Patient Choice

phideux

Forum Captain
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One of the agencies I work for gives the patient the choice of what hospital they want to go to. I hate it. This is the #1 abuse of the system. For the patient who really needs it, no problem, I'll take them anywhere. But the frequent fliers that know that we will take them where they want, it's ridiculous. We are their taxi service. Had one the other day, 0630 Monday morning, his hip hurt since Friday. Meets us standing at the driveway, suitcase packed and all. Walks to the ambulance, able to climb the steps with no assistance. Wants to go downtown, 45 mile ride each way, have to pass 3 other hospitals to get there, and morning traffic is starting to pick up. Has an appointment at the VA hospital around the corner from the downtown hospital later that morning. Of course quitting time is 0645. So the little bit that Medicare will reimburse us is nowhere near the 3hrs of OT each for 2 medics, plus the gas for the ambulance which gets about 8mpg. This is a daily occurrence here. Want to cut down on system abuse and save some money, put hospital choice in the hands of the medic, closest appropriate facility. Or give us a stack of taxi vouchers.
Sorry, just one of those days, rant over.:wacko:
 

akflightmedic

Forum Deputy Chief
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If you are documenting properly and if your organization is submitting what you have documented, there is no way they received a penny for this transport.
 

Bluestar

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In the end its their choice where they go with in reason... otherwise it known as kidnapping. There's a place up here where they want to go to the local doctors office due to no hospital in that county. They have to advise them that there insurance won't pay but they go there all the time. I agree that the system is screwed up and we all see it. I also know that taking the choice from patients can be detrimental too due to those medics and emts... we all know who they are where we are that would abuse that choice and take them somewhere close other than where they truly need to be because they want off on time. We all would like to leave on time like normal jobs but this is the price we pay for what we do. Suck it up buttercup!!!
 
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phideux

Forum Captain
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It ain't the getting off on time part that bothers me. It's the waste of resources when a 911 ambulance with a large coverage area is taken out of service for 3hrs, for a person who had minor hip pain for 3 days, can walk without a limp, climb stairs, and basically just wants a ride to go to his regular doctors apt. We take this same person for a ride at least twice a month. I'm all about helping people, but this guy don't need a full ALS unit with 2 medics, he needs a taxi.
 

WolfmanHarris

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It used to be that the patient went to the closest "most appropriate" hospital, which for the longest time, just meant the closest unless they were a trauma patient; that was Ministry of Health policy. Enter STEMI, stroke bypass and dialysis bypass and we started bypassing more hospitals but still based on Pt. condition, not on their wishes.

Recently to help distribute patient load the reintroduced the limited ability for hospitals to go on redirect. CTAS 3-5 Patients (moderate to low acuity) but now be diverted to another hospital provided their is one within 20 mins difference in drive time. The patient now has the limited ability to provide a preference on hospital, though it cannot override the redirect and high acuity patients will still go to the closest hospital.
 

Veneficus

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It ain't the getting off on time part that bothers me. It's the waste of resources when a 911 ambulance with a large coverage area is taken out of service for 3hrs, for a person who had minor hip pain for 3 days, can walk without a limp, climb stairs, and basically just wants a ride to go to his regular doctors apt. We take this same person for a ride at least twice a month. I'm all about helping people, but this guy don't need a full ALS unit with 2 medics, he needs a taxi.

maybe your service should spring for one if it is that much of a drain on resources?

Or at least offer him the chief's car
 

Shishkabob

Forum Chief
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Talk to the higher-ups in your agency about starting a system abuser program, such as the one MedStar runs that I put in a thread just a couple of days ago.

If someone is known to abuse the system, IF a transport is warranted, they're taken to a 'home hospital'. They can request any other hospital they want, but they won't be taken to them, ONLY to the home. Either you go to the one offered, or you don't go.




