Healthcare reform and the rise of accountable care organizations are driving new models that are forcing providers to rethink fundamental assumptions about how care is delivered, and who delivers that care.
Community paramedicine or mobile integrated healthcare—where paramedics address non-emergent healthcare needs in the patient’s home—offers the promise of improving patient outcomes while reducing the burden on overcrowded EDs and minimizing avoidable readmissions.
The concept of community paramedicine sounds good. But does it work in practice? For at least one regional United States medical center, the answer is a resounding yes.
New Hanover Regional Medical Center (NHRMC) is a tertiary care teaching hospital and regional referral center serving seven counties in southeastern North Carolina. Like many medical centers, its ED was heavily taxed with dramatic growth in non-emergent cases, and in EMS calls from “familiar faces.”
In 2013 alone, 29% of all 9-1-1 requests at NHRMC were for non-emergent situations. And a large number of these calls—more than 700—involved just 10 people. The impact of these “Top 10” was particularly acute in the summer, when the local beach community population swells by 20,000–30,000 visitors, placing additional strain on EMS and ED resources. So the question was: Could EMS lead the way to a solution?
Through the New Hanover Regional Medical Center program, patients are shown how to effectively interpret nutritional values that have a direct impact on their conditions.
To find the answer, the EMS team at NHRMC conducted a six-month pilot program involving two paramedics and two patients—one a well-known “familiar face” and the other a congestive heart failure (CHF) patient who frequently required an EMS response.
When these patients had non-emergent needs, they were encouraged to call their assigned paramedics, rather than 9-1-1, so their needs could be met at home.
After six months, the results were impressive: the “familiar face” went from 13 ED visits the prior year to just one and the CHF patient was transported to the hospital just once—compared to five times over a five-week period prior to the start of the pilot project.
The EMS team submitted this data to hospital leadership and gained support for a broader community paramedicine initiative. The hospital then applied for and received a grant from The Duke Endowment to fund the cost of three community paramedics—two full-time and one part-time position.
In 2014, the results mimicked the pattern seen in the pilot project, with dramatic reductions in CHF hospital readmission as well as in unneeded visits to the ED. The 9-1-1 “familiar face” patients have gone from 29 visits to just four, resulting in a significant reduction in EMS resource response and cost-of-care in the hospital system.
Based on these early results, NHRMC received another grant to focus on further reducing 30-day readmissions for CHF patients, which will add two more community paramedics. The EMS team is now trying to expand its impact in a controlled way to maintain success, while simultaneously delivering quality care.
Community paramedics help patients understand their medications through review and reconciliation.
The Positive Patient Care Experience
These results underscore an important aspect of community paramedicine: It’s not just about improving the numbers, it’s also about improving the patient experience. In fact, community paramedicine can take much of the stress out of the patient experience by enabling the patients to receive care in the comfort and security of their homes.
In the new world of community paramedicine, crews no longer arrive with sirens blaring and haul a gurney, monitor and other medical supplies in through the front door. Today, a community paramedic arrives in a professional-looking, non-transport vehicle and the staff member assesses the patient’s condition and care requirements before making an informed decision to treat the patient on site or acquire additional medical assistance.
In many cases, it may be as simple as reminding a patient to take medications essential to their conditions, or arranging a ride to a doctor’s appointment. Addressing these noncritical but important needs reduces the demand for EMS resources and stress on the patient, and also serves to improve patient satisfaction.
Each patient participating in NHRMC’s community paramedicine program is given a survey to rate their satisfaction on everything from the paramedic’s willingness to listen and explain things clearly, to the overall effectiveness of the program. So far, patient satisfaction has been rated 4.6 out of 5—proof the program is working.
Key Factors of Success
The goal of community paramedicine is to deliver care in the most appropriate setting—whether it’s in the home or en route to a clinic, hospital or other care facility.
The experience at NHRMC illustrates the potential for positive impact. However, there are lessons from this community paramedicine program that highlight important success factors.
