Let’s be honest; a lot of the calls EMS providers go on simply aren’t once-in-a-lifetime emergencies. They’re not the situations that get your heart racing. They aren’t the ones you dreamed of after falling asleep in your EMT books. They’re the calls where, perhaps if you’re tired at the end of your shift, you wonder why you even get called to the incident at all. But that doesn’t make them any less important than the congestive heart failure (CHF) or cardiac arrest calls, particularly because your actions may prevent them from becoming one.
Many of these you see on a daily basis are “regulars”—people you recognize because you pick them up a lot. Or they’re people who can’t afford health insurance and call 9-1-1 when they need help but have no primary care provider to call. Or they’re patients who simply have medical conditions they struggle to manage.
You can remind yourself that it’s your job to transport patients to the hospital. And you can rest assured the majority of those patients are having a better day the minute you arrived. But if you’ve ever wondered what your work day would be like if even some of those patients had access to the care they needed without an ambulance, you’re not alone.
The five programs featured in this article have visionary leaders who first wondered and then moved forward with initiatives for approaches that focus on how they could better care for patients.
These leaders may call their programs different things: “transitional response,” or “advanced practice,” “rural” or “community” paramedicine. They may even have different partnerships and funding models, but they’ve all developed programs with the same end result—sending advanced healthcare providers into the field to assess certain predetermined populations with high-acuity, low-frequency calls in an attempt to avoid overburdening EMS units and, most importantly, emergency departments (EDs).
A primary goal is also to get the best care to the patient earliest, before the patient’s condition deteriorates and places an unnecessary burden on hospitals and EMS resources. They also believe it’s the wave of the future of EMS.
The Mother of Invention
The Wake County (N.C.) Advanced Practice Para-medic (APP) program was born out of necessity, says Brent Myers, MD, MPH. In 2007, the administrators of the Wake County Department of EMS realized the experience level of its workforce was dropping, with more than 40% of its providers having less than two years of experience (as compared with previous levels of 10–15%).
“Our concern was that when you call 9-1-1, I don’t know if you’re going to get an experienced paramedic,” says Myers, director of the Wake County Department of EMS. “That matters with their ability to treat your emergency.”
They decided they wanted to ensure an experienced paramedic went on high-acuity calls for which advanced clinical decision-making would be necessary. Thus, the APP program was born.
“As we were planning for that, we realized the high-acuity calls were only 20% of our calls,” Myers says. “So what will they do the rest of the time?” They took a look at their frequent flyers, which included patients with CHF and diabetes, as well as those with mental illnesses. They realized their community EDs had no beds for psychiatric patients, which meant these patients had to wait to be transferred out of the community. That wait was an average of 14 hours.
Myers’ group wanted to keep those patients out of the ED in the first place by moving them directly from the field to the other facility. They found an eight-week course at the local community college where the APPs could learn crisis intervention and advanced pharmacology, and they incorporated these concepts into the program.
More providers applied than could be accepted. Those who were chosen were trained and hit the ground in 2009 in what was supposed to be a multi-year rollout. Then the economy stuttered. The program currently features five APPs and one supervisor on shift during peak daytime hours and two on overnight shifts—half the APPs that were originally planned for.
An APP’s typical day involves what Myers calls the three “r”s: response, reduction and redirection.
Response: This is unchanged from the program’s inception. APPs respond with an ambulance as a resource for crews on cardiac arrests and high-acuity respiratory calls.
Reduction: This involves patients with known conditions, such as CHF and diabetes, who need follow-up and monitoring once they’ve been released from the hospital.
Redirection: This includes the community paramedicine aspect of screening psychiatric patients to determine whether they can bypass the ED for other such facilities as county mental health or detoxification centers.
Myers says the program disproves the notion that taking every person who calls 9-1-1 to the ED is best. “The most important thing to me is that we are providing for the patient rather than providing for ourselves,” Myers says. “The key is to be able to safely offer them an alternative. And that’s what this program does.”
The Critical (Care) Component
Shortly after Myers’ team launched its APP program in North Carolina, Dr. Jeff Beeson’s team in Ft. Worth, Texas, was sending providers with advanced knowledge into the field. MedStar EMS launched its Advanced Practice Paramedic program in July 2009 to send highly experienced paramedics on high-acuity, low-frequency calls.
