Webinar: Emergency Triage, Treat, and Transport (ET3) Model - Model Application Tutorial slides
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The Emergency Triage, Treat, and Transport (ET3) model aims to enhance emergency medical services by allowing Medicare beneficiaries to receive appropriate care in lower-acuity settings rather than traditional emergency departments. The document outlines the model's application process, eligibility criteria, payment structures, and intervention designs, emphasizing stakeholder collaboration and patient-centered care. Key components for applicants include demonstrating compliance, interoperability plans, and engagement with various payers to successfully implement the model.
Webinar: Emergency Triage, Treat, and Transport (ET3) Model - Model Application Tutorial slides
- 1. Emergency Triage, Treat, and Transport (ET3) Model Application Tutorial August 8, 2019 Center for Medicare and Medicaid Innovation (CMMI) Centers for Medicare & Medicaid Services (CMS) 1
- 2. Presentation Overview 2 • Review of the ET3 Model • Application Orientation • Q&A o Eligibility o Proposed Model Regions o Applicant Governance o ET3 Model Intervention o Interoperability Plan o Compliance Analysis and Plan o Payer Strategy o Patient-Centered Design o Letters of Intent
- 3. Review of the Emergency Triage, Treat, and Transport (ET3) Model 3
- 4. Current State 4 Medicare currently pays for emergency ground ambulance services only when beneficiaries are transported to a limited number of covered destinations even when a lower-acuity, lower- cost setting may more appropriately meet an individual's needs. 911 call received Ambulance service initiated Ambulance arrives, but does not transport the individual Ambulance transports the individual to a covered destination (e.g., hospital ED, skilled nursing facility)
- 5. Re-aligning Incentives for Future State 5 ET3 Model interventions allow beneficiaries to get the care they need and enable ambulances to work more efficiently. Blue = Model Services Orange = Standard Medicare Services 911 call received Ambulance service initiated ET3 Model intervention ET3 Model intervention Standard intervention Ambulance transports to alternative destination (e.g., urgent care) A qualified health care practitioner provides treatment in place either on site or via telehealth Ambulance transports to a covered destination (e.g., ED) ET3 Model intervention A health care professional discusses health concern(s) and may refer the individual to a community resource and/or divert the caller from ambulance services/emergency department (ED) if appropriate Note: Entities administering this intervention will apply through the NOFO at a later date; this factsheet is not applicable to NOFO applicants.
- 6. ET3 Model Payment Approach 6 New payments available under the model will build on Medicare’s existing fee-for-service structure to offer greater flexibility. Performance-based payment adjustment for achievement on key quality measures (up to 5% upward adjustment – no sooner than year 3 of the model) 15% increase in rate for care provided by qualified health care practitioner between 8:00pm-8:00am Ambulance suppliers and providers paid based on level of service provided (BLS-E or ALS1-E rate) Mileage and applicable adjustments Transport to Alternative Destination Treatment in Place (In-person or via Telehealth) Ambulance suppliers and providers paid based on level of service provided (BLS-E or ALS1-E rate) Qualified health care practitioners paid current Medicare Fee-for-Service rate. Payment for Model Interventions Payment Adjustment
- 7. ET3 Model Participants and Partners 7 Medicare-Enrolled Ambulance Suppliers & Providers will apply through the Request for Applications (RFA) to become participants in the ET3 Model. As part of the application, they will describe their chosen interventions and their partners. Alternative Destinations Required Partners Optional Partners Recommended Relationships Treatment In Place Providers (In-person or via Telehealth) Non-Medicare Payers 911 Dispatches* *911 Dispatches will apply through a separate process
- 8. Key Requirements 8 Applicants will need to demonstrate the following to be considered for participation. Transport to Alternative Destination. Participants will be required to implement transportation to alternative destinations. 24/7 Availability of Model Interventions. Participants will be required to ensure that transport to an alternative destination, treatment in place, or a combination of the two, is available 24/7. Interoperability Plan. Applicants must describe an interoperability plan that demonstrates the Applicant’s ability to share patient data among key partners and stakeholders.
- 9. Important Considerations 9 CMS expects to make available conditional payment and policy waivers of certain Medicare requirements for purposes of testing the ET3 Model, including to waive the telehealth originating site and geographic requirements. Applicants must either describe a strategy for engaging other payers in their area, or explain how they would successfully implement the model for Medicare FFS beneficiaries only. Applicants will be asked to provide information on all proposed partners and payers and should include Letters of Intent to Partner as part of the application. Applicants should consider the following when preparing to apply for the ET3 Model.