Contrary to what some here say, it is not considered kidnapping, and I have never heard of a single person getting in legal trouble for taking a patient to a different hospital than the one they asked. An ambulance is not a private vehicle, patients have no legal right to be in it, nor tell it where to go. They are given a ride in it. They USUALLY get an option as to where to go, not as a legal requirement, but as a courtesy. Have you ever heard of a bus driver being arrested and the transportation authority being sued because someone took the bus but the bus didn't go to the location they wanted? Yeah, doesn't happen. They choose to go with you, they can leave at any time, therefore it's not kidnapping. People need to quit perpetuating this fallacy.





That does NOT mean I advocate taking your problem child of a patient to the closest hospital just because. You still need to discuss this issue with your higher-ups, and lay out a cost savings plan so they will jump on board. If he has Medicaid, show him the number on the back of his card that gets him a free taxi.
 
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jjesusfreak01

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Its not kidnapping when the patient has every right to get out at any point they wish. You just make it clear that in your professional opinion they should go to the closest appropriate hospital. If they want to somewhere else, too bad. They can not get into the ambulance. If they really think they're sick, they'll go where you tell them to.
 

Veneficus

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Just out of curiosity,

if the patient is being managed for his long term health problems at a particular facility, from the medical standpoint, how is that not the most appropriate facility?

It sounds to me like there is too much focus on the system and not enough on the patient.

If you take this pt to the wrong facility, you are just going to create a discharge without help and then you will be going out to his place again.

It really sounds to me like there is a legit issue here on how best to serve this person.
 

DrankTheKoolaid

Forum Deputy Chief
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Thankfully our LEMSA has basically put it in the hands of the provider to make the transport decision based on presentation and facility abilities with the exception of traumas. Not to say we dont take into consideration specialty needs of the patients as needed though. And obviously if they are discharged from A and are not happy with whatever care was deemed neededby the ED MD then when whoever comes to pick them up at discharge come transport them to facility B if patient so chooses. And if discharged and someone is able to pick them up, did they really need the first ambulance trip at all
 

medicdan

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On the other hand, it could be aruged that the private EMS industry treats customers not patients, especially for non-emergency transports. If you patient has a legitimate doctor's appointment a block from your destination hospital, and are unable to transport themselves, do they qualify for Chair Car (van) transport under Medicaid? If they are unable to ambulate without assistance (it sounds like they are), can they get a Certification of Medical Necessity (med nec, PMN, CMN, whatever you call it) for non-emergent trip to the VA?

Once you take this patient out of the 911 system, where they are likely a drain, can we find other (more appropriate) approaches to their care?
 

abckidsmom

Dances with Patients
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I have a soapbox I get on from time to time, and here I go again:

The time to make decisions about how the system is run is NOT on the scene of a call with a patient. It doesn't matter how many trucks are in the system, how much it costs, how much is pisses you off, or whatever. When you (the collective, universal you) are with a patient, you are charged with the responsibility to make decisions in the best interest of the patient in front of you. Only.

I work in a rural system in which resources are stretched thin. This does not mean I should tell the little old person with a boring problem that she doesn't need an ambulance because there's a better call getting toned out right now. Also doesn't mean that she goes to the absolute closest facility because the system is NUA right now.

Look at the patient you're treating, make a transport or treatment decision that applies to that patient only, and don't think too high above your pay grade on the scene. You can address any issues you think have come up AFTER the call, with the appropriate person. Anything else is just inciting discontent among your coworkers.

You're part of the problem, or you're part of the solution.
 
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phideux

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On this particular patient, he does not get treated where we transport him to. He has regular visits at a local VA clinic, which is around the corner from the ER he goes to. We do not transport to the local VA clinic because they do not have an ER. His sister also lives near the VA Clinic. When it is time for his VA clinic appointment, he will call 911 complaining of whatever. According to our rules we cannot refuse transport, and have to transport to the facility of the patients choice, as long as they do not need a specialty center(cardiac, stroke, trauma, etc). So we bite the bullet, and give him the 45 mile ride downtown. Like I said, he will meet you at the end of his driveway, with his little suitcase packed. We take him downtown, he will sign out of the ER, go to his sisters house, go to his appointment, spend a couple of days with his sister. For patients like this the VA needs to send a van, his sister needs to come pick him up, he needs to take a taxi, whatever. There has to be a better way. He just needs a ride for his monthly checkup, refill his prescriptions, and visit his sister. He's not sick, does not need 2 medics and an ALS rig. Like I said, I'm all for taking care of the patients, but for some folks there needs to be a better way. 911 shouldn't be called for regular transport to doctors appointments.
 

