Originally published in Journal of Emergency Medical Services (JEMS).
By Elsie Kusel, EMT P, BS, P. & Brian Savino, MD.
November 23, 2015
Mobile integrated healthcare and community paramedicine (MIH-CP) is making significant strides in areas across the United States. Although goals of MIH-CP programs will differ based on a jurisdiction’s needs, many if not most of them allow paramedics to perform assessments outside of the 9-1-1 system and then refer patients to non-emergent healthcare and social services in collaboration with patients, primary care providers, social workers and others who may contribute to healthcare decisions.
In June 2015, Alameda County (Calif.) EMS, along with the city of Alameda Fire Department and Alameda Hospital, began an MIH-CP pilot program with two goals: reducing 30-day readmission rates at Alameda Hospital (part of the Alameda Health System), and reducing frequent, repetitive utilization of EMS resources for non-emergencies.
The program is part of a statewide initiative taking place in multiple sites coordinated by the California EMS Authority and Office of Statewide Health Planning and Development (OSHPD). The University of California, San Francisco, is coordinating the data portion of the project.
With the Centers for Medicare and Medicaid Services (CMS) discontinuing reimbursement for hospital readmissions within 30 days after discharge, cost savings to the healthcare system will likely be an outcome of this pilot; however, the goal is to “test and evaluate new or expanded roles for healthcare professionals and new healthcare delivery,” as well as to link patients to appropriate healthcare and other services, ultimately leading to better health outcomes.
Goal 1: Curbing readmissions. In Alameda County, over 30% of the 9,000 discharged patients from Alameda Health Systems in 2013 had one of five diagnoses: congestive in the community paramedic program are heart failure, chronic obstructive pulmonary disease, myocardial infarction, sepsis and pneumonia. These conditions, in addition to diabetes, were selected as the diagnoses for which Alameda County’s MIH-CP pilot would seek to curb 30-day hospital readmission rates.
Goal 2: Reducing frequent users. The program’s other aim seeks to solve a problem familiar to many EMS systems: targeting frequent users of 9-1-1 for non-urgent needs who tie up valuable response and care resources, compromising the system’s ability to respond to acute medical emergencies.
The statistics from Alameda County are overwhelming. In 2013, 163 patients were transported more than 20 times, 32 patients were transported more than 50 times, 11 patients were transported more than 100 times, and three patients were transported more than 200 times. One patient even used EMS 358 times in one year—almost once every day.
Connecting these “familiar faces” with more appropriate and sustainable services rather than 9-1-1 and EDs is expected to free EMS resources for emergency response needs.
In the lead-up to the MIH-CP program launch, concerns were raised about patient safety, with critics arguing that paramedics typically receive limited education and training when compared to other advanced clinicians. Concerns were also voiced that MIH-CP would result in lost jobs in the current healthcare workforce.
Misconceptions also existed among the seasoned medics recruited for the pilot program. When asked what he originally thought about being a community paramedic, Stephen Lucero, Jr., from the city of Alameda Fire Department, stated, “I thought we were going to provide in-home wound care and medication administration. I envisioned that we would have an expanded scope and provide in-home nursing-type skills, like changing Foley catheters, IVs and bandages. [This is] not the case.”
Lucero said that within the early weeks of completing the core curriculum required by the California EMS Authority for all state MIH-CP pilots, he realized that skills involved in the community paramedic program are “extremely different.”
Indeed, there’s not so much an expanded scope as there is an expanded role. Clients seen by community paramedics are the same or similar to patients seen through the 9-1-1 system: recently discharged patients whose conditions have exacerbated or a patient or family member fears has been exacerbated, exaggerated by their own unease about symptoms experienced away from a hospital setting.
Comparing the role of a community paramedic to a 9-1-1 paramedic, Lucero says, “The workload is different in that you take responsibility for a client and his or her case. You spend a lot of time thinking on game plans for these clients, as opposed to 20 minutes on-scene time and 40 minutes total transport. Many 9-1-1 calls end there. When making forward progress with clients, there will be steps back. You must be patient and able to adapt to your client’s situation. Usually it’s a waiting game. When your client is ready, then you can use your tools.”
Program enrollment is voluntary; frequent 9-1-1/ED patients are identified by reviewing prehospital and ED records and by field or ED referral, and hospital case managers can offer enrollment to any patient scheduled for discharge from Alameda Hospital with one of the six diagnoses.
Upon consent, the patient’s information and discharge instructions are sent to the MIH-CP coordinator. A community paramedic visit in the client’s home is then scheduled within 24–48 hours post-discharge.
Bio-psych-social and home safety assessments are performed on the initial visit, and community paramedic assistance with follow- up discharge plans subsequently help clients avoid a downturn in health that would result in readmission. As found by other MIH-CP programs, communication between community paramedics and the client’s primary care physician was identified as a crucial resource in facilitating appropriate follow-up care. If an emergent concern is identified at any time during a visit, 9-1-1 is activated and appropriate interventions are initiated by the community paramedic.
If an eligible client is homeless, the community paramedic attempts to engage the person at his or her last known location. Similar to post-discharge clients, assessments are performed that address physical condition and complaints, safety, dietary intake, medication compliance, social needs, and access to resources. Based on findings, achievable goals are determined by the client, community paramedic and involved healthcare providers.
Successful referrals connecting the client with useful resources are essential in helping enrolled clients improve their health and address their non-emergent needs in an appropriate and cost-efficient way. “I was surprised how frustrating it is to navigate someone who needs or accepts help through the healthcare system—especially for substance abuse treatment,” said Lucero, describing his experience with these frequent faces. “The current system has a lot of red tape, paperwork and lag time to help someone in need. There’s no instant help and that’s frustrating, especially for someone who finally accepts help.”
Alameda County EMS is proud of its ability and reputation for delivering excellent prehospital care. Furthermore, the county is excited to have the opportunity to improve the community’s health with this two-year MIH-CP pilot. Although cost-savings and decreased unnecessary resource utilization will benefit the overall healthcare system, the true value of this program is connecting individuals with safe and appropriate healthcare.
Summarizing the program’s impact and his role, Lucero says, “Not only are we helping people who are slipping through the [healthcare] system’s gaps, we’re also connecting local resources to one another. Networking is 80% of the job and the other 20% is listening to your client. I feel [community paramedics] are the ‘the boots on the ground,’ holding people accountable and helping those with needs—from medical questions, connections to resources and to just be present—to show that someone out there cares.”
Photos courtesy Alameda EMS/Alameda Fire Department.
Edited on June 13, 2018.