The demands placed on emergency health services today differ greatly from those of the past fifty years and yet we have only recently seen changes enacted to improve our responsiveness. One major burden on hospitals and emergency departments in particular, is the issue of overcrowding and the decreased quality of care that is associated with it (Kellermann, Hsia, Yeh, & Morganti, 2013). Kellermann and his team propose an approach to overcrowding in emergency rooms that utilizes an integrated approach involving many players within the hospital and the local emergency health services system. Kellermann et al, argues for a preventative model of medicine in order to prevent readmissions to the hospital by “disrupting the chain of events that precedes many 911 calls” (Kellermann, Hsia, Yeh, & Morganti, 2013). In order to address reducing hospital readmissions and perhaps in some cases the initial admission of a patient, we can turn to the newly developing practice of community paramedicine.
The concept of community paramedicine has been around for more than twenty years, but it has only found success in practice recently (Heightman, 2013). In the simplest of explanations, community paramedicine is a component of emergency health services that is concerned with preventative medical care outside of the traditional medical environment. Community paramedicine sees paramedics moving away from the traditional emergency response functions of a 911 system in favor of providing more general medical services that address the specific needs within the community (Heightman, 2013). Among some of the most common goals for community paramedicine programs are managing high-frequency users, helping hospital reduce 30-day readmission rates, and offering appropriate alternative destinations for complaints that don’t require transport to a hospital emergency department. While these are often the goals of community paramedicine programs there is no standardization across systems. Currently there are many community paramedicine programs being implemented and some in practice; all of which are being geared specifically for the community that they serve. The ambiguity in definition has caused confusion and misunderstanding in the EHS community, but the flexibility that it provides also has allowed for effective systems to be in place.
As community paramedicine moves into the future, this hodgepodge of systems and models is being analyzed to create best practices as well as models for implementation. There are many questions about what the responsibilities, benefits, and costs of community paramedicine may be and the mixed results thus far have led healthcare leaders to outline a core set of values for community paramedicine as well as begin the discussion of how proactive community based initiatives will receive funding under new health care laws. Six principles were outlined at a 2013 conference in Chicago that involved the prominent community paramedicine programs at the time (Tan, 2013). The principals are as follows: First, systems must identify gaps in the current framework of care, from ambulance to hospital (Tan, 2013). Second, all stakeholders in the system must be involved and committed to the success of the program (Tan, 2013). Three, addresses ‘universal program development’ challenges (Tan, 2013). These challenges are faced by all community paramedicine programs and are not specific to the community being served. Development of this criterion benefits all community paramedicine programs. Four, community specific needs must be identified and plans made to mitigate these needs (Tan, 2013). Five, addresses the integration of a community paramedicine program with mobile integrated health care practices in order to provide funding and integrate these practices with the larger health care system (Tan, 2013). Six, a system for measuring the effectiveness of the program must be established with means to redress any shortcomings as well (Tan, 2013). These six factors have been exhibited by the most effective community paramedicine programs in the United States and are in line with the goal to reduce hospital readmissions for thirty days after discharge.
As community paramedicine programs become a prominent and effective component of EHS, we must consider the new scope of practice that these providers must have. In order to meet the needs established by the Chicago committee on community paramedicine, paramedics must expand their knowledge to include preventative medicine. While the scope and skills that paramedics will have to know will vary to some degree from system to system, much like traditional EMS skills, some skills will likely be seen throughout the community paramedicine model (Bigham, Kennedy, Drennan, & Morrison, 2013). One example of this may be the administration of vaccinations. This skill can be taught to a paramedic easily and could provide great benefit to the community by reaching a community that is not able to travel to get their flu shot, such as the bed ridden or elderly. Ultimately, the scope of the paramedic working in a community paramedicine program will need to change such that they can act independently of the traditional load and go mentality that comprises much of EMS at the moment (Krumperman, 2010).
