Where does the healthcare continuum really begin?

With prevention?

In the home?

With the Primary Care Provider?

In the Emergency Department?

Although an argument can certainly be made for any of the four choices above, I’d like to challenge your opinion and perspective with a different answer…the continuum for many begins with Emergency Medical Services (EMS).

This past year I had the privilege to be included in two standard setting and forward thinking discussion forums-- AHRQ’s 2010 Annual Conference and HCIE Innovators Event as well as Hope Street Group’s Policy 2.0: Using Open Innovation to Reinvent Primary Care Project. Both of these events offered diverse perspectives from diverse participants in academia, corporations and all levels of government and localities who gathered to discuss and make recommendations to improve the health care system. Interestingly, the first responder perspective of EMS was only a footnote in these discussions. I believe that policy makers and leaders within healthcare all too often fail to look outside their sphere of influence and familiarity for answers or more importantly the critical questions. That said, I know this minimalization was not intended or planned, but a result of historical processes and comfort levels.

The numbers…

EMS contributes 15% or 17.25 million patients to the nations 123.8 million annual Emergency Department (ED) visits (CDC, 2008), yet Fire, EMS or Law Enforcement respond to over 240 million 911 calls per year (NENA, 2009). It’s difficult to accurately breakdown the national percentages of 911 call types, but upwards of 60% of EMS calls are generally considered low-acuity or non-emergent. To put this into a local perspective, the City of Tucson AZ with a population of approximately 530,000 (2005) generates approx. 79,000 Fire and EMS 911 calls per year, 84% or ~67,000 of these are medical in nature and 60% of those, ~46,000 require only Basic Life Support (BLS) care (TFD, 2009).

So what does that really mean? It means that the 911 system provides a substantial safety net for the Nation’s healthcare system. While this should come as no surprise, the volume of patients utilizing EMS, Emergency Departments and the 911 system continues to grow. Over 15 years ago, the National Highway Traffic Safety Administration and the Health Resources and Services Administration joined with leaders from the EMS community to put forth an EMS plan that would require significant collaboration with acute care, primary care and public health. This provided one of the earliest, nationwide, use of the scale-up-and spread model and was published as the1996 EMS Agenda for the Future (NHTSA, 1996).

The past…

To implement that vision and professional template, EMS has continued to grow it’s service provision model from one that was historically created for stabilization and transport of the acutely ill and injured; one that was set-up to intervene only when patients needed emergent support; one that operated in relative isolation from other health care and community resources; one that was not involved in the business of ensuring social service follow-up and one that did not have a working knowledge of community health care providers and regional health care organizations (NHTSA, 1996).

The present…

Today, EMS is integrated with other health care providers, public health and public safety agencies to provide community-based healthcare and management. EMS agencies and providers are involved in activities related to prevention education, illness and injury risk, acute illness and injury care, follow-up, treatment of chronic conditions and community health monitoring. This vision is also shared by the Injury Response Division of the National Center for Injury Prevention and Control/Centers for Disease Control and Prevention (NCIPC/CDC) and the American College of Emergency Physicians (ACEP) who have called for a better understanding of roles and collaboration between Public Health and EMS through their Appleseed Project initiative (CDC, 2004).

The reality …

As you can see, EMS has developed into more than a group of fire departments, rescue services and ambulance companies. While providing these additional and collaborative services, EMS remains the public’s emergency medical safety net.  Looking back to those 240 million 911 calls and the 17.25 million EMS-to-ED admissions, it’s clear that a significant amount of health assessment, care and triage occurs outside the hospital walls. In fact, there are no other healthcare providers that see patients in their own home or living environment quite like EMS. The “scene assessment” which is a fundamental EMS skill reveals more information about a person, their living conditions, their health, their support system and their coping mechanisms than any other assessment tool.  How many Primary Care providers, case managers or health plan administrators have this perspective into their own patient’s lives?

From where I sit with over 30 years of experience as an RN in Maternal-Child Health and EMS, I see several important questions that need further discussion and clarification before we can begin to understand how to move forward in improving the healthcare of our Nation.

• How can we better educate individuals to utilize the 911 system for acuity appropriate reasons?
  
• How do we encourage the use of Primary Care practitioners for non-emergent and urgent medical and injury complaints instead of defaulting to the approach of “if this is a medical emergency, please hang up and dial 911?
  
• How do we share the burden of after-hours and weekend low-acuity patient needs?
  
• How do we facilitate better communication and collaboration between EMS, public health, acute and chronic care case management, behavioral health and community services?
  
• How do we move patients calling 911 for non-emergent or non-healthcare reasons into a public or human services system that will better meet their needs?
  

