Innovations in EMS

How can EMS evolve beyond a traditional 911 response model to address the root causes of patient crises? In this episode of Registry Insider, Bill Seifarth speaks with Nate Metz, CEO of Phoenix Paramedic Solutions, about overcoming “tradition bias” and redefining value in healthcare. Metz shares how his organization expanded into occupational and behavioral health, reducing 911 overuse by 38% and lowering annual care costs to $998 per patient. The conversation also explores how this mission shift can reduce burnout by empowering Clinicians to support long-term patient outcomes.

Transcript

SPEAKER_01 0:14

Welcome to the Registry Insider. I'm Bill Seiferth from the National Registry of EMTs. And today we're broadcasting from the EMS Association Summit in Kansas City, Kansas. And in today's episode, uh, we're talking about innovations in EMS making the unconventional more conventional. And uh joining me for this episode is Nate Metz. He is the CEO for for Phoenix Paramedic Solutions in Lafayette, Indiana. Um, so Nate, thanks for joining me today for this episode.

SPEAKER_02 0:44

Yeah, thank you for uh having me and let me talk a little bit about our ideas and our approaches to healthcare.

SPEAKER_01 0:49

Cool. Um, and an interesting aspect there. Um, you said innovations or aspects or approaches to healthcare, not just EMS. Yeah. So before we get into the topic today, which is innovations in what you're doing with your role, tell us a little bit about your background. I think that'll set the stage nicely.

SPEAKER_02 1:08

Yeah, you know, I mean, I'll just start with the EMS portion, even though there's, you know, we all have a history of why we got to that point. Sure. Um, but you know, I I I've been a paramedic for quite some time. That was an EMT before that. I cut my teeth being a paramedic in rural communities in Indiana, spent a lot of my time, you know, working 24-hour shifts and then going and working a 12-hour shift at an interfacility transport company, going back and forth and did that for for some time. And then I was given some opportunities for leadership and education in those departments. And then I was offered an opportunity to move over to the private sector, and in which I I advanced up to uh vice president for at the time what was the largest ambulance service in the state of Indiana. And that's actually where I started my first community paramedicine programs and and got you know buy-in from my executives at the time to kind of chase down these some really early crazy ideas, whenever it was still kind of a new, fresh topic. And and I mean, no, I know there's those CMS innovation grants in the early 2000s, and I was following all those as a young paramedic, you know, sitting down at the table reading all these articles and studies and grant programs. And I remember reading the initial manual and workbook from Eagle County Paramedic Services and like, how can we do this and getting my shift to start doing stuff, and then that that went to the private sector and where I got to actually take control and had support to start my own and first community paramedicine program. And uh, you know, I I haven't looked back since, and I really fell in love with the idea of um trying to solve simpler defined problems in healthcare. And what I mean with that, and actually it comes from a lot of lessons from one of my uh favorite individuals to follow, he he won a Nobel Prize in economics, actually, Daniel Kahnman, and he talks about cognitive bias. And what once I started studying him, you look around and you know, you see it everywhere. It's just like whenever you own a white car, you see white cars everywhere. Um and so I started applying those principles to healthcare and how we attack problems uh in our communities. And you know, at the end of the day, the biggest problem we have, in my opinion, now this is obviously shortchanging it, and it's more complex than that, but a simplest term. We have a value to cost problem in healthcare. Explain more. Well, you know, we we don't seem to be getting healthier. And and costs in healthcare continuously go up despite uh grants and monies and investments. And in my mind, that means there's a mismatch somewhere. We're doing something wrong. We need to approach the problem differently. And you could look at all different kinds of cognitive bias, everything from narrow framing bias that he he talks about, which I think contributes to the siloing of healthcare entities and understanding what each person can bring to a problem and a solution inside of a community. I'm seeing that now with a lot of 988 systems that aren't connecting with 911 PSAP centers to understand things like how they dispatch and how they collect data that could be super valuable. Um, and they're kind of recreating a first response program, but on the behavioral health side. And in all of that work that was done previously was done by EMS. But often EMS doesn't sit at the table. And so those are silos that are existing. Um, even in billing and all that other kind of stuff, there's silos that we just don't see how other other, you know, ways that other provider types do stuff. And the siloing reduces our ability to see new solutions or ones that we didn't think of before. And so one of the things I I started on, you know, started doing very early on was starting to try to find tough problems, and then just getting a bunch of passionate people together, like, let's try to solve it. Like, tough problems in healthcare for sure. Absolutely.

