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HomeMy WebLinkAboutevolving-patient-and-community-needs-swot-finalEvolving Patient and Community Needs Work Group SWOT Analysis of Focus Areas ET3: Strengths - Adapted well to COVID in ALCO with Treat and Refer with Telehelp use. - Components being used already successfully. - Physicians interested in a collaborative approach to ET3 in patient centered manner. - Local model (Contra Costa) to learn from - Recent legislation supports this. - CAT and Rapid Response Already in the system up and running similar to ET3. Weaknesses - Clinic offload times and establishing relationships with them (ie. Burbank). - Undefined issues – does transport have to be an ambulance? Opportunities - Partnership to create a patient centered system. - Increased efficiency - Several clinics already in place - Recent legislation (AB1544) that includes alternative destinations. - Bring in CalChiefs for a better understanding. - Different funding streams - The need to take a proactive stance in Medicare reimbursement. Threats - Program needs to be defined to ensure patient focus and care. - Electronic PCR form that is not an adaptable platform – multiple alternatives available - Always needs a physician on-call (as written right now). - Potential additional workload. - Funding challenges. Community Paramedicine: Strengths - Highly customizable for the region/community. - Medics are in the field and get to observe not just patient, but patient’s environment. - Community medics are hands on in the field and know community health needs very well (on-going relationships are formed with patients and healthcare providers). - Gets the right patient to the right place, sickest patients to acute care, minor patients in non-acute care. Weaknesses - Funding needs Medical/Medicare. - Community medics require additional training/CE to optimize their impact on community health. - Would require community education. Opportunities - build relationships with other resources/ agencies for continuation of care. - There is capacity within FRALs units if there is the ability to divert. - Ability to create a program that is a win-win within the healthcare system. - Possibility to work in conjunction with the Assess and Refer program. - Options – paramedic-initiated refusal, Telemedicine, Alternate Transport Threats - For reimbursement, agencies need to follow what Medicare does to ensure funding. - Administrators worry about decreased census, possible opposition from hospitals, nurses, Doctors, etc. - Lack of established alternative transport and destinations. Alternate Destinations: Strengths - Gets patient to right destination for the right treatment – Patient focused. Weaknesses - Current assembly bill only covers two alternate destinations – recovery center and behavioral health center. This would need to expand. - Need to work with pre-hospital lobbyists to gain legislative approval for alternate destinations. - Difficult to make the program rely on the medics getting receiving clinic approval for transport, should establish criteria that allows transport to alternate destinations (ie. Urgent Care, clinics, etc.) - Possible long(er) offload times - Perception of lesser level of care if they do not go to an ED. Opportunities - Create alternatives to use of ambulance, other options, app based rides. - Could be a non-911 system unit doing assessment and/or transport. - Create a minimum receiving facility standard. - Stand-up clinics to support this system? Demand based pop-up clinic. - Paramedics with Community Paramedic training could become true experts. - 911 Paramedic refers to CP, CP counsels on options, system does not necessarily provide the transport, but access to alternatives may exist. - Staff a clinic with ambulance personnel who can assist with patient care during peak times and transport if a patient’s condition changes. - Insurance companies as benefactors of this can partner on implementation/legislative initiatives needed. - Higher level of care in field response with specialized care. - Set expectations with alternate destinations regarding offload times Threats - Starts to look more like routine healthcare than 911 system – is this the right path? - Community learns of new access point to system creating a new demand. Dispatch Direct/ Redirect Strengths - Prioritizes care to those who need it most. - Access point to other options - Gets the right level of care provider and equipment to the scene. Weaknesses - May mis-triage some calls - Currently some calls that do not translate well between Priority 1-4 (ACRECC) and A-E (Oakland). Efficacy data may be available and is needed. - Telemedicine is not a substitution for in person contact (including the information garnered by observing scene conditions). - Potential loss of information in transferring calls Opportunities - Telemedicine direct from dispatch