunities by staying fully informed regarding emerging policy and the changing healthcare landscape is key. Whatever the future holds, we intend to be ahead of it; we hope to see you there!

Teresa Toland is the CEO of Tandem365


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