SPEAKER_01 5:07

Yeah. So uh and and again, I mentioned earlier, but you you want to solve the tough problems in healthcare, not just EMS, yeah. Which is getting to the you really what I want to get into the meat of this is the innovations of what you've done. So uh in our conversation prior to to filming, you were saying that um the I believe the company that you founded originally was doing mostly 95% 911 traditional stuff. Yeah tell a little bit of that timeline how that evolved and to where you are today and what you're doing as it relates to solving these tough problems in in healthcare.

SPEAKER_02 5:43

Yeah, you know, so I I was given an opportunity in my previous role as VP for Prompt Medical. The owners um beforehand, Gary and Sharp Miller, uh, really gave me an opportunity to start my own company whenever they wanted to retire. And that's whenever Phoenix was born. And it was aptly named Phoenix because we looked at it as we wanted to kind of burn down the EMS industry and see what rose from the ashes. Yeah, nice. And at the time we did that transition, the part of the company that I took over was about 70% 911 in rural communities, two separate rural counties in Indiana, pretty rural. I I know some of our partners out here out west, they I I say the populations are like, well, that's not rural, like we have 4,000 people in our county, you know what I mean? And so these are about anywhere between 15 to 30,000 people in a county, you know, critical access hospitals if they had one. And we enjoyed that work. Financially, it was stressful, but we enjoyed that problem, and and that's what we did for a long time. And then we had an opportunity, and we sat down at the table with community partners, we were invited to a table, uh, also by the university next door, Purdue University, to try to start attacking the opioid epidemic in 2017. Now, I had a community paramedicine program before then, and that was actually in the occupational health setting. And that's grown substantially, and that program is self-sustainable, lots of flexibility in that market for what we could do. The nice thing in Indiana is that we are not a floor scope of care state. We're a ceiling, or uh uh we are a floor scope of care state, not a ceiling scope of care. So that allows us a lot of flexibility on what a paramedic practice, yeah. Yeah. And so we started doing this occupational health stuff, we were making money off of it, and so we wanted to grow from that. So we we still run that program today. We have like 42 clients on the occupational health side, uh, even embedded clinics. But we we had this table to sit down with behavior health to try to solve the opioid epidemic problem. And it was a small little pilot grant that started where we started hiring peers. And part of the reason why we came to the table is because at the time we were the only healthcare entity at the table that wanted to take a chance on hiring peers because peers often have criminal records and they're in recovery, and so everybody was kind of uncertain about how to bring them to the mix, and we dared to say yes. Well, we'll do it. So we hired on peers from that little tiny grant program in one little community, it's turned into a nine-county radius behavioral health program and also a crisis response program. I think we were talking just towards the end of the last year, we finally crested 10,000 patients during that. So high volume, um, a lot of good work on that side. And one of our things we're most proud about is that during the uh COVID, overdose rates climbed nationally by about 35%. In the state of Indiana was very similar. The counties that our programs are in, we had a negative 1% reduction in overdose tests.

SPEAKER_01 8:42

Fantastic.

SPEAKER_02 8:43

Yeah, and even our 10,000 patients, not a single one of our 10,000 patients have overdosed since they've been in our program.

SPEAKER_01 8:51

That's cool. That's very cool. And that's that's just mental health specific to opioid overdose. Yeah.

