The Emergency Room Problem
There are many individuals without health insurance. Many of these individuals turn to the emergency room of the nearby hospital for even the most basic medical needs.
Other high-risk populations with conditions such as congestive heart failure, pneumonia and myocardial infarction require more active, regular care and often turn to the ER when they have a concern that could be addressed by a non-specialist.
As a result, ERs become congested, decreasing efficiency and increasing:
- Wait times for those with more serious needs
- The need for more available beds
- The burden on highly-educated medical personnel
- The overall staffing and facility cost
Another problem for our overwhelmed hospitals is unnecessary readmissions. When patients are discharged from a hospital, if they are readmitted for the same condition they were originally hospitalized for within 30 days, the hospital receives a financial penalty from Medicare. Private insurers are also offering incentives to health care providers who are most effective at keeping patients out of the hospital.
The goal in creating the financial penalty was to increase the quality of care provided by the hospital, but in practice, readmissions often are unrelated to the care provided during the initial hospital visit. For example, a readmission can be due to the patient's failure to take medications as prescribed, confusion about minor aches and pains or other complaints that could more easily and affordably be serviced outside of the hospital.
The solution is a new model of health care distributed in the community: Community Paramedicine or Mobile Integrated Healthcare. The hospital provider, primary care physicians, case workers and local first responders work together to address patient care in the community as opposed to solely in the hospital setting or ER. This innovative model is designed to:
- Reduce emergency room overuse and abuse
- Lower readmission rates
- Help discharged patients with wound care, medications and questions related to their recovery
- Control costs and impacts of substance abuse through ER abuse
- Provide proactive care to those in need throughout a community
- Create a seamless partnership between medics, municipalities and area hospitals to share data and communicate patient care
Regulations around Community Paramedicine or MIH are in their infancy, as many hospitals are developing models and partnerships with community EMS providers and firefighters to support in-the-field care. The Commonwealth of Massachusetts Department of Public Health has recently modified the regulation 105 CMR 173.000: Mobile Integrated Health Care and Community EMS Programs.
The other concern for the future of Community Paramedicine includes the financial support for the program. Because there is multi-agency coordination to make the program work, funding for these programs is often a challenge. Many states are creating grants that hospitals can take advantage of, but there are still high costs associated with delivering Community Paramedicine. The beneficiaries of these programs are obviously the patients, but also the hospital in its ability to serve emergency patients and reduce readmissions for reimbursement from insurers.
Expanding the Role of EMS Providers
In addition to paramedics from local fire departments, EMS/ambulance providers are now stepping up to provide additional paramedics as well as transportation of patients when necessary, dispatch communications and medical record control. These specific services close the gap in patient care and also provide the communications coordination that many Community Paramedicine programs lack.
In communities across the US, paramedics who have undergone additional training are coordinating through strategic partnerships with hospitals, clinics and municipalities to deliver home-based care that would have otherwise taken place in a hospital ER or gone neglected and resulted in a readmission.
Technology allows paramedics to access a patient's medical records digitally from any location and perform evaluations in the home. Being in the patient's home provides the paramedics a view of potential risk factors that might be missed if the patient had been seen in a hospital, such as:
- Smoking or drug abuse
- Possible fall hazards
- Sanitary conditions
- Evidence of medication non-compliance
- Evidence of malnutrition
Paramedics can provide many services in a patient's home that would have in the past required a visit to a doctor's office or hospital, such as:
- Blood tests
- Wound care
- Medication administration
- Respiratory evaluation
- Tests for blood sugar levels
- Post-discharge follow up specific to condition
Community Paramedicine or MIH paramedics are trained to evaluate patients and recommend whether or not they are in need of more extensive treatment, which is communicated to the primary care physician or nurse coordinator. They can also transport patients to a hospital, doctor's office, urgent care center, mental health facility or substance abuse treatment center if needed. In addition, they can also provide patients with health education and help them manage a chronic condition such as diabetes.
As with most medical programs, how community paramedicine works in a specific community depends on how the community paramedic program is developed. Some provide emergency services that are sent if health care coordinator determines the patient is better served at home. Others provide routine and follow-up care. Some include fall prevention by evaluating the homes of elderly or at-risk patients for possible fall risks and suggest how to eliminate them.
Every observation, treatment and suggestion made by a Community Paramedicine or MIH paramedic is entered in the patient's electronic medical record to close the loop and provide their primary care physician—who is part of the communication circle regarding the patient's care—a complete picture of the patient.
What is the business side of community paramedicine?
A 2015 survey by the National Association of Medical Technicians revealed that 33 states and the District of Columbia have launched more than 100 Community Paramedicine/Mobile Integrated Medicine programs.
These pilot programs are currently being paid for by foundations, federal agencies and other parties who have a stake in seeing CP/MIH programs succeed. But data on the economics and practicality of these programs is still yet to be compiled and reviewed by the funding agencies.
Community Paramedicine seems a bright star on the horizon, but in order for it to become a reality nationwide, it will need support from Medicaid, Medicare and private insurers.
Home Health Care Conflict
In Minnesota, a nurses' association and home health care association joined forces to try to block community paramedicine expansion in their state. The Community Paramedicine program in Eagle County, Colorado, had to take a hiatus when home health companies complained that the paramedics were not qualified for home visits. The Colorado Department of Public Health ruled that the EMS provider would need to be licensed as a home health provider and the paramedics were required to receive additional training.
Community Paramedicine as the Wild Wild West
As with any new model, it takes time to establish standards, evaluate results, identify roles and understand financial costs and long-term benefits to sustain the model. Multi-organizational initiatives take time to stabilize because there are many moving parts and often lack leadership because each organization has a distinct agenda and budget to support such initiatives. Although the desire to do good in the community remains steady, finding the means to pay for it and standardize procedures is up to the agencies involved.