Earlier this year, the Centers for Medicare and Medicaid Services (CMS) announced a new voluntary alternative payment model called Emergency Triage, Treat and Transport or ET3. Under this model, CMS will pay participating Emergency Medical Services (EMS) providers to either:
The ET3 model gives communities the potential to reduce costs from avoidable emergency room transports and to better meet the patient’s needs.
Researchers in New York recently published a study on the potential for EMS to expand a community paramedicine (CP) program to treat very sick and high acuity patients in an extended primary care role. Northwell Health, an integrated delivery system in downstate New York, operates an EMS agency as well as an advanced illness management (AIM) program in Queens, Nassau and Suffolk counties. The system's EMS agency provides CP within the system’s AIM program as well as 911 services to the wider population.
Nearly 30 AIM program physicians, nurse practitioners, registered nurses, medical coordinators and social workers supported home-based primary care to 2,000 homebound patients. A cadre of community paramedics provided mobile integrated health services. They had additional training in geriatrics and home-based primary and palliative care and were equipped with an extensive supply of essential medications and diagnostic tools.
When a participating AIM patient called the program's central number (enrollees were encouraged to call a 10-digit alternative to 911) to report a change in their condition, a registered nurse answered the call and provided nurse triage. When needed, an AIM clinician was contacted and the decision to dispatch community paramedics was made.
All calls were dispatched through the agency's EMS system using the Advanced Medical Priority Dispatch System. If community paramedics were dispatched, their response was overseen by AIM program physicians who were credentialed to provide New York State Online Medical Control by video or teleconferencing.
The AIM physician, using input from the community paramedic on scene and the patient/caregiver's goals of care, determined whether to transport the patient to the emergency department or if in-home intervention was appropriate. If they performed an in-home intervention, a registered nurse followed-up four to six hours after the intervention.
Over a four-year period ending in January 2017:
Important to know: current barriers to this model
- A traditional 911 EMS system is regulated by the U.S. Department of Transportation and has no other option than to transport to an emergency department. There is no reimbursement in that system for an EMS response that does not involve an emergency department transport.
- Local and state regulations on EMS services vary and may not support this type of program.
- AIM programs may not have active partnerships with EMS providers. Current reimbursement models may inhibit close collaboration.
Can your department benefit from ET3?
ET3 is a voluntary, five-year payment model that provides greater flexibility for EMS to address emergency health care needs of Medicare beneficiaries following a 911 call. Interested in participating in ET3? Your department can apply at CMS.gov.
Summary information for this article was provided by the NETC Library. Read the research paper.
Abrashkin, K., Poku, A., Ramjit, A., Washko, J., Zhang, J., Guttenberg, M, Smith, K. (2019). Community paramedics treat high acuity conditions in the home: a prospective observational study. BMJ Supportive and Palliative Care: Epub ahead of print 6/18/19, pp 1-8. https://doi.org/10.1136/bmjspcare-2018-001746.