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Hawaii is creating a community paramedicine program that officials hope will mean fewer ambulance trips to hospitals.
Minor wounds, rashes, gout pain — these are some of the many medical conditions that should be taken seriously, but they may not merit a 911 call or a trip to the emergency room.
Hawaii health officials are considering how to reduce unnecessary ER visits through a community paramedicine program. The revised emergency transport system that could begin next year would allow medical professionals to transfer patients to predesignated destinations, such as urgent care clinics, or even provide complete treatment at the scene.
“Can paramedics go treat people in the field, in the community setting under a physician’s direction, and offer a treatment when they don’t need to go anywhere?” asked James Ireland, a nephrologist and the former director of the Honolulu Emergency Services Department. “Can they do some simple wound cleaning and start the patient on some antibiotics under the guidance of a physician? I think that’s where the huge cost savings can be.”
When Gov. David Ige signed Act 140 into law June 25, it marked the latest development in an effort to make Hawaii’s emergency response system run more smoothly. Starting as early as next year, the law will allow paramedics or other medical professionals to treat some patients at the scene of an emergency — or nonemergency — and navigate them to appropriate care at other clinical sites.
The Hawaii Department of Health has until July 2020 to outline the program’s parameters, such as how many additional people will be hired, what kind of vehicles it will require and how to delegate medical treatment.
It likely won’t provide service 24 hours a day. A 2016 Community Paramedicine Working Group recommended the program involve certified health workers, social workers, doctors and a medical director.
Officials say the program could alleviate pressure on overloaded ERs and save the state money, but it will require careful planning, training, partnership-building and vetting. And no one knows exactly how it will be structured yet, especially without a monetary appropriation from the state.
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A new pilot program through the Oahu Healthcare Partnership is finding success in its first year. The project aims to reduce the number of avoidable emergency room visits by identifying frequent users of the ER and targeting them with interventions. So far, the program has achieved a 62% reduction in ER visits in its first two cohorts of high ER utilizers.
The Oahu Healthcare Partnership is a forum for a broad range of health care industry leaders looking to collaborate on improvements to the state’s health care system. The Chamber of Commerce Hawaii and the University of Hawaii convene the partnership along with several other public partners.
One priority of the Partnership is system integration and promoting an integrated model of care.
With this priority in mind, health care leaders at The Queen’s Medical Center and Kalihi-Palama Health Center (KPHC) partnered together to form the pilot program.
The program formed two separate cohorts of high ER utilizers. The two groups were provided with interventions aimed to engage them in their own care, coordinate their care, and link them to other resources and services.
“One of the weaknesses in the health care sector is the fragmentation of the system,” Dr. Emmanuel Kintu, CEO of Kalihi-Palama Health Center, says. “The system is fragmented. And so what we were trying to do is to see if there is a way in which, through our actions, we could ease or reduce the fragmentation.”
The goals of these services and supports are to assist this population with earlier and more efficient access to care, and to avoid the costs of emergency room care.
With access to these support, the first cohort, consisting of 17 individuals, reduced their ER visits from 145 to 55. The 18-person second cohort reduced their ER visits from 88 to 25.
Look forward, Kintu says several additional cohorts have been started, and Queens is now spreading this to other providers.
“It’s no longer a pilot for us, it’s the way we do business now,” says Kintu.
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An industry-led pilot program created by the Chamber of Commerce Hawaii and the University of Hawaii has achieved a 62% reduction in emergency room visits in its first year.
The program, which was made successful through its ability to convene public and private stakeholders, was a result of partnership with health care industry leaders at The Queen’s Medical Center and Kalihi-Palama Health Center.
“As a community, we all have a role to play in addressing pressing issues, including homelessness,” said Sherry Menor-McNamara, Chamber of Commerce Hawaii president & CEO. “The outcome has been more industry leaders working together to identify common issues. When we all talk to each other, it’s much more effective.”
The Systems Integration Committee of about 12 industry members brought together health care partners to form its first cohort in 2018, targeting the population that frequents emergency rooms, and drive unnecessary and expensive health care costs.
The first group, Cohort A, included 17 people with a total of 145 visits in the baseline period. For this group, emergency room visits dropped from 145 to 55 — a 62% reduction in visits.
Cohort B was established one month later and included 18 people with a total of 88 emergency room visits in the baseline period. Cohort B’s visits dropped from 88 to 25 — an almost 72% reduction in visits.
Both cohorts took part in interventions that included identification, engagement, motivational interviewing, education, collaboration and care coordination — with the goal being to get the patient to seek and access care in an efficient manner.
“We’re taking care of a need before it becomes a critical need,” explained Dr. Emmanuel Kintu, CEO of Kalihi-Palama Health Center. “We must identify people, identify our resources and identify how to engage with a primary care physician.”
Kintu gave the example of a homeless patient who required three shots of insulin a day and often visited the emergency room for care. By assessing the problem outside of the patient’s physical needs, health providers realized that the woman needed a refrigerator to keep the medication stored, and were able to connect her with a primary care physician who would give her an appropriate level of care.
“We’re looking at the whole person, and some of that is social determinants of health, but another part is getting that quick connection to a primary care physician and identifying avoidable emergency room utilization,” Kintu said.
Menor-McNamara says the long-term goal of the program is to continue addressing these issues collectively, building a talent pipeline for different industries, and offering better care that ultimately leads to health cost savings