Community paramedicine has been shown to reduce unnecessary transports to the emergency department (Finn et al., 2013). Finn et al. provides us with an evidence based approach that provides alternative approaches for community paramedics to avoid transporting patients unnecessarily. Among the alternatives are both transport and non-transport options. In respect to transport options, the community paramedic can opt to bring the patient to a facility other than the ED such as an urgent care clinic. In respect to non-transport options, the community paramedic’s role and scope must become more dynamic. In order to avoid transporting the patient to the hospital, the provider must be able to render effective care on scene and then be able to justify not transporting the patient. This is a stark contrast to traditional EMS where essentially every patient that is not transported does so against medical advice (Jensen, 2014). A second option that avoids transport would be providing care with the recommendation for the patient to follow up with their primary care physician (Jensen, 2014). Both of these non-transport options represent emergent responses that do not require transport. One additional non-transport option is proactive care. When providers to see individuals in the community preemptively, they are reducing the chance of the individual accessing EMS through 911 and subsequently being transported to the hospital. By catching something early or preventing it entirely, the community paramedicine program is able to reduce long term likelihoods for transporting high acuity patients (Jensen, 2014). All of these alternatives are ideal for low acuity patients or frequent users of the EMS systems in place.
In discussing community paramedicine, we have yet to address how a system that does not transport patients will be funded. Traditional EMS models often rely on billing related to patient transports (Morganti, Alpert, Margolis, Wasserman, & Kellermann, 2014). Where most patients are currently transported, this has proved to be an economically sustainable model for the time being in many systems. However, with community paramedicine programs specifically designed to prevent unnecessary hospital transports, new billing models must be addressed. Fortunately, Accountable Care Organizations (ACOs), a major cause for this new form of paramedicine is likely to also be associated with its funding. Accountable Care Organizations are groups of health care providers who come together to optimize patient care, improve patient outcomes, and simultaneously save money. Medicare rewards providers who participate in these systems and reduce costs through financial incentives. The percentage of the cost that is reimbursed is based on the quality of care given, which is measured in a variety of different ways. There are various models that an ACO may form in, which have different methods of measuring quality and distributing savings. In order for an ACO to create the most efficient, optimized system of health care possible, they will have to bring all providers that are part of a population’s health care system into a collaborative organization. This includes emergency medical services that provide important pre-hospital care and do not necessarily transport the patient to the hospital (Jensen, 2014).
As we consider the role of community paramedicine programs with in ACOs, we are left with their ideal position with in mobile integrated health care (MIH). MIH is a cohesive process that unifies organizations, agencies, and providers towards a common goal. This means that an MIH includes not just the community paramedics but their agency, coworkers that are traditional medics or EMTs, and the organizations that the agency is associated with. MIH is designed to maximize customer service by providing high quality patient care while reducing the amount of resources used by the system as a whole. This model lends itself to the reduction of hospital readmissions as there are often better suited patient care alternatives that represent less of a burden on the already overused hospital emergency departments.
There are currently several community paramedicine programs in the United States and the number is increasing steadily over time. As the number of community paramedicine programs has increased, there has been a trend towards reduced burdens on existing infrastructure that includes hospitals and traditional 911 emergency response systems. Changing health care regulations and the high demand placed on emergency departments in recent years has necessitated the changes we have discussed. As a result of community paramedicine and equivalent programs, the patient volumes in emergency departments have begun to reflect the new initiatives. Community paramedicine programs therefore not only are able to increase the quality of patient care provided outside the hospital but also to indirectly allow the hospital to increase their level of patient care by decreasing the volume of unnecessary patients. Community paramedicine programs as they are in practice today remain relatively experimental and evidence of their effectiveness is only now becoming apparent. As the growing body of scholarly research increases and more data becomes available, community paramedicine programs will continue to improve and better respond to the populations they serve.
We will next consider various implementations of community paramedicine programs in order to consider their identified strengths and weaknesses. With these cases in mind we will consider the common strengths that programs with successful outcomes have exhibited. We will contrast this by considering the challenges that a community paramedicine program must overcome to become instilled in the community in an effective way. These case studies will provide an abstract framework based on evidence based findings rather than academic jargon. This will inform our academic discussion of community paramedicine as well as next week’s application of this type of program at my agency.