Shishkabob

Forum Chief
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And as I said, as much as an advocate as I am to ridding the system of abusers, it has to be done the right way. Have the discussion with your higher ups, detail the cost savings, show them the agencies who are currently doing provider refusals / system abuse no rides / at home checkups instead of transports and they'll likely listen.


When transporting him, educate him. Ask him why he thinks it's okay to call 911 for a pre-schedule doctors appointment. Ask him why he lacks reliable transportation and how you might be able to help. Show him the different options he has (such as the free taxi I pointed out).




We wont fix problems if we placate people and don't call out ignorance.
 
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abckidsmom

Dances with Patients
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On this particular patient, he does not get treated where we transport him to. He has regular visits at a local VA clinic, which is around the corner from the ER he goes to. We do not transport to the local VA clinic because they do not have an ER. His sister also lives near the VA Clinic. When it is time for his VA clinic appointment, he will call 911 complaining of whatever. According to our rules we cannot refuse transport, and have to transport to the facility of the patients choice, as long as they do not need a specialty center(cardiac, stroke, trauma, etc). So we bite the bullet, and give him the 45 mile ride downtown. Like I said, he will meet you at the end of his driveway, with his little suitcase packed. We take him downtown, he will sign out of the ER, go to his sisters house, go to his appointment, spend a couple of days with his sister. For patients like this the VA needs to send a van, his sister needs to come pick him up, he needs to take a taxi, whatever. There has to be a better way. He just needs a ride for his monthly checkup, refill his prescriptions, and visit his sister. He's not sick, does not need 2 medics and an ALS rig. Like I said, I'm all for taking care of the patients, but for some folks there needs to be a better way. 911 shouldn't be called for regular transport to doctors appointments.

Talk to your system administrators, document this trend, and have your administrators make a plan with him to call a cab next time.
 

Aidey

Community Leader Emeritus
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On the other hand, it could be aruged that the private EMS industry treats customers not patients, especially for non-emergency transports. If you patient has a legitimate doctor's appointment a block from your destination hospital, and are unable to transport themselves, do they qualify for Chair Car (van) transport under Medicaid? If they are unable to ambulate without assistance (it sounds like they are), can they get a Certification of Medical Necessity (med nec, PMN, CMN, whatever you call it) for non-emergent trip to the VA?

Once you take this patient out of the 911 system, where they are likely a drain, can we find other (more appropriate) approaches to their care?


Unable to ambulate without assistance is not an automatic qualifier for medical necessity for ambulance transport. If a person's primary mode of movement is a wheelchair it is stupid to remove it to transport them another way.
 

Sasha

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Unable to ambulate without assistance is not an automatic qualifier for medical necessity for ambulance transport. If a person's primary mode of movement is a wheelchair it is stupid to remove it to transport them another way.

The fact they can ambulate at all means they don't meet medical necessity. They have to be bed confined. That means they are not able to be out of bed at all. No chair, no wheel chair. If they ambulate even with assistance they're not confined to a bed.
 

JPINFV

Gadfly
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The fact they can ambulate at all means they don't meet medical necessity. They have to be bed confined. That means they are not able to be out of bed at all. No chair, no wheel chair. If they ambulate even with assistance they're not confined to a bed.


No. It means they don't meet the definition of bed confined, but bed confined isn't the only valid reason for medical necessity.
 

Shishkabob

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Linuss' quick guide to medical necessity:

If they can walk to your ambulance, and all you do is a staring contest for the duration of the ride, they don't meet criteria for an ambulance transport.
 

Sasha

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No. It means they don't meet the definition of bed confined, but bed confined isn't the only valid reason for medical necessity.

If you're basing medical necessity on bed confinement which is what it sounded like then they just disqualified medical necessity
 
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