center - FRALS unit may respond Code 2, be divertible or not at all. - Berkeley not doing MPDS, interested in connecting to other services, - Further regionalize communications centers to prevent loss of important information. - Create a third-tier center to handle non fire/ambulance calls or expand existing centers to accommodate. Nurse in the center. Third transfer of a 911 call does, however, raise concerns. - Like Contra Costa, can place a health care provider (RN) in the dispatch center. - Alternate response unit for lower acuity calls - Create a different EMS Call prioritization, or one with greater options in lower acuity situations. Threats - What size dispatch center is too big/too small, too many agencies, too few. Pros and cons with all - May need to transfer non-urgent calls to a different center creating in many cases a third or even fourth call transfer. - Some dispatch centers have physical limitations and challenges with co-location of additional call screeners. 5150 Patients Strengths - CAT Team – here has an EMT and a Social Worker. Started 7/20. EMS does an in-service, CIT, 69 hours of mental health training. Pilot modeled to have 12 teams. 5 staffed now (staffing challenges). Going to 9 teams on 2/14. CAT Team only 4-6% transported to JGPH, ables to translate to other locations, similar data with ERS – 11-12%. - Approx. 20,000 presentations to JGPH. 0.5% turn arounds to ER – very low - Under CATT, patients are called clients. Can go to shelters, sobering centers, stay home with follow-up. - Existing Mobile crisis team with 2 social workers is in-service right now. - Existing Mobile eval team staffed with social worker and police officer is in-service right now. - Existing programs like Familiar Faces, Bonita House, iHOD and other programs Weaknesses - Wall times at receiving facilities JGPH. - Medical assessments needed which often tethers the patient to a 911 medic under current system. - 5150 transfers from JGPH create negative system impact. - Lack of staffing and funds. - Use of ambulances – are we just doing it because we are used to it? JGPH being used as a shelter. - CAT would work better if there were after hours alternate receiving facilities and if it served the entire Alameda County – 1 or more units per city. - There is no psych shelter for sub-acute available to EMS. Opportunities - To define the patient – need for medical component to be evaluated. Need to decriminalize behavioral health. Words discussed include patient and client. - Law Enforcement gets taxed by a 5150 call. Time on call impacts services to the citizens. Most times this is neither a Law Enforcement problem nor an EMS specific problem. And yet the lack of a viable system impacts each service significantly. It is a Behavioral Health issue as they are the experts on caring for these clients. We need to work together to create the solution for the behavioral health client. - Non-EMS or single service transport options under appropriate conditions ie Uber type transport - San Mateo Co. model where there are mental health paramedics that can write 5150 holds. - Third service or through CAT expansion – dedicated transport in alternate type unit ie. SUV – ambulance still would transport combative/restrained patients. - Behavioral Health Telemedicine - Use of Measure C money an option. - Access available funds from the County or other source and have Behavioral Health contract with someone to handle 5150 transports. – (different process for current) - Create an ability for field providers to access patient records to get a better picture of the client’s overall situation. - Significant need to allow transport of behavioral health clients to alternate facilities. Threats - Staffing and funds - CAT Program is grant funded, which may limit sustainability. - JGPH can be a system choke point. - Having access to an alternate destination is critical for meaningful change. This would require a change to Title 22 as understood by the workgroup. Specialty Care and Populations – Overview For the purposes of our discussion, defined as: domestic violence, autism, elderly, hearing and sight impaired, developmental challenges, bariatrics, patients attached to medical technology, homeless, hospice, chronically ill, system abusers, behavioral issues, dementia, Alzheimer’s, neonatal. Strengths - System currently has some ability to link to services that already exist, but the people may not have already been able to access. Field providers may deepen this role. - EMS System can sometimes be the only advocate for some populations. - EMS System sees people in their home environments. Weaknesses - EMS System often does not satisfy the need that they accessed the system for - Currently, we are poor at recognition and resourcing. Needs specialized training for success. - Lack of a plan for alternative transportation. - System presently does not link field