SPEAKER_02 8:57

But it but wait, there's more. There is, yeah. Um, during that same time period, we we uh, you know, because when you start getting a reputation for tackling problems in a community, your programs grow because people want to come and work with you and collaborate with you. And how can you help us solve this problem? How can we work together? And we had another opportunity like that with one of our local uh uh homeless shelters, LTHC, where we embedded a clinic inside their LTH inside of their facility to care for individuals, not just uh on the behavioral health side and the addiction side and the recovery side, but also on the clinical and medical side. So we had embedded community paramedics and even you know nurses that were connected to it, and EMTs and peers and community health workers, and they were working with that population, giving them resources, helping them with their care. And one of the coolest things about that program was that you know, that that cost measure, that problem I mentioned earlier on, when that program after its first year, there was a couple of statistics that came out of it that were pretty fascinating. First one was that that was the highest, uh that address was the highest volume 911 response address in that county. In the first 60 days, we reduced that by 38 percent. Wow. And so now these resources aren't being overtaxed to one to one location. Absolutely. The other thing we did is that financially what we were able to pull off, and this was our goal, I wanted to be able to provide care to a patient over the period of a year for less than a thousand dollars a patient. And whenever we did the finances, they end up came in at$998 per patient. So mission accomplished. Mission accomplished. Because what's the average cost per patient now a year? What is like$10,000,$12,000, something like that? We did it for$998. And we saw corresponding changes and health outcomes and even getting people helping them get housed and getting them jobs. And, you know, uh, we we we didn't assess it then, we only started assessing it in later programs. I wish we would have known more because we would have started assessing it, you know, our programs now we do like a WHO five uh assessment to see what their overall well-being is. I wish we would have assessed it during this program because I just I know based off of the clients that we've seen that it would have skyrocketed for a lot of different people. Um and then, you know, a little bit later down the road, the 988 systems coming out, and ironically, us in our community, we came together and I built what was called the Tippekanoe County uh Crisis Continuum. And so we actually designed our 988 crisis response program before 988 even rolled out. We were about four years ahead of it. Um and so then as soon as the 988 came out, and you know, we got our MCTR mobile crisis designation, and we started working with partners like FQHC lookalikes and CCBHC programs and community mental health centers, even the health departments. We immediately fell into that role because there was a perfect mix between EMS and peers and crisis response in what we were already doing. And so we created a subacute care crisis response program where we have access to NPs, on-call therapists, um, you know, nurses and and paramedics. Does it is it just mental health or is it beyond mental health? It is beyond mental health. Um it started as just crisis and mental health. Uh, but you know, the interesting thing is about working with like an FQHC look like or a CCBHC program, is that whenever they get that designation, it's not just about behavioral or mental health anymore. It's the whole health continuum, everything from dental to vision to just traditional medical and general practitioner to then you get into your behavioral health and your addiction services and all that kind of good stuff too. Um, or even family intervention teams. We have a fit team that's associated with our program that's specific for families. Um we have uh programs that are specific for kiddos because actually, you know, we've been running that crisis group now for three years, and uh, you know, 10% of the people who come into our unit that our calls are on are people under the age of 16. Wow. And so we had to be specific about it, you you know, and um and one of the fascinating things that are starting to happen with that, and and I remember one of the guys we work with, uh, his name's Mick, he's a licensed clinical addiction counselor, he's been working with other programs for a while, and one of the things that he was most shocked about with our programming was um no show rates for appointments. They used to have about a 25% show rate for appointments, so patients would only show up 25% of the time for an appointment. As soon as our program started working with their clients, that went to 78%. Like almost overnight. What was the key to success there? How did that? You know, I I we could get technical, but at the end of the day, it's just being human. Okay. And being available to someone and making connection with them and not treating someone like they're not a number, and knowing that they have an advocate and an ally who can help them manage the healthcare system and keep them on track. You know, it's always one of these funny things that I find whenever we we talk about these either low access populations in rural communities or certain individuals of social demographics or individuals who are in recovery or have had issues with law enforcement or maybe are uninsured at the moment. You know, you take a single mom of five who's struggled with addiction and maybe even had some issues with uh the legal system, and maybe she doesn't have a license anymore. And you expect her to be a mom, to make sure she goes to work. She has to make it to all of her correctional officer appointments, otherwise she'll go back, maybe even lose her kiddos. And also, she's got to make it to her Matt appointment by a certain time to get her medications to help her. And she has to do all this without a car, and she lives in a rural community where the access isn't there, so she has to travel 40 minutes to even do all that stuff. That that's impossible without help. And it's amazing how if you just shift the care a little bit and take it outside of the walls. So making the unconventional conventional. Yes, exactly. If if you just break the tradition bias of, oh, when the patient leaves my door, I don't know what happens anymore. Instead, follow them and be an advocate with them and understand the struggles they have, it's amazing how much they engage in their health care and how much they want to get better. And that was one of the biggest impacts that we have seen. Um and that's not the only place there's impacts. I mean, even on the occupational health front, just for the sake of what these kind of models can do to a system. We were working with one of our clients just recently and they were doing their total spend. Now, this is a large manufacturer, and uh in one year we save them$550,000 in workers' workmen's cop expenses. Just one year. Those are the kind of numbers that make CEOs want to invest in you. Yeah. You know, um, and if we can do that for a business, we can do it for the healthcare system too. Yeah. Yeah. And that's what we're trying to do. We're trying to break that mold. Um, now I know you you referenced earlier what other kind of impacts have that had on my business. And I'm wondering what where would your mind go on those questions if if you had to ask what, you know, how did that impact my organization when we transitioned from 911 over to this? Like what are what are some of those questions you think people would have with regards to things we experienced when we did that? Just curious.

