STAFF REPORT
Meeting Date: December 6, 2022
To: Honorable Mayor & City Council
From: Gregory Barton, Fire Chief
Sean Stokes, EMS Administrator
Gabriella Yap, Deputy City Manager
Subject: Request from Vice Mayor Gold for an Update on the Nurse Practitioner Program and the City’s Participation in the Emergency Triage, Treat, and Transport (Et3) Program
Attachments: None
INTRODUCTION
Vice Mayor Gold requested an update on the Nurse Practitioner Program (NPP) and the City’s participation in the federal government’s Emergency Triage, Treat and Transport (ET3) pilot program.
DISCUSSION
The Beverly Hills Fire Department (BHFD) introduced the Nurse Practitioner Program (NPP) as a pilot program in January 2019. The NPRU, staffed by a Nurse Practitioner (NP) and Firefighter/Paramedic (FF/PM), responds to patients in the field, whether it be their home, workplace, or out in the community. It has proven to be an alternative to transporting low acuity patients to the emergency department for evaluation and treatment.
The NPP response model has two approaches: ‘reactive’ and ‘proactive’. Responding to Emergency Medical Service (EMS) requests represents the ‘reactive’ response model.
As an alternative to transporting such call types to the Emergency Department for evaluation and treatment, Nurse Practitioner Response Unit (NPRU), staffed by a Nurse Practitioner and Firefighter Paramedic, can come to the patient in the field, whether it be Meeting Date: December 6, 2022
their home, workplace, or out in the community. The NPRU contains capabilities similar to an Urgent Care:
• Performing simple lab testing (e.g. testing blood and urine for infection) • Performing simple procedures (e.g. laceration repair, foreign body removal, abscess debridement)
• Administering initial doses of select medications and providing prescriptions (e.g. antibiotics, anti-inflammatories, antipyretics) Additionally, the NPRU is able to contact and collaborate with a patient’s private provider to arrange for follow up treatment.
The other response model, the ‘proactive’ approach, focuses on following up on patients, either seen in the past or referred by BHFD personnel. The spirit of the proactive approach is preventative. BHFD seeks to visit one’s home, providing a comprehensive assessment, identifying current and or potential future medical ailments, and identifying health risks before one reaches the emergent medical state in which 911 is called. The team communicates with the patient’s primary care provider, specialists, ancillary medical providers, and medical networks for follow-up treatment. The NPRU’s primary focus are the City’s chronically ill and vulnerable, of which healthcare resources provided to them have since waned, no family member to provide care, or the residents themselves lack the ability to abide by their prescribed medical appointments and regimen. This “next level” care by the NPRU far exceeds what is typically offered in cities.
At the December 7, 2019, City Council meeting, official direction was given to expand NPRU’s coverage to seven days a week, from 8 a.m. to 6 p.m. Currently, there are 5 NP consultants and each has an agreement with the City. They are paired with one Firefighter/Paramedic to treat patients in the field. The NPRU operates under the medical supervision of the City’s contracted Medical Director who is licensed to practice in the state.
The NPRU continues to integrate pre-hospital treatment with primary care providers, hospital case managers, social workers, County healthcare workers, and other community healthcare partners. Hospital providers and personnel are, now, communicating with the NPRU regarding patients who are soon-to-be or have been discharged. This serves as a critical period, between discharge and patient follow-up with their primary care provider, for the patient. It is at this stage where hospitals and the NPRU collaborate to make sure patients do not regress during hospital discharge and re-evaluation with their primary care provider.
Program Outcomes
Over the last three years, the NPP has demonstrated success in key metrics. Said metrics include, but are not limited to:
• Over 1,000 individual patient encounters
• Deferral of patients from Emergency Department over-utilization • In-home health management
o Minimizing patients from health regression such that they require emergent (911) resources
• Access to social services such that social determinants of health are mitigated and health regression is minimized
Meeting Date: December 6, 2022
• Integration with partnering providers:
o local hospital case managers, social workers, discharge planners, providers and medical groups
• Integration with partnering governmental entities
o Los Angeles County EMS Agency, Los County Adult Protective Services, and Los Angeles County Department of Public Health
o Progression in participation with Centers for Medicare and Medicaid Services’ (CMS) Emergency Triage Treatment and Transfer (ET3) Model
Centers for Medicare & Medicaid Services’ (CMS) Emergency Triage, Treat and Transport (ET3) Program
The NPRU is participating in CMS’ ET3 Model and Federal, State, and Local initiatives specific to advanced providers in the pre hospital sector. The City of Beverly Hills Fire Department was selected as one of 206 agencies to be included in the ET3 pilot. To date, approximately 170 agencies remain in the program, as some agencies have surrendered their participant standing due to being unable to meet the Pilot requirements.