- 10. Application Orientation Note: This presentation contains select questions from the model application. Please refer to the model application for the full list of application questions. 10
- 11. Timeline* 11 May 2019 Early August 2019 Late September 2019 Late 2019 Early 2020 Request for Applications (RFA) PDF Released RFA Application Portal Open RFA Application Portal Closes ET3 Model Participants are announced ET3 Model Go Live *Dates are subject to change
- 12. 12 Application Components CMS will establish guidelines for reviewers and will prioritize applications based on the following application components: Organizational Information Proposed Model Region Governance Structure and Capacity to Implement the ET3 Model Intervention Design: Alternative Destination Intervention Design: Treatment in Place (Optional) Interoperability Plan Compliance Analysis and Plan Payer Strategy Patient-Centered Design
- 13. Application Registration 13 Open the ET3 Model website: https://innovation.cms.gov/initiatives/et3/ Find the link for the application portal in the Request for Applications section Create an account through the registration link 1 2 3
- 14. Functionality of the Portal 14 Save often, the portal times out after 30 minutes of inactivity You are able to start and stop the application as needed Fields are formatted as numbers or letters All numbers should be entered as whole numbers Character limits are displayed in each field Helpful Tips Understanding the following features and tips for using the application portal will assist with successfully completing an application. All fields are required, unless noted as optional You are able to skip required fields, move through the application and come back to those fields later You will receive an error message if you attempt to submit the application with any missing required fields
- 15. Eligibility and ET3 Model Applicant Information 15
- 16. 16 Applicant Eligibility The following are some key criteria that must be met to be considered as an eligible Applicant: Ambulance supplier or provider currently enrolled in Medicare and in good standing. Currently operating in a state that meets minimum transport thresholds Capacity and willingness to ensure the availability of one or more non-ED options 24 hours per day, 7 days per week.
- 17. 17 Eligibility Page The first section of the application will establish eligibility. Responses in this section determine whether an Applicant may continue with the application. Only Medicare-enrolled ambulance suppliers or hospital-based ambulance providers are eligible to apply. Applicants must currently provide emergency ambulance services in the entirety of the region they propose and continue to do so throughout the model.
- 18. 18 ET3 Model Applicant Information Provide Applicant’s Organizational National Provider Identifier (NPI) Number to identify the organization to CMS. All Applicants will provide their organizational information and Applicant contact information as a required part of the application. Provide Applicant’s Organizational Information, if you are completing this application on behalf of the ambulance supplier or provider, your information will be required on the “Certify & Submit” page.
- 20. 20 Model Regions Applicants will propose a model region of counties or county equivalents and will need to consider the number of Medicare FFS emergency ambulance transports when selecting counties. All states in a proposed region must have had at least 15,0000 Medicare FFS emergency ambulance transports in 2017. Preference will be given to applications that indicate in their application that their region includes at least one county with 7,500 emergency ambulance transports in 2017.
- 21. 21 Proposed Region Applicants can add multiple states and multiple counties. All counties that are part of the proposed region need to be included in this section. Select the state in your region. Select one state at a time if you are proposing a region spanning multiple states. Select each county or county equivalent in that state that is included in your proposed region. After adding all counties in one state, you may add another state and additional counties by selecting “Save & New”.
- 22. 22 Open the ET3 Model website: https://innovation.cms.gov/initiatives/et3/. Scroll down to find the “Additional Information” section and select “Appendix D: Number of Medicare FFS Emergency Transport Claims by State and County Equivalent Entity 2017 (PDF).” https://innovation.cms.gov/Files/x/et3-ffs-emergencytrans-claims.pdf Emergency Transport Claims Data You can find emergency transport claims data on the ET3 Model website to inform your organization’s application. 1 2
- 23. 23 Kansas Missouri Regional Example Proposed Service area: Kansas City Verify Kansas had 15,000 Medicare transports in 2017 using data on model website. Verify Missouri had 15,000 Medicare transports in 2017 using data on model website. Check if a county in the proposed service area of Kansas City had at least 7,500 Medicare transports. The steps below illustrate how an Applicant can confirm that a region meets the emergency transport threshold using Medicare data on the model website.
- 24. Applicant Governance Structure and Capacity to Implement the ET3 Model 24
- 25. 25 Governance Structure and Capacity Explain how the governing body or other organizational mechanisms would: (1) make and execute decisions related to the ET3 Model; (2) develop, implement, and monitor ET3 Model interventions; and (3) develop and oversee compliance with all federal fraud and abuse requirements. Describe your current unscheduled, emergency ambulance services capacity. In this section, Applicants describe organizational mechanisms to support ET3 Model innovations and describe their current transport capacity.
- 26. ET3 Model Intervention Design 26
- 27. 27 Required Intervention: Alternative Destinations All Applicants are required to implement transportation to alternative destinations and will need to describe strategies for executing this intervention safely and effectively. Describe groups of beneficiaries that may be appropriate for transport to alternative destinations. Applicants who identify that they have formal relationships for transport to an alternative destination will be asked to provide a letter of intent later in the application.
- 28. 28 Optional Intervention: Treatment In Place Applicants who choose to offer the treatment in place intervention must describe strategies for executing this intervention safely and effectively. Indicate in your application if you intend to implement treatment in place and whether this will be in- person, via Telehealth or both. Applicants who identify that they have formal relationships for treatment in place will be asked to provide a letter of intent later in the application.
- 30. 30 Interoperability Plan Applicants must describe an interoperability plan that demonstrates their ability to share patient data, including protected health information, among key stakeholders. Selecting "yes” or selecting “no” in these questions will yield different follow up questions. Should you select “no” to either of the previous questions, you will be asked to provide a plan to obtain the functionality described.