providers with all the available resources. Opportunities - Bridge between patient and services with properly trained provider/case manager role. Accessing these resources can solve some of the problems in a long-term/sustainable manner. - Train providers on how to serve as this role. - Reduce stress on the system through preventative actions or getting them to the right place. - Coordinate data/patients on a regional approach –patients will often cross borders ie. EDIE – Sutter emergency department patient information exchange – opportunity to create this for EMS. - High system utilizers often are bigger than EMS (lift assist, law enforcement, other resources) – is there a way to thread system use? - Education and sharing of resources present day. - Create a system to link field-based responders with existing resources with multiple access points including web, app and phone - These groups require specialty knowledge and involve use of infrequent skills. Instead of one annual P&P update, focus ALCO paramedics training monthly to address specialty populations/needs. Threats - Lack of follow through, system really may not have depth to meet all needs, patient may not handle their role in follow-up. - EMS filling a gap that is not otherwise filled (or non-EMS units accessed through the system) - Getting lost in a new system that we have created (“Handoff”) - Depth in system to ensure services are delivered. - Service levels required may not exist. Referral may not always be a solution. Special Needs Populations Notes by Sub-Group - Hearing and sight impaired o Training exists but could be standardized amongst all providers. o Perhaps something in the protocol manual o Limited sign language resources, braille forms o Is there a facetime interpreter out there? - Work with the schools for the Deaf and blind – likely have resources. - Agencies that have language differentials include ASL. - People on the spectrum o Some training, but on a spectrum as well – Is improving. o Some resources in our group and at EMS with firsthand experience, community resources, o Innate abilities and use of other resources on the scene. o Partner with agencies doing this work. o What works with these patients may not work with others. o Protective families - Bariatric Patients o Bariatric Unit – exists but not staffed, and not everyone cross-trained. o Other agencies may have bariatric units. o Most ambulances can now transport up to 750lbs. o Stryker with bat wings helps but doesn’t capture all patients’ parts. o Ferno may be a better alternative. Torso width a big issue o Need appears to be decreasing. o Challenges of getting patient to the gurney. o Would need more units ideally staged throughout the County. o Hospital coordination is a challenge with these patients.  Supervisor/BC often ends up at hospital to help. o Most (maybe all) hospitals have “Lift Teams” that should be called out for patient transfers o Even hospitals not equipped, may have to order a bed from their vendor. o There may be benefit to identify bariatric receiving hospitals - Victims of Violence (domestic, child abuse) and Sex Trafficking o Annual training on recognition, treatment, and appropriate notifications needed. - Neonatal o Infrequent skill, and potentially intimidating to care providers that should be addressed through training. o Lack of neonatal official destination protocol despite 3 receiving facilities equipped for this. - Also discussed geriatric, hospice, Alzheimer’s, dementia, those reliant on medical devices Exclusive Operating Area/Next RFP Strengths - Maintaining the EOA provides for single point of contact, significant decrease in complexity for dispatching, continuity of service. Weaknesses - JPA Model – considered by the group to be overly complex with minimal benefit. - Open system – considered by the group to be ineffective and potentially risky. - Third Public Service – considered by the group to be overly costly. - EOA – a job action or provider fiscal stability can threaten service. Opportunities - Our group believes that an EOA with a single bidder is the proper model to continue with. We did not achieve consensus on whether this was through an alliance model or a single contractor (likely private) model. o Alliance  Potential for additional revenue streams o Single Contractor  One agency to deal with - Create an RFP that allows for trial, error and trying again at improving the EMS system – build a learning system that can evolve within the term of the contract. - Create a system that supports a wider look at field care as discussed in all our other focus areas. - Enhance dispatch up to support proposals in new system. Threats - Alliance model revenue not returned to EMS system. - No models under consideration necessarily address job satisfaction and/or employee turnover. Discussion on whether it best to accept this as it may not be changeable.