Mic Gunderson, an EMS1 columnist, occasionally receives questions from EMS leaders who find themselves in the design and improvement of systems about which he writes. The following is a question Gunderson received from a reader and is happy to answer.
Question: “How would someone evaluate the value when looking at the costs of more frequent 911 transports and responses, such as calls related to alcohol, mental health or poorly managed chronic illness?”
— Elsie Kusel, prehospital care coordinator in Alameda County and a paramedic in San Joaquin County.
Response: The key thing to remember about value measurement, as opposed to subjective impressions of value, is that you want to try to have a number that reflects on what a service costs (in money, resources, etc.) to deliver; and another number that reflects on what was received or changed.
The cost factor goes in the denominator and the benefit/change goes in the numerator.
The numbers need to be formatted in way that the number in the denominator gets larger when the cost and resource use is larger. Similarly, the number in the numerator needs to get larger when there is a positive change and gets smaller if the benefit is less.
In a value equation for the process of EMS care delivery to chronic inebriates, you might have something like this
Process Goal: Reduce the number of patients classified as chronic inebriates in a defined group of 500 individuals that were classified as chronic inebriate patients at the start of the program.
Numerator: Number of cases from a defined target population of 500 patients that are no longer classified as chronic inebriates is the numerator. Note: the numerator number will increase with a positive change.
Denominator: The denominator is the sum of the costs to deliver the intervention to the target population. It might include: (EMS unit hours spent in the calendar month on calls involving chronic inebriates x average ambulance or MIH unit hour cost as applicable) + (hours spent by social services staff delivering services to the target population x average cost of social service delivery) + costs of unscheduled ED visits + costs of medical clinic care
Using this numerator / denominator, you can compare the value of one strategy versus another. Perhaps one strategy is the status quo – chronic inebriates call 911, EMS responds and ED transport ensues. Compare that to a community paramedic program strategy coupled with an ED social worker intervention program.
Until you start bringing patients out of the chronic inebriate category, you’re not going to show value. The more patients that transition out of the chronic inebriate status, and the less it costs to make the change, the higher value quotient will be.
This is a rough example to demonstrate the general idea of how it works.