1. Education and experience: Community paramedics must be highly experienced and thoroughly educated. NHRMC’s services are provided by paramedics with substantial clinical backgrounds. The individuals delivering this new level of out-of-hospital assessment, care and referral must have the training and certification to understand more complex medication formularies and assess more complex conditions—essential prerequisites to a successful mobile integrated healthcare program.
In addition, they should possess specialized training in areas central to the program’s expanded objectives. The NHRMC program includes 100 hours of online and classroom training, plus 200 hours of training in multiple specialties, such as nutritional planning, social service, behavioral health, CHF, pulmonary medicine, rehabilitation and healthcare policy. This training, together with a demonstrated ability to relate to patients one-on-one, is crucial to achieving positive outcomes.
2. Portable technology: Having the right portable technology—and the knowledge and training to use it appropriately—is a crucial success factor. Community paramedics are called upon to assess and address a wide variety of patient conditions. Many patients, such as the CHF patients targeted by NHRMC, may have complex comorbidities that call for additional diagnostic tools.
The program supplies community paramedics with portable technology to assist in treating and sharing data for a variety of patient conditions that may be encountered.
Leveraging the latest innovations in portable healthcare technology that provide easily interpretable information is essential to realize the full potential for community paramedicine. Diagnostic tools, including point-of-care testing devices, as well as data sharing tools, such as 12-lead ECG upload and transmission and EPIC charting software, are among the tools community paramedics rely on daily.
3. Hospital-to-home, home-to-hospital focus: Breaking down barriers across the care continuum, so care is delivered in the most appropriate and effective manner, is crucial for a successful community paramedicine initiative.
Community paramedicine is about bringing care to those who need it, when and where they need it. At NHRMC, it often begins before a patient goes home. If the team receives a referral within the hospital, the paramedic can begin care at the patient’s bedside the day before discharge or in the ED.
NHRMC reports that most patients welcome the idea of having a community paramedic looking out for them.
4. Whole patient approach: Community paramedics must be sensitive to the broadest range of possibilities when assessing a patient’s needs. They must look for mobility barriers that are preventing patients from getting to the doctor on their own—something as basic as the need for a ramp to the front door or a neighbor to drive them. They have to look for fall hazards in the home, or whether the patient is eating properly and taking the right medications at the right times and right doses.
Paying attention to the small details of daily life can often reveal the patterns that drove the patient to call 9-1-1 in the first place. Earning the patient’s trust and confidence enables the community paramedic to make gentle suggestions that can improve patient compliance or result in lifestyle changes, while reducing 9-1-1 calls.
5. Partnering with payers: The community paramedicine model is still ahead of the curve when it comes to traditional payer models, which are focused on reimbursing EMS for transporting patients to the hospital. To date, NHRMC has been fortunate enough to garner grants totaling more than $475,000 to help fund its program. The NHRMC leadership has been extremely supportive—taking a, “we’ll deal with the dollars later” approach and focusing first on improving patient care.
However, for community paramedicine to be sustainable, payers will need to be convinced that this innovative approach has clinical benefits as well. As the early experience at NHRMC shows, community paramedicine has tremendous potential for reducing avoidable ED visits and readmissions, particularly among the small percentage of “familiar faces” and for those chronic conditions like CHF.
Hopefully, momentum will build for changing insurance reimbursement models to support new community care initiatives, as evidence of the advantages continues to mount. NHRMC has shown forward-looking EMS providers are making the business case for community paramedicine, forging partnerships with medical centers that benefit everyone—hospitals, EMS, patients and the community at large.
Bridging the Gap
The experience of NHRMC isn’t unique. According to the National Association of EMTs, there are approximately 250 formal community paramedicine programs, with new ones being added continuously. But perhaps the greatest result of community paramedicine has been the bridging of the gap that so often separates hospitals and EMS professionals.
It’s bringing to light the fact that we’re all healthcare professionals, all dedicated to serving patients and the community, and all working toward a healthcare system that does more with less.
Tapping the talent that’s already out in the healthcare community and providing them with training and technology to enable connected care across the continuum will help drive this healthcare transformation.
NHRMC has shared its community paramedicine best practices with several other startups across the country, many of which are adopting a similar model. It’s possible to achieve high impact with a relatively low investment.