Paramedicine is merely 40 years in the making. Therefore it's still evolving in the context of the larger health-care profession, which is now also in transition with health-care reform. Since the 1980s, EMS medical directors, system administrators and paramedics have acted to expand the scope of services EMS provides and, in some cases, the scope of practice as well. There have been two distinct clinical directions for this expanded role on both ends of the patient acuity spectrum.
The first direction involves the advancement of paramedics' clinical skills toward those of critical care nursing, for the care and transport of critical patients from one hospital to another. Initially, some opposed this initiative, primarily nurses who were concerned that expanded-role paramedics would replace them. However, the critical care paramedic became increasingly accepted and utilized due to the practical realities of nursing shortages, expanded career opportunities for nurses, Emergency Medical Treatment and Labor Act and the fact that paramedics are trained to work in a medical transportation environment.
The Centers for Medicare & Medicaid Services establishes provider legitimacy and financial value of health-care services through its Medicare reimbursement policy. In 2002, CMS enacted in the Ambulance Fee Schedule a new level of reimbursement for specialty care transport: the interfacility transport of critically ill patients. This action recognized the reality in many communities that paramedics had already broadened their scope of services to include critical care transport (CCT) in order to fill a crucial need within the health-care system.
The second direction for expansion of the paramedic role is at the opposite end of the patient acuity continuum. EMS systems, as initially conceived of in the Emergency Medical Services Systems Act of 1973 (PL 93-154), were primarily designed for patient care of emergency medical conditions. However, EMS increasingly cares for patients with non-emergent episodic medical problems. Studies place the number of low-acuity transports (e.g., sprains or flu-like systems) at 10–40% of EMS transports. The reasons for utilizing an ambulance service for transport to the ED due to a non-emergency condition are many, including lack of access to or availability of primary care, lack of insurance and lack of transportation. Many of these patients could be cared for at primary care physicians' offices, clinics and urgent care centers. In 2006, 24.1% of ED visits were classified as semi-urgent and non-urgent.(1)
Several distinct developments proved the catalyst for efforts to expand EMS care for low-acuity patients. In the early 1990s, EMS systems were impacted by opposing trends in the overall health-care system—a growing utilization of EDs, along with decreased hospital capacity for the purpose of cost reduction.(2) EDs were increasingly filled to capacity, causing long wait times for patients and EMS crews; ambulance diversion to other, less crowded hospitals; and the boarding of patients in EDs for hours and even days because regular hospital beds were not available.
One solution offered for this problem was to have EMS divert non-emergency patients from the ED destination to their primary care physicians or urgent care clinics. This idea had particular appeal in rural areas, where transport times to hospitals can take EMS resources out of service for hours.
In the 1990s, advances in medical technology offered increased opportunities to provide more definitive diagnosis in the field. From point-of-care testing to telemedicine to monitoring advances brought home from the battlefield, EMS leaders contemplated providing more services on scene rather than transporting every patient; however, reimbursement remained an obstacle.
At the same time, the health-care system was responding to the growth of managed care. One managed care principle was to provide the right care, at the right time, by the right provider. Presumably, this would result in primary care providers delivering more care at less cost to the health-care system. The concept of EMS treat, release and refer complemented this philosophy well. With this service expansion, patients with certain low-acuity conditions would be assessed and treated on scene with a follow-up referral or transport to the patient's primary care provider.
This new service requires additional training in patient assessment and certain new procedures, protocols and treatments. Many low-acuity patients have chronic health problems, such as diabetes and hypertension. A logical extension of this expanded scope of paramedic practice is the monitoring of frequent EMS users with chronic illness through home visits, similar to the past tradition of public health nurses. "Community paramedic" is the title often used for this paramedic with an expanded role within the community.
The national public policy agenda has sought alternatives for providing appropriate care for patients with low-acuity episodic medical problems since the mid-1990s. In 1993, the U.S. General Accounting Office reported on innovative programs using non-physicians, including Alaska's community health aides and the proposed use of paramedics for immunizations and chronic illness health care screenings in underserved areas.(3)
Most significantly, in 1996, the "EMS Agenda for the Future"—developed by the EMS community with the support and guidance of the National Highway Traffic Safety Administration—illustrated an EMS call in 2006 in which an elderly woman has fallen and activated the 9-1-1 system.(4) On arrival, the paramedics don't find any life threats but assess her ankle as a likely sprain. The paramedics make an appointment with her primary care provider for follow-up care. At the same time, the paramedics recognize some trip hazards in the patient's home and make another referral to resolve that problem. This is the image of the community paramedic.
In the late 1990s, Orange County, N.C., and the state of Idaho independently incorporated alternative approaches to the low-acuity patient. Initiated in 1996 and 1997, respectively, these programs continue today. The Orange County program enables paramedics with additional training to choose alternative disposition for patients based on their assessment of the patient's needs. Low-acuity patients can be treated and referred to a primary care provider for follow-up. Alternatively, the patient can be transported by ambulance or other appropriate means (e.g., from personal vehicle, wheelchair vans or taxis), to a physician's office or some form of primary care clinic.
The program in Idaho recognized the fact that ambulance services responded to many requests for service but did not transport a significant minority of the patients. However, without transport, ambulance services were not compensated for these responses and on-scene treatments. The Idaho program was the first of its kind to create new Medicaid coverage and payment for "respond and evaluate" and "treat and release." The state also required individual services to develop their own protocols and procedures for patient transport and non-transport services.
