Community paramedics fill gaps, take load off EDs
With demand for emergency care straining hospital resources, some health care systems are exploring new ways to leverage paramedics to better meet the needs of patients who don't necessarily require emergency care. For instance, Wake County Emergency Medical Services (EMS) in Raleigh, NC, is testing a pilot program that enables specially trained paramedics to assess patients with mental health care or addiction problems, and to transport these patients to alternative facilities, when appropriate.
The program, which is now in its third year of operation, was first initiated by Brent Myers, MD, MPH, FACEP, an emergency physician who is well acquainted with the flood of mental health patients that routinely present to the ED for care. However, given that Myers is also the medical director of Wake County Emergency Medical Services, he also sees an opportunity to address the problem with what he views as an under-utilized resource: paramedics. "We have an infrastructure to respond to emergencies that is very robust," explains Myers. "We have just been in a silo for the past 20 or 30 years."
Enlist experienced paramedics
At the federal level, EMS resides in the Department of Transportation, not the Department of Health and Human Services, observes Myers. "We were created to respond to traffic accidents," he says. "Every year, 8% of the population calls EMS for medical assistance, but our payment structure treats every one of those people as if they had a car accident on the interstate highway."
Under the terms of the pilot program, Wake County is enabling a group of paramedics who have received additional training to transport patients to alternative facilities when the ED is not the most appropriate setting for their needs. Currently, the facilities participating in the program include a crisis and assessment intake center, two faith-based detoxification centers, and a private psychiatric hospital, explains Myers. "We know that in the first two years of the pilot program, we had about 200 patients per year who were diverted [to these alternative facilities]," he says.
At press time, the data for 2013, the third year of the pilot, were still being compiled, but Myers notes that more than 300 patients were diverted. "We know there were no bad outcomes for those patients, but it looks like 20% to 25% of these patients ended up going to the hospital [after being diverted to an alternative facility], although in some cases, this was 48 hours later," he says. "The patients have all been safe and fine, but we are still looking at the process, and why those patients required a hospital visit."
The paramedics participating in the program are a select group of medics who have each seen at least 750 patients in the system before becoming eligible to participate in a special academy consisting of 240 hours of additional education. "The first 40 hours of the curriculum come from a law enforcement/critical incident course," explains Myers. "We modified some of the law enforcement [content] to make sense on the medical side, and then we used faculty from the state poison center to come talk about substance abuse, toxicology, and those types of concerns."
Myers estimates that the paramedics spend about 60 hours focused on toxicology, substance abuse, and dealing with an acute mental health crisis. "The medics then also rotate through each of the [alternative] facilities that are participating in the program," he says.
In a system that is designed to serve about one million people, only 16 paramedics out of a total of 300 are currently trained and authorized to do this work, notes Myers. Consequently, while the impact is relatively small, there is at least one way to calculate the value. "We know that these [mental health] patients spend, on average, 14 hours in an ED bed so every time we successfully divert a patient [away from the ED toward one of the participating facilities], we return 14 bed-hours to the ED," he explains. "When we take that average, we can calculate that we return at least 2,500 bed hours to the ED each year."
Collaborate on protocols
There is a real potential to make even more impact, notes Myers. Currently, the participating facilities in the program want EMS to expand the pilot's protocol so that the paramedics can actually come to the participating facilities and screen certain patients who are asymptomatic following a reported overdose to determine whether they require transfer to the hospital. This routinely involves a large group of patients, says Myers. "We have worked with our psychiatry group and our emergency medicine group to develop a protocol that will actually allow these paramedics to go into a facility, do a blood draw, do an assessment, document all of that, and leave patients safely behind once we have screened them to be safe," he says. "This is the next step to help to further decrease the burden on the ED while still doing the right thing for the patient."
While patients with mental health and addiction issues are the focus of this pilot program, Wake County EMS is also operating a second pilot that focuses on patients who experience falls in an assisted-living facility but have no obvious injuries. The program is being coordinated with the facility's primary care physician (PCP) group. "We will evaluate these patients in their assisted-living facility, call the PCP on the phone and discuss our findings, and then ask them whether the patients need to go to the ED or if they can be seen by the PCP," says Myers. "The promise we have with that group is that they will see these patients within 18 hours in their homes."
Thus far, paramedics have evaluated about 150 patients who have suffered falls in the assisted-living facility, and of this group, about half have been safely left behind to be seen by their PCP with no bad outcomes, explains Myers. "Our next step is to branch this out to patients in hospice care, and then our next step after that will be to [expand it to include] falls that occur in private homes," he says. "Right now, we are just doing this in the assisted-living facility as a pilot because it is an easy population to monitor, but once we are satisfied that it is a safe protocol, then we will expand it to other areas as well."
One not so insignificant stumbling block to the continued use of this approach is funding. "The EMS visits are currently not paid for in any way, and that is the push we are making now," offers Myers. "The state Medicaid program has bought in, and is looking at being able to pay us; we have had good conversations with private payers and we are getting ready to sit down with accountable care organizations. I think this is a short-term problem."
Target gaps in care
North Memorial Medical Center in Robbins-dale, MN, has also started a community paramedicine program aimed at reaching patients who might otherwise present to the ED for care for non-urgent concerns, and to address medical issues before they escalate to the point at which an ED visit or hospitalization is necessary.