SPEAKER_01 16:29

I I think the the the biggest thing is um why would you do that? Which I think that you've answered that, because there is, you know, the the landscape of healthcare under our feet is moving pretty rapidly right now from workforce shortages to access issues, which you've talked about from um the hospital shutting down, clinics shutting down. So um the the why I think would be a question that people would ask. But uh another question I think is um what does it look like now completely? I mean, obviously we said 95% was 911. Now you're what percentage is 911 now? None. Exactly. Zero. So uh but you're still using traditional EMS assets plus other assets um to to meet the the unmet healthcare needs in the various communities you're working. So what what's the disperse? Uh how would how would you disperse in terms of the percentages of uh community paramedicine, mental health versus what the other the other?

SPEAKER_02 17:35

Um so first thing I'll mention is on your why, because that's really important. What one thing that we decided to do whenever we started as a company was that we weren't going to define ourselves based off of our provider type or our credentials. So many people do that, and they do that in EMS, or oh, we're a 911 agency only. We only do emergencies. Well, that's the Star Life is not an asterisk. Okay. It's it you're supposed to care for people, that's what we're there for. And so that doesn't mean just care for people who fit our definition of what we're supposed to be doing. You're you're an asset in the community, so do it. And so we decided that we were going to be a mission-driven organization. And our mission statement is to break barriers, defy tradition bias, and make absolutely no exceptions when it comes to providing compassionate care to those in need. Period. That's our company. It's a very nonprofit mission statement. It is. It is. Um, and that's our company. Everything else are just tools. Our provider type, our credentials, our licensing, the providers we bring in, or don't those are all just tools to execute a mission statement. Because some of our most impactful for me moments, and even in my entire career, I got in this to help people, have been because of this mission statement and empowering my staff to ferociously chase it. I I just I'll share a brief story on that and I'll get into your statistics, but I think it's powerful. Um, hopefully I won't tear up. Um one of the individuals that we had in our employee, um, he was a peer. And he's moved on. He's actually a fantastic peer in another organization. He gets recommendations and he's taken on leadership roles and all that kind of stuff. But when when he came to me, he was removed from being homeless maybe about a year. And he had spent about four years out in the streets homeless. Um, was an active addiction too, so he's an individual in recovery. And we gave him peer training, told him to come in and start working with people on that behavioral health side. And I remember it was just before Thanksgiving. This was right during the pandemic. And he came into the office and he looked frazzled, I guess is a word. You could just tell he was off. And I like, I'm like, what's going on, bud? Like, what's up? He said, It's cold outside. And I go, yeah, I know. He's like, No, you don't. I go, what do you mean? He goes, All due respect, man. He goes, I love you, but you don't. You don't know. I go, well, teach me. What do you mean? And he goes, you know, they shut the shelters down because there were outbreaks of COVID. Oh, wow. And he goes, and there's a lot of people that are stuck outside tonight. And he goes, You don't know cold until you felt the cold of concrete seep into your bones because that's where you have to sleep. He goes, you just don't know cold until you feel that. And I remember I looked at him, I go, okay. I grabbed him and I walked him over to our mission statement on the wall. I go, it's part of your job responsibility to fix this. Look at the mission statement. I go, so what are you gonna do about it? He goes, What do you mean, what am I gonna do about it? I go, what are you going to do about it? So I don't know. I go, fix it. I go, you literally have six hours to tell me how you're gonna fix this. I go, it's part of your job. And he just came back with a simple idea. He goes, I don't know, maybe we give them somewhere to sleep. I go, sounds great. Within four days from that conversation, we had an eight-agency collaboration. We opened up our own homeless shelter for all those individuals where we provided them three meals a day, a place to sleep, resources, social workers, access to showers. We even got some of the people housed. And we started that just before Thanksgiving. Carried it all the way through the holidays and all the way into the spring. Worked at 24-7, not one complaint from a single one of my staff members. I was down there working too. And we have hundreds of stories like that. Where our programs have literally just started because we allowed our employees to see a need, fill a need. Doesn't matter. That's our mission statement. Doesn't have to be EMS related, it doesn't have to be about transports, it's about the person, it's about the human. How do we make that person better? And once we empower our staff to do that, all of these cool programs started coming up. I mean, we had one Misfit Toy program. We serviced, we've been doing that for like six years now, and each year we service 450 to 500 families for Christmas, but it's actually a social services program that we disguise as a toy adoption program for kiddos. And that all just became because we allowed our staff to fulfill their mission statement. So the why is super important whenever you do any of these. Or even try to solve a problem because it's how we define ourselves. If I defined myself as an EMS agency with an asterisk, I would have never even gone to these tables where these opportunities were. Because I wouldn't have thought I belonged there. And so that's really important. Now, on to like our business model. So when we started the company, we started Phoenix, and even whenever I started, I talked to my team, I go, I want to reinvent EMS. And I go, that could be risky. I go, we could be out of business in a year. I have no idea how this is going to work. I go, but we're going to go for it. And as I started to try to do that, I got caught in a loop where I could not create new programs because all of my bandwidth was going to maintaining 911 programs, staffing, call-offs, all of the work that comes into these no-fail programs was taking all of my staff's time and management time. So we had no capacity to build cool programs of huge impact. And we all kind of came together and we said, well, we're not doing what we said we were originally going to come out to do because we're stuck doing this stuff. And so if we want to actually take this chance, we've got to open up capacity and actually jump both feet in and change. And so we did, and we divested. Um and we divested a lot. I mean, I'm talking, we were, you know, I'm still a smaller company, but you know, we were around$7.5 million of revenue. And we went from$7.5 million of revenue, uh about 98 employees, and we divested down to, in the first year,$1.1 million of revenue and 22 employees, where we had about a three-month stretch where all of us were busting our butts, working ridiculous hours to get through that transition hump financially. On the other end of that, there was some pretty amazing things that happened. The first thing was our culture. That a paramedic who continuously sees the same problem in front of them over and over and over again without the ability to fix it. I felt that. Go into that repeat customer on the 911 system over and over and over again, and it's like a revolving door, but their problems never get fixed.

