Expanding East Oakland Access to Primary Care for 911/Emergency Medical Service
In partnership with Alameda County Health Care Services Agency (HCSA), Roots is proposing an innovative pilot aimed at expanding its care model to strengthen the safety net for a cohort of 911/EMS super users, and evaluating its effectiveness as a health care service delivery model for patients who are high need, uninsured, and/or chronically ill. While each patient comes with his or her own set of individual care needs, the goals are similar: improve individual and community health, reduce unnecessary 911 utilization, hospitalizations and ED visits, and cut the economic and social cost of chronic illness.
Core Whole Healthcare Area: Care
Program:
Themes, Keywords & Tags: EMS
Expanding East Oakland Access to Primary Care for 911/Emergency Medical Service
The aim of this project is to both evaluate and address the most pressing concerns affecting 911/EMS super users in East Oakland. Guided by data from HCSA and Alameda County EMS to identify eligible individuals, Roots will expand its care model to fill the much needed primary care and chronic disease management gap, with the goals of improving health outcomes among a specific medically vulnerable population, and reducing health care costs by piloting an intervention aimed at preventing unnecessary ambulance trips, ED visits and hospitalizations. To enliven these goals, the Roots Care Team will provide a mix of primary care services and community-based prevention and social service support which will be informed by an evaluation of the underlying reasons for EMS/ED misuse.
Core Whole Healthcare Area: Care
Program:
Themes, Keywords & Tags: EMS
Expanding East Oakland Access to Primary Care for 911/Emergency Medical Service
Program Goals
- Implement a risk-stratification tool to assess super users’ underlying reasons for and ongoing likelihood of 911/EMS utilization
- Determine whether a home-based model of expanded primary care access can reduce the emergency medical care utilization for frequent users of 911/EMS, thereby reducing hospital readmissions, unnecessary health care expenditures, 911 call volume, and expanding ED capacity
- Increase access to/proper utilization of existing primary care resources, and improve health outcomes for at-risk and the medically underserved
- Expand the outreach and public education efforts of Roots Community Health Center in East Oakland
Core Whole Healthcare Area: Care
Program:
Themes, Keywords & Tags: EMS
Expanding East Oakland Access to Primary Care for 911/Emergency Medical Service
Members of the Roots Care Team will provide in-home and telephone-based medical support for a cohort of 15 patients who frequently utilize 911/EMS as their primary source of health care. Collaboration with EMS: In partnership with Alameda County HCSA/EMS East Oakland (Fire Station #20) Roots will develop a criteria and process for classifying patients according to their 911/ED use. Patient utilization will be monitored throughout the pilot project period. Periodic case conferences between Roots and EMS personnel will be conducted to facilitate the monitoring of the cohort’s utilization and sharing of pertinent information as appropriate. Enrollment: Patients identified via internal analysis and referral as eligible for the program will receive a phone call followed by a home visit from the Roots Care Team. The staff person(s) will explain the benefits of the program to the patient, family members, and caregivers as appropriate. Interested patients will provide their consent to participate in the program and authorize the release of their medical records as appropriate.
Core Whole Healthcare Area: Care
Program:
Themes, Keywords & Tags: EMS
Expanding East Oakland Access to Primary Care for 911/Emergency Medical Service
Roots care model offers a unique opportunity to reduce 911 and emergency room contact while improving health outcomes for medically underserved patients. The goal of this model is to demonstrate that if people are given alternatives, they will stop going to the ER for non-emergency reasons.
Core Whole Healthcare Area: Care
Program:
Themes, Keywords & Tags: EMS
Expanding East Oakland Access to Primary Care for 911/Emergency Medical Service
This pilot will answer the following questions:
- Will a coordinated, home-based care intervention decrease EMS and Emergency Department use among identified “super users” in East Oakland? Measures of effectiveness will include pre- and post-implementation comparisons of health outcomes and 911 calls/EMS utilization among the patient cohort, along with estimates of the cost savings generated and ED capacity freed up as a result of strengthening care and reducing EMS utilization. Periodic data on cost and program effectiveness will help evaluate the impact of this innovative intervention on individual health and health care costs.
