ET3 Provides Quality Care, Closer to Home

Low-Acuity 911 Transports Create Challenges for Patients, Communities and Clinicians

While the vast majority of individuals who call 911 have emergent medical issues, not every patient requires transport to the Emergency Department (ED). Transporting patients with non-emergent medical needs to the ED can have negative consequences for patients and the community.

Low-acuity transports tie up ambulance resources. In rural communities in particular, where there are often only one or two ambulances, 911 patients may have to wait much longer for emergency services personnel, regardless of the severity of their health crisis.

Low-acuity transports can contribute to the increase in the cost of care. Treating preventable conditions in the ED can cost nearly 12 times more than addressing the condition in a primary care setting or 10 times more than in an urgent care setting.

Non-emergent ED visits also place additional pressure on our caregivers at a time when there already is rampant burnout and a growing clinician shortage. According to the Some areas of the country already are reporting EMT and paramedic shortages.

Matters are no better in the ED, especially in rural communities. According to the 2020 National Study of the Emergency Physician Workforce, the nation’s rural emergency physician shortage will get worse over the next few years. That’s because of the 48,835 clinically active emergency physicians in the U.S., only 8 percent (less than 4,000 individuals) practice in rural communities.

Burnout in the ED and among emergency services personnel is real. Clinicians need a lifeline. Emergency Triage, Treat and Transport (ET3) and Community Paramedicine can help.

What Is ET3? What Is Community Paramedicine?

In January 2021, the Centers for Medicare and Medicaid Services (CMS) launched Emergency Triage, Treat and Transport (ET3). ET3 is a voluntary, EMS-led initiative that encourages local governments and other entities that operate 911 dispatches to evaluate low-acuity 911 calls, both at the level of dispatch or once EMS personnel are on scene.

Some low-acuity 911 callers may receive advice from a healthcare professional at dispatch that directs the caller to a primary care or urgent care visit instead of an emergency response to their location. This is the “triage” portion of ET3. Often EMS caregivers will be dispatched to evaluate the 911 caller in person to determine the best place for their medical care. Using protocols and virtual health technology, the EMS caregivers will discuss options with the 911 caller, including treatment in place by a virtual qualified health provider or transport to an alternate destination such as an urgent care center.

Patients who require more complex care are still transported to the ED.

Community Paramedicine (CP) involves a scheduled visit with a specially trained paramedic meant to address their primary and preventative care needs. Working under the supervision of a physician, and often on a virtual health platform, the paramedic can administer specific orders and interventions that would otherwise require a visit to a physician office or hospital. Community paramedicine is also referred to as mobile integrated healthcare.

CP and ET3 are designed to more appropriately utilize emergency medical services, increase EMS efficiency and deliver a patient-centered approach to emergency response by delivering the right care at the right time in the right place.

Envision partners with local officials and EMS providers to offer treat in place programs. Community partners are supported by our national network of more than 60 EMS medical directors and 3,500 board-certified emergency medicine clinicians serving more than 100 U.S. counties and 20 million patients. We also use two-way real-time audio/video communications to connect on-the-ground teams to a range of specialists. We have worked with partners to develop community paramedic protocols and provided hundreds of hours of training for paramedics to provide expanded assessment and treatment.

Implementing CP and ET3 models requires a virtual health platform and deep connections within the community and industry. CP and ET3 programs should:

• Direct patients to the most appropriate level of care
• Facilitate hand-offs between EMS and receiving facilities
• Connect patients to caregivers via virtual health technologies
• Provide access to a national network of EMS medical directors and expert clinicians
• Offer start-up training and continuing education for all participants
• Provide existing relationships with national and local EMS agencies

What Are the Potential Benefits Of Community Paramedicine And ET3?

• Quick access to physician-guided clinical decision-making
• Quality care when and where it is needed
• Improved patient and caregiver experiences
• Ability to care for more patients
• Reduced healthcare costs
• Improved overall population health

These programs also can help reduce 911 call volumes and non-emergent ED transports, which allows for a more intentional utilization of resources across the healthcare continuum.

Community Paramedicine Experiences Prove the Promise of ET3

The movement toward Community Paramedicine began at the grassroots — with emergency services clinicians and paramedics who were looking for ways to improve the quality of care in their communities. Hundreds of cities across the U.S. have adopted the model.

Memphis, Tenn., established a community emergency response system in the mid-1960s. According to Kevin Spratlin, who leads the city fire department's CP program, the system had been experiencing ambulance and clinician shortages almost since its inception, which reduced throughput and increased care costs.

By implementing a CP program in 2015, Memphis has successfully reduced unnecessary transports to the ED without diminishing patient outcomes. First responders even help 911 callers make appointments with primary care physicians. According to city data, 9 out of 10 callers who made appointments keep them.

Memphis is not alone.

According to a study published in The Western Journal of Emergency Medicine, within 12 months of implementing a virtual health-enabled CP program, the Houston Fire Department drastically reduced its number of ED transports. Comparing the 5,570 patients who participated in the program to a control group, researchers found a 56 percent absolute reduction in ambulance transports to the ED. Emergency services productivity was 44 minutes faster for patients in the program and there were no statistically significant differences in mortality or patient satisfaction.

Not only is the promise of CP being proven throughout the U.S. — it is also supported by research. Writing in BMC Health Services Research in 2021, researchers from Canada and Australia said there is “clear evidence that Community Paramedic programs had a positive impact on the health of patients and on the wider healthcare system.” Similarly, Utah State University professors reviewed multiple studies evaluating CP programs and found that 48 states support the CP model of care. Research has also indicated that systems that use CP have a per patient savings of up to $8,500.

What Does the ET3 Patient Experience Look Like?

In March 2021, a female patient was having trouble with her oxygen concentrator. She and her daughter called 911 in DeKalb County, Ga., and, with the ET3 model in place, the operator deployed EMS services, including a medic.

Conferring with one of our remote physicians via virtual health technologies, the medic was able to fix the oxygen concentrator. Soon, the patient was oxygenating normally at her baseline two-liter oxygen requirement. At no time did she feel short of breath, have chest pain, or experience light headedness or dizziness. The patient said she felt comfortable with the treatment in place and planned to follow up with her primary care physician within 48 hours.

The medic and remote physician took the time to help the patient and daughter understand how to troubleshoot common oxygen concentrator malfunctions in case they should run into trouble again.

Patients Ready to Embrace Virtual Technology in Their Community

CMS is not the only force driving changes in community-based medicine. The COVID-19 pandemic has introduced millions of Americans to the promise of virtual healthcare technology, which enables them to stay closer to home and avoid ambulance rides.

According to research published by the Kaiser Family Foundation (KFF), virtual health acceptance has skyrocketed since the beginning of the COVID-19 pandemic — even among generations who are not digital natives. Specifically, 64 percent of Medicare beneficiaries said their provider offers virtual health appointments, up from 18 percent before the pandemic. Almost half of those surveyed, 45 percent, said they had a virtual visit with a doctor or other health professional between the summer and fall of 2020.

Patients who used virtual health during the pandemic had very good experiences and want to use digital platforms in the future. According to a survey by the American Medical Association, 79 percent of patients were very satisfied with the care received during their last virtual health visit and 73 percent will continue to use virtual services in the future.

Communities that previously had been hesitant to offer virtual health platforms in emergency settings before can rest easier now. Patients and clinicians alike understand that by leveraging digital platforms, we can bring together local emergency responders and expert physicians to provide high-quality, compassionate care without sacrificing patient satisfaction, comfort or health. Treat in place protocols allow communities to deliver a patient-centered approach to emergency response by delivering the right care at the right time in the right place.