SPEAKER_01 24:25

Yeah.

SPEAKER_02 24:26

And that that weighs on your culture, your organizational culture. It causes fatigue, it causes burnout, and all of a sudden your EMTs and paramedics aren't being the nicest to these patients anymore because they're stressed and they're taxed, and they almost have to like remove themselves from it to be able to deal with it. And so one of the first things that happened was our culture. People felt like they were making a difference now. An impactful difference. Yeah. And so it changed our culture 100%. Just flipped it. 180. And so we became a super healthy culture. Um, that was one impact. The other thing that started happening was as we started approaching this different work, we started finding new partners, and some of those silos that exist before started just completely evaporating. And we started finding all new ways of doing stuff and different thought processes, and we started challenging our own cognitive bias on how to approach problems. And so as we started to grow that from the financial perspective, the margins were not as financially stressful as they were on the ambulance side. Which not only impacted me as a leader, okay, your whole workforce too. A whole workforce, too. Um, and so even though we weren't as big a company anymore, and we still aren't, um, we're a healthier company. And we're doing what we love still. The reason why we got into this field and using our skills in new creative ways. And that impact was quite profound on us as a business and on an organization. And we don't plan on stopping. We we we plan on continuing to evolve our programs based off of the needs of our community. And we've got a reputation for that now. If there's a problem in the community that people don't think they have the bandwidth to solve, or maybe they're tied up in the bureaucracy of a giant healthcare system and they don't think they can move or flex. Or they can't be partners with anyone. Yeah, exactly. They come to us and say, we identified this problem, but you know how it is, right? You know how this big hospital system is, or how I can't get movement, but you can, which actually comes to why I'm not a nonprofit, but operate like one. Because I don't have to go to a board to do something tomorrow. I go to my team, I ask them about it. Does this fit our mission? Yeah, let's do it. Excellent. And that helps us.