- Does Roots’ risk stratification tool inform strategies and interventions that reduce 911/EMS utilization among “super users”? 911/EMS utilization among the patient cohort will be compared against results of the risk stratification tool for each patient to determine whether the tool is predictive. Utilization patterns and their correlation to the tool among the patient cohort will be utilized to draw conclusions about the utility of such a tool beyond the pilot.
- Does a coordinated, home based care model improve health outcomes in identified 911/EMS “super users”? The Roots Care Team will regularly review EHRs and coordinate with primary care providers as indicated to evaluate the progress of individual patients with respect to their health status. This information will be reported aggregately to ensure HIPPA compliance.
Core Whole Healthcare Area: Care
Program:
Themes, Keywords & Tags: EMS
The Alliance Health Home Pilot
Since our inception, Roots has prioritized unprecedented access to primary care services, particularly at the time of a critical transition. As a result, we have become a reliable and responsive partner to our local hospitals and emergency rooms, accommodating post-Emergency Department (ED) and post-hospital follow-up appointments in a timely manner. In addition, for the past year Roots has provided effective interventions and intensive case management to individuals being released from the emergency department or hospital following a gun-related or gang related injury through a partnership with the City of Oakland and Ceasefire. Our OaklandSTOMP mobile medical unit (see 2 below for greater detail) prevents ED and hospital visits on a daily basis by providing care at the time and place of need, including transportation for specialty appointments, surgery, etc. Our STOMP team works closely with Alameda County Medical Center’s ED and hospital staff to provide wraparound support for our patients and ensure that they receive care in the most appropriate setting. While we continue to work to obtain real-time information regarding patient ED visits and hospitalizations to enhance care coordination, we have begun collecting self-reported data regarding ED/hospital visits upon intake and post-engagement with Roots. While our data remains preliminary, it is clear that upon linking to Roots as the primary care medical home, the overwhelming majority of our patients cease to utilize the emergency department as their source of primary/episodic care. And as they receive support from the care team and build their own skills in self-advocacy, primary care utilization continues to increase while inappropriate ED use diminishes. Our expertise and success in reducing inappropriate utilization for some of our community’s “hardest to reach” positions us well to increase the numbers of this target population into our care and case management model, and to implement formal analysis of utilization data to help inform program design and implementation.
ref. AAH Response_FINAL_2017 The Alliance Health Home Pilot, 2017 – Dan Abrahamson
Core Whole Healthcare Area:
Program: STOMP
Themes, Keywords & Tags: EMS; Emergency Room
The Alliance Health Home Pilot
Since its inception, Roots has served Oakland residents experiencing homelessness and unstable housing. In 2015, in partnership with the Alameda County Department of Public Health’s Healthcare for the Homeless Program, Roots built upon this work to implement the Oakland Street Team Outreach Medical Program (STOMP), a physician-led street outreach healthcare team serving the homeless across Oakland. The goal of Oakland STOMP is to seek and treat the sickest and most vulnerable among Oakland’s homeless population, preventing morbidity, mortality, and avoidable utilization of hospital and emergency systems. In order to accomplish this, the STOMP team has developed recognition and trust among Oakland’s homeless population, interacting with homeless residents in East Oakland, downtown Oakland and West Oakland. The team informs homeless residents about our services, distributes basic needs supplies, and builds rapport and trust as they interact in these communities. Often, multiple interactions with the same individual are required before the individual is trusting enough to avail themselves of medical services. These repeated interactions, and our visibility and stability providing services to Oakland’s homeless residents, position us well to provide expanded outreach services to more homeless residents, including those who may not have medical/clinical needs.
ref. PATH Strategy 8 Narr_FINAL, April 2018 – Dan Abrahamson
Core Whole Healthcare Area:
Program:
Themes, Keywords & Tags: EMS; Homeless; Emergency Systems