Communication, collaboration, connectivity, consistency and caring are all functions of healthcare, yet as the patient numbers and range of patient complaints increase, we all need to utilize each others skills, knowledge and expertise to meet the needs of our patient population. Reaching out to our colleagues may be the first step toward improvement, integration and understanding of our healthcare system.

http://www.911dispatch.com/info/fact_figures.html

http://www.cdc.gov/nchs/data/ahcd/nhamcs_emergency/nhamcsed2008.pdf

http://cms3.tucsonaz.gov/sites/default/files/imported/data/demographic/eecpop00_05.pdf

http://www.nena.org/911-statistics

http://www.cdc.gov/injury/publications/index.html

http://www.nremt.org/nremt/about/emsAgendaFuture.asp

http://www.tucsonaz.gov/fire/AnnualReport.pdf

A prohibition was lifted on human dissection in 3^rd century Greece, under one condition, that the anatomists not involve themselves with the corpse’s soul. Body and soul at the time were considered separate entities, thus, the medical model was born. The focus on the symptom or body part from a purely physical and biological aspect of disease is still in place and has served us well until the recent explosion in chronic illness. The toll that chronic illness places on our larger macro economy and our collective quality of life is enormous and eating into our national prosperity.

As we look for ways to bend the health care inflation curve, it is fair to say, by every quality and cost measure, that what we are doing in traditional health care is not working. The chronic illness tsunami is upon us, diabetes, stroke, and heart disease with deeply disturbing upticks among ethnic and racial groups. What is really making us sick is how we live our lives everyday- what we eat, how we care for our bodies, how we engage in nourishing relationships [with others, with our vocation]. No amount of pharmaceuticals or “patient education” will reverse the chronicity epidemic unless and until we get smarter about sparking motivation.  So what is the back-story to motivation and how do we leverage the spark into healthy  action?

A  truth that is rarely said out loud is that most chronic illnesses are entirely reversible.  Much of what we do in our delivery system is prescribe pharmaceuticals and information to patients, regardless of whether they have a knowledge deficit or are ready to receive information. We have a health care workforce that rarely tries to reverse diseases but rather jump directly to “managing” them.

Traditional health care providers have a narrow and limited skill set in helping people achieve sustained and dramatic lifestyle change.  Pharmaceuticals and knowledge cannot be the only way---patients need guidance through a change process, including emancipatory self-knowledge to realize one’s own potential or latent ability, not a yielding to our laziest or weakest selves.  

We assume that motivation is a fixed state and that some patients are inherently unmotivated to change.  Nonadherence, non-compliance and addictive personality are highly negative terms that exemplify this assumption that all patients are ready to change and present to us  in a highly motivated state.   People need to desire change before anything can begin.  Without that, providing information often leads to resistance.

Many practitioners are not trained nor do they practice the very basic evidence-based motivational interviewing techniques grounded in the Transtheoretical Change Model.  Many do not know how to elicit intrinsic motivation, the jet-fuel for change, or to build up individual competency for change.  We know that people enter a predictable, sequenced cycle of change and that interventions tailored to their state of readiness for change is a far more nuanced, effective approach.    We will never promote behavior change in an environment in which patients feel judged, diminished and/or are given advice which seems impossible to carry out.   We often confuse motivation with agreement to engage in health benefiting behaviors.

Uncovering, Igniting and Sustaining Motivation

More exciting are techniques available to us from the coaching world that are grounded in several principles that must be adopted by the larger health care workforce.  It expunges “non-compliant” and “non-adherence” from the vocabulary and starts with the notion that all people have some desire to be healthy and that identifying and amplifying strengths rather than spending time on the weakness is the key towards lasting change.   Coaching principles are grounded in the knowledge that motivation is a state of readiness or eagerness to change and that this state can be influenced when we remember that:

• People must be put in charge of their own change process and can solve their own problems.
  
  
• No one can make another do what s/he does not want to.
  
  
• When there is an atmosphere of equality and respect, people will grow.
  
  
• When people have what they need, they will engage in positive activity.
  
  
• Individual strengths are to be built up rather than placing focus on problems or weakness (e.g.  If a person has been successful in the business realm, those strengths of persistence and “closing the deal” can be brought to the fore in the wellness and health arena)
  
  
• Success breads success. Small successes lead to larger and more sustained success.   Never let a patient leave the office with a goal unless they have a 70% or higher self efficacy rating (chance they say they will do it).
  
  
• Radical acceptance and unconditional positive regard enables individuals to get unstuck, learn, and grow.
  
  
• Growth and change are necessarily imperfect,  falls /slips are seen as buoyancy
  
  
• The capacity to change is enhanced by positivism, self efficacy and resilience.
  
  

Coaching techniques that are particularly applicable to chronic disease include appreciative inquiry. This technique necessitates that a conversation centers on what the patient truly wants in their life.  This leads to patient-directed goals and can often set off a cascade of change – when we get patients to say out loud what they want in great detail, the patient comes up with their own goals. The coach is there to mine strengths and identify and overcome obstacles. So let’s stop telling people what to do, and start asking them what they want.

Dr. Eileen O’Grady is a Certified Nurse Practitioner and Wellness Coach; she lives just outside of Washington DC. where she tries very hard to live every day in balance.  www.eileenogrady.net