Barb Andrews, NREMT-P, CP, RN, has been managing the program since it was first rolled out in October of 2012. "We have a lot of complicated patients who are not entirely successful at following through with their care plans," she explains. "These people kind of fall through the cracks in that they are not eligible for home health care, but they need additional resources that our previous system did not have a way to address."
For instance, if a patient is seen in the ED, and the physician is concerned that the individual is at risk for a return visit to the ED or an inpatient hospitalization, the physician can put in a referral for a community paramedicine home visit, explains Andrews. "Also, any one of our PCPs can refer one of their patients to the program," she says. The paramedic visits are often triggered when a patient's eligibility for home health care has expired, but he or she still needs to be followed, or the home health care nurse is concerned the patient will relapse and end up back in the hospital.
While the paramedic home visits are usually scheduled, there are occasions when they occur on the fly. Andrews recalls one recent case in which a PCP received a call from a patient who was feeling despondent and potentially suicidal. "The PCP tried to talk the patient into coming into the clinic, but the patient refused, so the physician called the community paramedic," she explains. "The paramedic went to patient's house, did some intervention, arranged for a hold to be placed, and had the patient transported."
Previously, the only option available to the physician would have been to call the police, who would have then sent squad cars over to the house. "That is not the most patient-friendly way to deal with a psychological emergency," notes Andrews.
Get state backing
In Minnesota, the training and credentialing of community paramedics has been formalized by the state legislature. "All of our community paramedics are certified community paramedics, which is regulated by the Minnesota Emergency Medical Services regulatory board," says Andrews, who has gone through the process herself. "The program includes more than 300 hours of additional training that focuses on community needs, community resources, social intervention, psychological intervention, and chronic disease management."
Paramedics spend most of this training in the clinical environment, performing wound care, spending time in primary care clinics, and gaining an understanding of chronic disease management, observes Andrews. "[Paramedics] are really good at dealing with an emergent need, but we don't know as much about how to manage patients longer term so the training really expands upon our existing knowledge," she says.
For instance, Andrews notes that the paramedics learn how blood pressure medications interact with other medicines, how much weight is too much to gain in a 24-hour period for a patient with congestive heart failure, and other critical issues that come up with respect to the management of chronic conditions. Further, once the paramedics are certified as community paramedics, there are continuing education requirements to maintain the certification.
The state legislation that governs the training and credentialing of community paramedics also stipulates that visits performed by community paramedics are paid for by the state's Medicaid program, but Andrews notes that many commercial insurers are either paying for the visits or are in the process of negotiating reimbursement for such services. "It is much less expensive to send a community paramedic out to someone's home than to pay for an ED visit," says Andrews.
However, there have been times when the community paramedic has determined that the patient really needs to go the ED. In those instances, the paramedic will either coordinate through the system's ambulance service or through 911 if the location is not in the health system's service area, explains Andrews. However, the more common scenario is that a trip to the ED or an inpatient hospitalization is prevented.
For instance, Andrews recalls the case of a diabetic patient who had been dealing with open wounds for the past eight years. "Besides home health care, the patient had spent time in the hospital and in transitional care units, and all of these failed [to improve his condition], so [the patient's providers] were ready to move forward with amputation," says Andrews. "In a last-ditch effort, a podiatrist who had used us before successfully referred him to the community paramedicine program."
The patient's wound is now healed and he is currently volunteering at one of the transitional care units where he spent time as a patient, says Andrews. "There is obviously an impact on life that is hard to measure," she says, "but we figured out that it would have taken 10 years of three-times-a-week paramedic visits to cost what a couple of toe amputations would have cost the system."
Explore paramedics as a resource
While community paramedics can help to relieve the ED of some frequent utilizers, the program is also a referral source for ED physicians who have concerns about the ongoing care of patients. "We might refer patients who need frequent wound checks who have a hard time getting to their PCP office, or [patients] who need help managing a chronic disease like diabetes or COPD [chronic obstructive pulmonary disease] so we can stay on top of their disease before it gets so bad that they end up back in the ED or worse, admitted to the hospital," explains Joey Duren, MD, an emergency physician and director of Urgency Centers and Affiliated Facilities at North Memorial Medical Center.
It will take time to gauge the larger impact of the program on ED utilization and overall costs. There are currently only eight certified community paramedics who still spend most of their time serving as traditional paramedics. "They work one day per week as a community paramedic. It involves a different uniform and different equipment, and they drive their own personal vehicles when they make visits," explains Andrews. "Some people don't want the neighbors knowing that [medical personnel] are coming by, so they prefer not having an ambulance pull up in front of their home."
The community paramedicine program is still in its infancy at North Memorial, but Andrews believes that other health systems should consider going down a similar road. "It is absolutely worth exploring because our current system is broken, and there are a lot of patients who fall through the cracks of the structure we already have," she says. "Tapping into paramedics and expanding their training as community paramedics is a resource that has great potential."
- Barbara Andrews, NREMT-P, CP, RN, Manager, North Memorial Medical Center & Community Paramedic Program, Robbinsdale, MN. E-mail: email@example.com.
- Joey Duren, MD, Emergency Physician and Director, Urgency Centers and Affiliated Facilities, North Memorial Medical Center, Robbinsdale, MN. E-mail: firstname.lastname@example.org.
- Brent Myers, Medical Director, Wake County Emergency Medical Services, Raleigh, NC. E-mail: email@example.com.