Historically, EMS systems were only reimbursed for the services they provided if the patient was transported to the emergency department (ED), not for patients treated in place nor for patients transported to non-ED facilities. The Centers for Medicare & Medicaid Services, or CMS, recognized these challenges along with the high number of low acuity/non-emergency visits to the ED burden the US health care system both financially and operationally. This led to the development of CMS’ Emergency Triage, Treat and Transport (ET3) model which was launched in January 2021 to encourage participating EMS agencies to partner with qualified health professionals (QHP) to provide patients with the most appropriate treatment at the right time and place. This includes evaluating whether patients need to be transported to the ED or an alternative care destination, like an urgent care, or if they can receive treatment in place. Under the program, CMS will continue to pay for the transport of patients to a hospital’s ED and will also pay for new options to transport patients to alternative care destinations or provide treatment in place.
With CMS willing to pay for new options to transport patients to alternative care destinations or provide treatment in place, the City is at the front of the pack in terms of reimagining service delivery for patients and also benefits to the City and community.
Creating a more robust level response in terms of medical knowledge and building a system of partnership with seamless handoffs creates benefits such as:
• Enabling Firefighters to have less “wall” time if they can handoff low acuity patients to the NPRU, making them readily available to answer emergent calls • More positive health outcomes for residents with metrics showing the potential for fewer rekindles
• Providing each patient with the opportunity to access definitive care The advent of this model provides significant potential for EMS reimbursements for these “next level” services already being provided through the NPRU. The ET3 program will provide reimbursement for treatment to QHPs who provide care to 9-1-1 calls through:
Meeting Date: December 6, 2022
• Standard Intervention – Treating patients in the field in lieu of Ambulance transportation to the emergency department
• Alternative Care Destination Transportation – referring an alternative care destination (e.g. urgent care, rehabilitation facility, or primary care facility) for treatment
Moving Forward
BHFD’s NP Program is continually evolving to create and maintain a comprehensive and integrated service in which patients can ‘Age in Place’ at home, have health managed out of hospital in concert with private medical providers and health networks, and promote an enhanced wellbeing. Steps to accomplish such goals are centered on coordinated partnerships and continual communication with all those involved in the patients care, notably:
• Family
• Primary care providers
• Consultants
• Hospital internists
• Case managers and discharge planners
• Adjunct health providers
• Social services (Focusing on seniors, homeless and those with psychiatric needs) • City and County resources
• Fire and EMS resources
BHFD is working to collate patient encounter data, notably, Paramedic (911) utilization, referrals to the Emergency Department, and Hospital Admission with correlating admission length of stay. It is the goal of said collation to show value as it relates to patient outcomes, program evolution, and financial benefit.
Next Steps
In order for the City to be able to potentially obtain reimbursement from Medicare and Medicaid, the City is required to fill out an application to obtain a Clinical Supplier National Provider Identifier (NPI) in order to bill for services. It is expected that issuance of a Clinical Supplier NPI number will take three to six months.
While the NPI number is being issued, the Fire Department will explore how to bill Medicare and Medicaid for services rendered. The City will work with Wittman Enterprises LLC, the vendor who provides billing for ambulance services to the City and the majority of cities in the County, to develop codes for reimbursement of various treatments provided in the field and determine what is reimbursable.
Many agencies have been unable to continue the program due to funding constraints.
Beverly Hills is one of the most developed NPRUs and is close to achieving the goal of reimagining the provision of patient care through their ability to bring nursing level care to patients in the field and in their homes, thereby reducing the burden on the hospital system. If successful in obtaining reimbursement from Medicare and Medicaid, the City will have paved a path forward for thousands of other agencies to be able to do the same.
Meeting Date: December 6, 2022
FISCAL IMPACT
There is currently no fiscal impact related to this item. However, the issuance of an NPI number to the City could enable the NPRU to recoup some of the costs for services provided in the field.
RECOMMENDATION
This report is provided as an update to the City Council on the NP Program and ET3 program and Council can provide direction as needed.
Gregory Barton,
Fire Chief
Approved By