MedStar is a young agency, a training ground for new paramedics, says Beeson, medical director of the not-for-profit system. The average tenure is four to five years.
“We wanted that advanced practice piece. We wanted that advanced practice paramedic to show up on the call and provide higher clinical decision-making skills,” Beeson says.
They knew what they wanted, but they then had to figure out how to fund it. The answer was to start making interfacility critical care transports. This became a revenue source for the program.
The second aspect to the APP program is the community health component. Beeson says 21 frequent users of their system, whom they call “loyal customers,” accounted for around 800 transports in 2008. “These 21 people consumed 2,100 ambulance hours,” he says, adding that those ambulance hours cost the healthcare system $150,000.
The APPs worked with these customers and local healthcare facilities to curb that behavior and decreased 9-1-1 calls by 57%. That evolved into providing in-home evaluations for CHF patients, which includes monitoring the patient and adjusting their diuretics if necessary, and a new pilot project with a private physician’s group to decrease unnecessary 23-hour observations in the hospital. Beeson says creating the APP program has had not only clinical success; it has also boosted morale, created a career ladder and cemented their role in the healthcare community.
He stresses the importance of working within your own community. “What we do here will not work for what you need in your community,” he says. “Our problems aren’t your problems. You need to identify your needs and who’s going to make you succeed in your community,” Beeson says.
The key to success is determining what your community’s needs are and then partnering with other healthcare agencies.
“You can’t do this alone. You have to work with your hospital. You have to partner with them, so what we have done is become a valuable resource to them,” Beeson says. “Ask yourself as an EMS agency: What do you provide other than medical transportation? The days of us getting paid to move people will end. So we have to become healthcare providers.”
The State-Supported Model
In 2011, Minnesota became the first state in the nation to establish a new healthcare provider type: the Community Paramedic. In 2012, state legislators passed a revision of the Community Health Bill that has a funding piece.
Although the program is fairly new, Minnesota lobbyist O.J. Doyle says he and fellow lobbyist Buck McAlpin had been talking about the general idea for 10 years and co-wrote 19 versions of the bill before it passed with a payment piece in April 2012.
Doyle says the first real community paramedic program in the state started when one of the state’s Native American tribes purchased a large mobile medical van in Scott County. They took a course curriculum that had been put together by the International Roundtable on Community Paramedicine and went out to perform various procedures.
It was intriguing, especially for a state with a dwindling rural population.
“We sold this as primarily a rural focus for a couple different reasons. Obviously, there’s less availability of healthcare in many parts of rural Minnesota. That’s the first thing. The other thing is that we lose two to three volunteer ambulance services a year just because demographically the younger people are moving out of the rural communities so we have shrinking populations in rural communities,” he says. “It’s not always financially viable to start up a paid service, and a larger, full-time service that may have an adjacent area may not be able to afford going in there.”
Doyle and McAlpin knew funding couldn’t come from non-government insurers. So they chose to focus their efforts into putting a community health EMS initiative into law and then adding a funding piece.
“We already know it works,” he says, adding that he used successful pilot programs from across the country to push his bill. “It was all of their work that really helped us get our bill passed.”
The cornerstone of it all was to standardize what a community paramedic was, and doing so meant getting state certification. So they found that the providers working the Scott County mobile medical van were getting training from Hennepin County Technical College. They used that to prove to Minnesota State Colleges and Universities (MNSCU), the state’s community college regulating body, that the training program was legitimate. MNSCU approved the community paramedic (CP) certification, which requires 300 hours above the paramedic certification level.
Once MNSCU approved the CP certification, the rest happened quickly. Doyle says when that approval came through, they were able to show the legislators that every aspect of this was legitimate. “All these things just kind of fell into place. It’s like it was really meant to be,” he says.
The Fire/NP Partnership
As a non-transporting first response department, Mesa (Ariz.) Fire Department doesn’t have to take lost Medicaid reimbursements into consideration for its Transitional Response Vehicle (TRV) program. Instead, it only has to consider what’s best for the patient, the local EDs and its own providers, says EMS Coordinator Terence Mason, RN.
The TRV program got its roots from a pilot program in 2007 that teamed a physician’s assistant (PA) up with a paramedic to answer low-level calls, such as urinary tract infections and other non-emergent requests. The team would examine the patient, and the PA would write up a prescription for antibiotics and not transport the patient to an ED. They would then follow-up a day or two later to ensure the patient saw their primary care physician.