In another expansion of services in the late 1990s, paramedics were beginning to be utilized in immunization programs for children and for adult flu immunization clinics. Medicare actually had a roster-based payment methodology in place to enable reimbursements for EMS providing these services. However, some states prohibited these immunization programs as being beyond paramedics' scope of practice. Today, in the post 9/11, bioterrorism, H1N1 world, paramedics are widely viewed as essential to the delivery of mass immunizations.(5)
In 2002, the Medicare Ambulance Fee schedule created a new service level for interfacility specialty care transport (SCT) of critical patients. It was a result of negotiated rulemaking that the Balanced Budget Act of 1997 required CMS to engage EMS stakeholders in revising the AFS. The stakeholders wanted to discuss treat, release and refer services for inclusion in the fee schedule, but CMS refused, claiming it was not authorized to create new service levels. It is interesting to note, however, that SCT was a new service level.
In 2004, the first version of the proposed EMS Scope of Practice was released. The SOP was one of five major components that make up the recommendations of the EMS Education Agenda for the Future. This version included the advanced practice paramedic—a new level of paramedic that had additional training encompassing much of what the Orange County paramedics were doing as well as the critical care skills of CCT paramedics. Although well received by many in the EMS community, there was also substantial opposition from some stakeholders and, as a result, the advanced practice paramedic did not appear in the subsequent or final versions of the SOP.
From a public policy perspective, one would think the end result of the SOP effort might have put a nail in the coffin of the expanded scope services for the non-acute patient. But this was not the case. In 2007, the Institute of Medicine released its report on the state of emergency medicine, including EMS, offering many recommendations.(6) In the context of ED overcrowding, ambulance diversion and misaligned financial incentives that don't reimburse for treat-and-release, the IOM report called on CMS to convene an expert panel to make recommendations on reimbursement methodology for EMS that addresses readiness costs and payment for treatment without transport. Responding to the recommendation of the National Emergency Medical Services Advisory Council in 2008, the Federal Interagency Committee on Emergency Medical Services asked CMS to address the IOM recommendation and whether it would act on the IOM recommendation. The CMS representative reported that CMS would take no action.
NEMSAC, in September 2009, continued to deliberate on this issue and made the following recommendations to NHTSA:
The issue of treating and referring patients rather than transporting certain sub-acute patients to alternative destinations has been researched and trialed numerous times in many locations and countries. There are several potential advantages from health care cost savings, EMS system efficiencies, reduction of ED overcrowding and building surge capacity of EMS systems during public health emergencies that these capabilities promote. In the current context of health care reform, NEMSAC advises NHTSA to utilize whatever governmental entity is best including but not limited to FICEMS, CEMC and the Office of Health Care Reform to advance the following recommendations as identified in the "EMS Makes a Difference" white paper:
A. Develop National Guidelines: Using the Evidence Based Practice Guideline Model, NHTSA should convene an expert panel to develop national guidelines for treat and refer and transport to alternative destinations.
B. Treat, Release and Refer: CMS should convene a negotiated rule making committee of stakeholder organizations to develop the relative value units (RVU) for EMS assessment, treatment and referral without transport of certain patients under medically approved protocols and oversight which would include but not be limited to diabetic patients in hypoglycemia and non-transport of non-viable cardiac arrest patients and a host of sub-acute medical conditions.
C. Transport to Alternative Receiving Facilities: The prehospital triage and treatment of patients that activate EMS through the 911 system and are classified as emergency calls but are transported to alternative care facilities (i.e., urgent care centers) after evaluation by EMS can be billed at the appropriate level of service (BLS or ALS1).
Although it's clear that the issue of how EMS can appropriately address the care of the low-acuity patient remains on the public policy agenda, there are other developments, many at the local level, that continue to push the issue. A few community paramedic programs have been implemented over the past two decades, some successfully and others not. In 2009, Wake County (N.C.) EMS developed and implemented an advanced practice paramedic program. These paramedics assist ambulance crews on critical calls and provide services and evaluations, without transport, of patients who are frequent EMS users. In Houston, Richmond (Va.) and (soon) Charlotte (N.C.), non-acute patients are triaged in the dispatch process, where nurse specialists further interview callers, provide instruction and/or referral to the appropriate resources (medical or social), and cancel the EMS response if appropriate.
Internationally, community paramedic is widely used in Canada and Australia, mainly in rural EMS systems. In the last four years, England has reorganized its EMS and primary care systems to include the new paramedic practitioner who focuses on community health. The International Roundtable on Community Paramedicine exists to bring together leaders of EMS systems that have or are interested in implementing community paramedicine. This organization is developing a curriculum for the community paramedic and prototype programs initiated in Minnesota in 2009 and Colorado in 2010.
In 2010, public policy intersects local action. The health-care reform legislation signed into law by President Barack Obama in March authorizes funding for four regional pilot projects supporting innovations for delivering coordinated, accountable regional systems of emergency care. This is the first IOM recommendation to make it into legislation. The goal is to get the patient to the right care, delivered by the right care provider, at the right time, resulting in the best outcomes and most efficient use of the region's health-care resources. Although the U.S. Department of Health and Human Services has not yet developed the specifications and requirements for these pilots, they represent an opportunity for communities interested in incorporating innovations in the EMS care of the non-acute patient into these proposals for the regional pilots.