For the Indianapolis case study, it seems that these preventative EMS based initiatives were effective methods for addressing frequent 911 callers, high risk heart patient release monitoring, and special medical needs referrals. The practices of the Community Outreach and Resource Efficiency (CORE) Care Team were shaped to address these needs through proactive response rather than traditional EMS reactionary responses. Many actors in the community became involved in this system by referring patients to the community paramedicine program. These role players include the hospital, social workers, and first responders. These role players represented the first step of the program: community outreach. Subsequently, community paramedics (couples with local pharmacy students for CHF patient) visit the homes of potential/identified patients in the community.
This model that has proved successful in Indianapolis can prove to be a valuable example to the broader EMS community, but must be considered as a specific case study in its own context. Dr. Tan wrote an article in the Journal of Emergency Medical Services in March of 2013 that highlights the importance of creating proactive programs that address the specific needs of the community of services. In his article, he addresses six considerations of implementing an effective community paramedicine system (Tan, 2013). These six categories were met by Indianapolis EMS through their CORE Team’s policies’ response to the needs of the community. The six principles are: Identify the gaps in our current state of affairs, work together with all stakeholders, address common or universal program development matters, identify community-specific missions, identify all the unique components to this approach to patient care, and establish benchmarks and performance metrics (Tan, 2013). In order to ensure that a program such as this is effective on a broader scale, these principles provide a good idea of the considerations that various agencies would have to consider in their creation of their own CORE Teams.
A 2012 National Association of Emergency Medical Services Physicians (NAEMSP) and the National Rural Health Association (NRHA) created a list of eight recommendations for effective Community Paramedicine programs based on their analysis of the Nova Scotia’s and Wake County’s Community Paramedicine programs. The first recommendation was that a program must have an engaged and knowledgeable physician medical director to lead the program (White & Wingrove, 2012). The second is that a model for regulation must be determined from the outset with both providers and the state being involved. This may be necessary to establish the service but also is crucial to ensuring funding and safety. The third recommendation is that each program must be tailored to meet the needs of the specific community being served (White & Wingrove, 2012). Fourth, as community paramedicine programs evolve regulations and oversight must evolve to keep pace with the innovative practices of these programs (White & Wingrove, 2012). Standards should only be established for community paramedicine programs once outcomes can be measured and performance based indicators and definitions can be understood. The fifth recommendation revolves around providing new services without duplicating existing offerings within the community (White & Wingrove, 2012). The sixth recommendation relates to the forth by establishing the need for data collection and evidence based findings to inform best practices and developments in programs (White & Wingrove, 2012). Seventh, the report calls for a new model of training that focuses on the specific skills needed as well as field based training that is appropriate to the unique needs of a given community (White & Wingrove, 2012). Lastly, the state needs to create a reimbursement system (such as is provided with ACOs) that can properly provide funding for programs that work preventatively rather than reactively (White & Wingrove, 2012). These findings summarize the lessons learned from many community paramedicine programs currently in place including the success of Nova Scotia’s program and the stagnation of Wake County’s program/funding.
Nova Scotia is a rural area with limited access to medical facilities. Both human and financial resources are limited and services must be stretched to care for two island communities, Long and Brier (CBC News, 2007). Access to the islands is restricted to ferries and transport time to definitive care can take over fifty minutes. The island was serviced by a paramedic ambulance that averaged one call roughly every three days (CBC News, 2007). Because of the downtime available, a community paramedicine program was enacted that sought to utilize these paramedics to perform non emergent care for islanders. Some responsibilities included flu shots, holding clinics and checking blood pressures and sugar levels. Eventually the paramedics were augmented with a nurse practitioner which expanded the scope of the team by looping in the nurse through an agreement with a physician in a neighboring community. The project greatly reduced emergency department visits by approximately 250-300 contacts a month (CBC News, 2007). This 23% decrease is demonstrative of an early successful implementation of community paramedicine. This program is still being developed and improved upon and will likely find even greater success in the future.
