Community Paramedicine - Addressing Questions as Programs Expand

CAL/AAEM News Service at
Wed Apr 20 12:20:08 PDT 2016



March 24, 2016


Community Paramedicine — Addressing Questions as Programs Expand



New England Journal of Medicine



By Lisa I. Iezzoni, M.D., Stephen C. Dorner, M.Sc., and Toyin Ajayi, M.B.,


Growing increasingly short of breath late one night, Ms. E. called her
health care provider’s urgent care line, anticipating that the on-call nurse
practitioner would have her transported to the emergency department (ED).
Over the past 6 months, Ms. E. had made many ED visits. She is 83 years old
and poor, lives alone, and has multiple health problems, including heart
failure, advanced kidney disease, hepatitis C with liver cirrhosis,
diabetes, and hypertension. In the ED, she generally endures long waits,
must repeatedly recite her lengthy medical history, and feels vulnerable and
helpless. She was therefore relieved when, instead of dialing 911, the nurse
practitioner dispatched a specially trained and equipped paramedic to her
home. As part of a pilot program overseen by the Massachusetts Department of
Public Health, the paramedic retrieved Ms. E.’s electronic health record,
performed a physical examination, and conducted blood tests while
communicating with her provider’s on-call physician. As instructed, the
paramedic administered intravenous diuretics and ensured that Ms. E. was
clinically stable before leaving her home, where her primary care team
followed up with her the next morning.


The Massachusetts acute community care program is one of numerous new
initiatives in the United States using emergency medical services (EMS)
personnel. These mobile integrated health care and community paramedicine
programs aim to address critical problems in local delivery systems, such as
insufficient primary and chronic care resources, overburdened EDs, and
costly, fragmented emergency and urgent care networks.1 Despite growing
enthusiasm for these programs,2 however, their performance has rarely been
rigorously evaluated, and they raise important questions about training,
oversight, care coordination, and value.


EMS systems were established in the United States in the 1950s and expanded,
using federal funding, in the 1970s to create 911 response networks
nationwide. Operating EMS systems around the clock requires trained workers
with diverse skills. In 1975, the American Medical Association recognized
emergency medical technicians (EMTs), paramedics, and other EMS staff as
allied health workers. The federal government specifies educational
standards for the various EMS occupations. As entry-level EMS providers, for
example, EMTs undergo about 6 months of training and must pass state
certification exams. In contrast, paramedics must have substantial prior EMT
experience and then complete at least 2 years of didactic and field training
before passing rigorous state licensing exams assessing knowledge and
psychomotor skills.


Since the 1980s, reduced federal funding has contributed to EMS
fragmentation. Local fire departments provide roughly half of today’s
emergency medical services. Almost all 911 calls result in transportation to
an ED because of state regulations and payment policies: insurers, including
Medicare, typically reimburse EMS providers only for transporting patients.
At the receiving end, many EDs face escalating demand and soaring costs, as
more people seek attention for nonurgent acute and chronic conditions — in
part because they lack regular sources of primary and chronic disease care.
One estimate suggests that about 15% of persons transported by ambulance to
EDs could safely receive care in non–urgent care settings, potentially
saving the system hundreds of millions of dollars each year.2


Other countries have faced similar health care delivery challenges, and some
have enlisted EMS personnel as part of their solutions. For example, in
Australia and Canada, specially trained paramedics provide preventive and
nonurgent primary care in rural regions, which benefits both patients and
the paramedics, who can use their clinical skills to maximum advantage in
regions with low emergency call volumes. In England, Wales, Canada,
Australia, and New Zealand, EMS personnel provide urgent care on scene,
averting unnecessary trips to the ED. The United Kingdom spent more than £4
million ($5.7 million) investigating new approaches that would allow EMS
personnel to safely care for people who called 999 — the U.K. equivalent of
911 — in their homes or communities.3 It implemented the successful
approaches to substantially change how EMS providers respond to 999 calls,
reducing ED transport rates from 90% in 2000 to 58% in 2012.3 These changes
have not affected patient safety.


Community paramedicine has come to the United States only recently, but
initiatives are already under way in nearly 20 states. These programs vary
widely.1 In Madison, Wisconsin, EMS personnel visit patients at home,
providing wound care and chronic disease management. In Clayton County,
Georgia, paramedics target ED “high utilizers” — persons who averaged at
least 17 ED visits in the previous year. Paramedics in Orange County,
California, can now make triage decisions, transporting patients to urgent
care centers rather than EDs when appropriate. In western Eagle County,
Colorado, paramedics provide home health care–type services to homeless
persons. And in Dallas and Fort Worth, Texas, the MedStar Mobile Healthcare
program educates and monitors persons with chronic disease, aiming to
prevent hospital readmissions for heart failure. Between 2010 and 2015,
MedStar Mobile Healthcare appears to have prevented a total of 1893 ED
transports for 146 patients, saving Medicare more than $800 million.1


Despite high expectations for mobile integrated health care and community
paramedicine programs, we largely lack rigorous data on their performance. A
systematic literature review funded by the U.S. Department of Health and
Human Services Office for Preparedness and Response evaluated the safety and
effectiveness of allowing EMS personnel to determine treatments and the
setting of care.4 The researchers sought answers to several important
questions — for example, what proportion of patients who would otherwise be
transported to the ED can be safely treated in alternative care settings?
The literature suggested that 11 to 61% of Medicare beneficiaries who
received ED transports might not actually have required ED care, but no
studies “described their methods in sufficient detail to support a firm
conclusion.”4 The researchers also examined whether, after on-scene
evaluations, EMS personnel could accurately determine whether patients could
be treated outside the ED, and again they found few studies that were
rigorous enough to “support confident conclusions.”4


Nonetheless, U.S. EMS systems, communities lacking primary and chronic care
resources, and delivery systems with overwhelmed EDs will probably continue
experimenting with new care models involving EMS personnel. Going forward,
community paramedicine programs will need to address multiple critical
issues.1,5 First, there are workforce issues such as identifying the best
methods for training EMS personnel, testing their competencies, and
maintaining those competencies over time. The roles of physicians (e.g.,
emergency medicine or primary care physicians) overseeing and supervising
these programs require specification, as do methods for establishing and
supporting these relationships. Effects on EMS personnel — including on
their job satisfaction and career aspirations, as well as on
employee-retention rates — also merit attention.


Second, questions have been raised about how community paramedicine programs
should be integrated and coordinated with services from local primary care
networks, regional EMS providers, and health care delivery systems. In
particular, how can electronic health data be retrieved at point of care and
documentation be shared among providers? Third, reimbursement and regulatory
policies will need to be changed to create incentives for the use of these
programs and to ensure that they provide high-quality care efficiently.
Finally, monitoring effects on patient and population health is paramount,
as are ensuring safety and optimizing patients’ comfort and experiences with


Mobile integrated health care and community paramedicine could offer
important benefits to individual patients like Ms. E. and relieve
overburdened delivery systems. New specialized initiatives are addressing
particularly challenging population health and health care needs, such as
end-of-life care (especially difficult symptom management at home); in-home
urgent care for persons with serious behavioral health or substance-use
problems, who often find ED care problematic; and care for children with
chronic conditions. Identifying and encouraging best practices among
community paramedicine initiatives while targeting local needs will require
collaboration among EMS regulators, payers, practitioners, and community
public health officials — as well as new ways of thinking about local health
care delivery along the continuum of care.




Jeff Wells
Deputy Editor, CAL/AAEM News Service


Brian Potts MD, MBA
Managing Editor, CAL/AAEM News Service

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