“The whole idea behind that was to lessen the burden on the ER,” says Mason, a former ED nurse. The next natural step to easing that burden was to use a mid-level provider, such as a PA or a nurse practitioner (NP), to clear psychiatric patients in the field.
“That’s something we’re looking at very closely because that would be a huge thing to take off [EMS and] the ER,” Mason says. “It’s a huge problem.”
Mason says his department asked several hospitals to partner with them, and Mountain Vista Medical Center agreed to fund an NP to go out with a paramedic captain on calls in the field 40 hours per week.
The Mesa program has been reactivated, and the NP should be on the streets this month. Mason says the NP will provide advanced medical knowledge, and the paramedic captain will provide supervisory knowledge. “It’s a symbiotic relationship because one is taking care of the nuts and bolts of how we’re going to do this, and the other is taking care of the nuts and bolts of the assessment. They will both basically feed off of each other in every situation because they will both be learning from each other,” he says.
He expects the team will reduce ED admissions for psychiatric patients. Patients who can’t be safely cleared in the field will be transported to the closest appropriate facility, which Mason says won’t always be the hospital funding the NP. He expects other area hospitals will consider participating in the program once they feel the relief from the reduced transfers. He also thinks that the NP community will respond positively to the alternate career path and that the program can open doors for EMS providers wanting to advance their medical knowledge but stay in the field.
The addition of the NP should benefit not only EDs, but also patients (because they will get quicker access to the proper care) and ALS providers (because it will free them up for other emergent calls). “It should be a win-win-win,” Mason says.
An Eagle Eye
In February 2009, Western Eagle County Ambulance District in Eagle County, (Colo.) Chief Christopher Montera, EMT-P, found himself part of a consulting team helping to bring together 10 ambulance agencies in Colorado. As part of the process, he interviewed interested parties, such as the area’s local service directors and county commissioners. He asked about their biggest challenges and noted their answers.
“A service director in one of the counties said he needed to pay people; he needed paramedics,” Montera says in the “EMS 10: Innovators in EMS 2010” supplement to the May 2011 issue of JEMS. “Then, I was talking to a county commissioner one night, and she said, ‘I have all this money from the state to do public health and primary care, but no one wants to move here.’ That night it all came together.”
Montera realized that he could deploy his paramedics, who were highly trained and already part of the healthcare system, into the area’s rural communities. He could take his paramedics and, with the help of the public health department, make them community paramedics.
The central theme of the community paramedic program is to take an Eagle County paramedic in their current role and change what they do every day without changing the scope of practice. This would include post-hospital discharge follow-up, fall prevention, blood draws and medication reconciliation.
Montera has engaged and aligned the local hospitals and medical providers, along with public health, into a new healthcare model. The program has allowed for increased access to healthcare, streamlined medical and public health services and decreased overall healthcare costs.
For other communities interested in starting a program of their own, Montera welcomes the opportunity to share what he knows.
“It’s not cookie cutter, but we’re going to give you the template and tools so that you can go back and find out what you need in your community so that you can do that for your community,” he says. “We want to make it replicable for other communities.”
Montera says the response to his community paramedic program has been positive. He’s had help from the local fire department and the Health and Human Services Agency. He attributes this generosity to people’s willingness to step up and take care of the community. “It’s about what’s right for our community, what’s right is taking care of people every day, and maybe lessening some of their suffering,” he says.
These programs all share similarities. They’re all designed to reduce the burdens and frustrations on EMS units and EDs. They all feature aspects of home assessment, home care and patient follow-up that hasn’t been part of mainstream EMS in the past. And they all focus resources on target population, follow-up care and prevention. They ensure that minor problems, often missed aren’t missed and, more importantly, don’t accelerate or deteriorate to a level that requires hospital admission or readmission.
These leaders agree that they have distinct differences that are expressions of the unique needs of their communities. They also agree that individual communities’ needs are different but that the need for EMS to become a stronger partner in their community’s healthcare structure is more universal. “I don’t think, in reality, that we have a choice. This is the way to go. We can’t sit in this mold [of emergent transport for all],” says Mason. “The whole landscape of medical care has changed and is changing before our eyes.”
Jennifer Berry is the managing editor of JEMS. She can be reached at [email protected]