Wake County established a community paramedic program in 2009 with the adaptation of Advanced Practice Paramedics. The goal of the program was to reduce the occurrence, or at least mitigate the effects of, medical crises for individuals in the community with conditions known to benefit from medical monitoring (Wake County Gov, 2012). By increasing monitoring and preventative actions, the goal was to reduce or eliminate costly emergency room visits and hospital stays. The program targeted diabetics, hypotensive patients with CHF, and those in the elderly population with sub-par health records (Wake County Gov, 2012). The program also had the added benefit of ensuring that an experienced provider was on each crew. This aided in the handling of high acuity calls. This program operates out of quick response vehicle/fly cars; this allows the Advanced Practice Paramedics to operate in a non-emergent capacity and then to respond in an emergency capacity with a responding unit. The scope of practice for these providers was also supplemented with over 300 hours of classroom and clinical practice (Wake County Gov, 2012). Ultimately this program had issues with implementation and funding; the results/effectiveness of Wake County’s community paramedicine program is therefore unclear.
I would consider that in the Nova Scotia case, the community paramedic program was able to greatly reduce doctors’ visits and emergency transports through their preventative medicine. This preventative care was provided by medics coupled with nurse practitioners and physicians in a manner that allowed for a high quality and much more convenient access to medical attention than (hour plus) emergency transports were providing. In respect to Wake County, the freeze of funding at the first year level indicates the programs potential but the inability to actively implement further phases. This represents progress compared to San Francisco’s program which lost all funding after five years due to political tension.
These three cases represent three unique approaches to community paramedicine. The difficulty of comparing these programs is that each targets a unique set of needs in their respective community. As we consider the effectiveness of each and the implications that this may have on future community paramedicine programs it is critical that we keep this in mind. Community paramedicine programs may very well represent the future of emergency medicine, but the role they will play is still largely undefined. As we consider implementation and best practices we must remember that community paramedicine will be constricted to the same limitations that our current model of EMS is. EMS is an intersection of many fields of study and every community that they interact with differs greatly. While we strive to standardize EMS the challenges and ambiguity of community paramedicine programs highlights how much room for growth the entire field of EMS still has to undergo.
Reference
- Bigham, B. L., Kennedy, S. M., Drennan, I., & Morrison, L. J. (2013). Expanding Paramedic Scope of Practice in the Community: A Systematic Review of the Literature. Prehospital Emergency Care, 17(3), 361-372. doi: 10.3109/10903127.2013.792890
- CBC News. (2007, June 28). Paramedics key to ER nurse shortage – Nova Scotia – CBC News. Retrieved from http://www.cbc.ca/news/canada/nova-scotia/paramedics-key-to-er-nurse-shortage-1.659255
- Finn, J. C., Fatovich, D. M., Arendts, G., Mountain, D., Tohira, H., Williams, T. A., … Jacobs, I. G. (2013). Evidence-based paramedic models of care to reduce unnecessary emergency department attendance – feasibility and safety. BMC Emergency Medicine, 13(1), 13. doi: 10.1186/1471-227X-13-13
- Heightman, A. J. (2013). What Is Community Paramedicine? JEMS.
- Jensen, A. (2014). San Diego’s Resource Access Program Successfully Reduces Costs While Helping Patients. JEMS.
- Kellermann, A. L., Hsia, R. Y., Yeh, C., & Morganti, K. G. (2013). Emergency Care: Then, Now, And Next. Health Affairs, 32(12), 2069-2074. doi: 10.1377/hlthaff.2013.0683
- Krumperman, K. (2010). History of Community Paramedicine. JEMS.
- Morganti, K. G., Alpert, A., Margolis, G., Wasserman, J., & Kellermann, A. L. (2014). The State of Innovative Emergency Medical Service Programs in the United States. Prehospital Emergency Care, 18(1), 76-85. doi: 10.3109/10903127.2013.831508
- Tan, D. K. (2013). The Role of EMS in Community Paramedicine. JEMS.
- Wake County Gov. (2012). WakeGOV. Retrieved from http://www.wakegov.com/ems/about/staff/Pages/advancedpracticeparamedics.aspx
- White R, Wingrove G. (2012)Principles for Community Paramedicine Programs: National Rural Health Association