SPEAKER_01 26:43

Where can people learn more about you? Learn more about your success as far as um thinking, you know, unconventionally, are doing some innovative steps to solve these problems that are typically um unsolvable in many communities. Where can they go to learn more about you, your company, um, and potentially get in touch with you?

SPEAKER_02 27:10

Yeah, absolutely. So, I mean, the company is Phoenix Paramedic Solutions. They've got a website online, um, it's Phoenix Paramedic Solutions.com. Um, if if anybody ever wants any advice or help or or anything with their programs or how to even find creative ways to fund it, or um, you know, uh uh how to manage protocols or or how to uh manage new systems. A lot of EMS systems aren't are people aren't familiar with, right? That was one of the learning curves of me. Going through and credentialing myself to become a behavioral health provider in addition to an ambulance provider. I did that the first time myself, specifically to learn. And it was a skill set that I know that a lot of EMS leaders haven't ever had to flex before. And so if you want any help with that, um, you can reach out directly to me at uh you know you can find me on phoenixsolutionsgroup.org, which is that side of the house where we try to help people with that kind of stuff. Um and we're always willing to share what we've learned and not just our successes, but we've learned more from our failures over the years than we ever did from our successes. And so we'll also share that and how if we would have had it over, how we would have done it and all that kind of stuff. And I love having those conversations, and I remember talking to you about this a little bit. I want our goal, my whole team's goal and my organization's goal, and even the work I do with the Indiana EMS Association or the work I do on the Community of Paramedics and Advisory Committee with the state of Indiana has always been how do we make this work for people? It can't be about personal gain, it has to be how do we fix the problem. And I want that idea to spread. And so anybody who has a like mind, you know, there's power in numbers. So let's see, let's see, you know, search each other out and start talking about how we can kind of do some of this stuff.

SPEAKER_01 28:55

There's definitely power in numbers, but there's also proof based on what you've managed to do for the last uh last decade or so.

SPEAKER_02 29:02

And a business model for it. I mean, a funny story we'll end on here, and I won't take up too much of your time, but I I had an individual reach out to us, another owner of uh uh an Indiana ambulance company. And it's actually ironic because it's one of the companies I got my first jobs at as an EMT. And uh they reached out to me not too long ago, and you know, he kind of made the comment, he goes, you know, we've actually been kind of following you close for the last eight years, and he goes, I gotta be honest with you. He goes, when you started doing all this stuff, he goes, I thought you were gonna be out of business in a year. He's like, I even remember going to my dad because it's a family-owned business, and he goes, Ah, this is stupid. He's like, How would this ever work financially as a business model? And then the immediate comment that came after that was, I was wrong. How are you doing it? And you can. You can. There's a business model for this, a good one. Yeah. And not only is it a good one, but if you look at the laws of economy, supply and demand, and you look through history. You know, I always use this one metaphor of the ice industry. Um, the ice industry back in the day was one of the fastest growing industries in the metaphor. About 10 years ago, ice industry, the fastest growing industry, completely. Why do I even need to do any of that? Why do I just need to work on it? We define ourselves. We define ourselves. This is the work we do. I think sometimes we forget the all the horrible help. We can define that for KPIs. You replacing system. And so now it's not like an opening.

SPEAKER_01 31:31

So that's what I've changed. Um, and I would encourage obviously folks to reach out to you to your website. And um thank you, Thomas. And uh being innovative and making uh the historically unconventional conventional. Absolutely. And congrats on your success. It's an amazing story.

SPEAKER_02 31:57

Thank you. It's my team's success. Um, and the really passionate providers that are out there. It's amazing the power and just letting people follow passions and being a guest leader sometimes today.

SPEAKER_01 32:10

I again want to thank Nate for joining us and sharing his story. Uh pretty remarkable. Um, and thank you as well for joining us. And as always, stay safe. Thank you for joining us for this episode. If you wouldn't mind, please click the like and subscribe buttons, as well as the notifications so you can get notifications of upcoming episodes. Also, for the latest and greatest happenings out of the National Registry, feel free to go to nrmt.org. Thank you very much, and again, stay safe.