- 31. 31 Interoperability Functionality A plan to participate in an HIE during the model; or the ability to use HIE standards such as APIs, JSON, FHIR*, or XML), or a plan to achieve this capability Details demonstrating an understanding of state and federal privacy laws and ensure compliance with these standards, including HIPAA privacy regulations and 42 C.F.R. Part 2. Explanation of when and how patient consent and authorization will be obtained, including written patient consent where required. *HL7 Fast Health Interoperability Resources Specification (FHIR®) is a standard for health care data exchange. More information is available on HL7’s website. Applicants that do not currently participate in a health information exchange (HIE) and/or do not have the ability to use HIE standards such as APIs, JSON, FHIR*, or XML), will be asked to provide some or all of the following information:
- 32. 32 Data Sharing Partners Other payers, including Medicaid payers Applicant (ambulance supplier or provider) Alternative destination sites Beneficiaries’ routine health care providers Potential Data Sharing Partners Medicare-enrolled qualified health care practitioners partnering with the Applicant to furnish ET3 Model services Other entities, systems, or individuals that the Applicant believes will have access to data related to model activities An interoperability plan can include many types of potential data sharing partners.
- 33. Compliance Analysis and Plan 33
- 34. 34 Compliance Analysis and Plan Describe your organization's current compliance program. Please note, CMS is not requesting copies of applicant policies. Provide an ET3 compliance plan. Consult the OIG’s voluntary Compliance Program Guidance for Ambulance Suppliers. Provide a plan for avoiding under-triage and successfully implementing the proposed intervention design within the context of relevant emergency medical services laws, regulations, and policies in the proposed service area. The compliance plan identifies risks and strategies to avoid inappropriate utilization and to implement the interventions within the context of relevant laws, regulations, and policies.
- 36. 36 Multi-Payer Alignment Applicants may engage regional payers such as Medicaid Fee-for-Service or managed care plans, Medicare Advantage plans, commercial insurance plans, or other payers in order to set forth a multi-payer alignment strategy. Rationale: • Participants who implement model interventions across multiple payers will be in the best position to achieve ET3 Model cost and quality goals. Requirements: • Each Applicant must describe its strategy for engaging other payers in its proposed service area, or explain how it would successfully implement the model for Medicare Fee-for- Service beneficiaries only. • The strategy must include the proposed payers, a timeline for implementing payment of ET3 Model EMS innovations with each payer, and a plan for identifying eligibility to receive services through the model.
- 37. 37 Multi-Payer Strategy Describe your multi-payer alignment strategy, including proposed payers, a timeline for implementing payment of ET3 innovations in each proposed payer, and a plan for identifying eligibility to receive services. In the Letters of Intent section later in the application, you may provide letters of intent with names and addresses of each payer you have engaged. Applicants can set forth a feasible multi-payer alignment strategy within the context of its proposed intervention design.
- 38. 38 Medicare FFS Only Payer Strategy If an Applicant proposes to implement the model in Medicare FFS only, the Applicant should explain how it will operationalize its proposed intervention design with only the Medicare FFS population. Explain how you will operationalize your proposed intervention design. Include how you will identify Medicare FFS beneficiaries by coverage status.
- 40. 40 Patient-Centered Care Applicants will be required to describe a design for providing patient-centered care and the policies that will support delivering this care. Applications should demonstrate their ability to engage beneficiaries and their families and/or caregivers in shared decision-making, taking into account patient preferences and choices. Participants will need to provide person-centered care, such that beneficiaries receive the appropriate level of care delivered safely at the right time and place, while having greater control of their healthcare through the availability of more care options. Applications should describe plans for communicating effectively with patients and caregivers, including those with communication challenges.
- 41. 41 Patient-Centered Design Provide a plan for engaging beneficiaries, families and/or caregivers with limited English proficiency, low health literacy, or other communication challenges. Applicants will demonstrate how their current person-centered care policies are aligned with, or will become aligned with, the proposed ET3 intervention design. Propose mechanisms to inform and educate patients about model interventions at the scene of a 911-initiated emergency ambulance response.
- 43. 43 Letters of Intent (LOI) You must submit a letter of intent at the time of application if you previously indicated in the application that you have (1) identified specific payer partners; and/or (2) established formal partnerships with alternative destinations or treatment in place practitioners. To the extent that the Applicant has identified specific payers, alternative destination sites, and/or qualified health care practitioners with which it proposes to partner, the Applicant should provide copies of LOIs. If you previously indicated in the application that you will not offer treatment in place, buttons in this section will not be operable.
- 44. Questions 44
- 45. 45 Resources and Contact Info Model Website https://innovation.cms.gov/initiatives/et3 Model Team Email Submit questions to the model team at ET3Model@cms.hhs.gov Please include “application assistance” in subject line Request for Applications (RFA) Access the online portal here. Model Listserv Subscribe to the ET3 Model Listserv using this link. Use the following resources to learn more about the ET3 Model and apply. Frequently Asked Questions https://innovation.cms.gov/initiatives/et3/faq.html