Imagine two hours of focused conversation with international leaders on any topic you want to ask about relating to the development, implementation and sustainability of mobile integrated healthcare/community paramedic (MIH-CP) programs. That was exactly what happened during EMS Today’s MIH-CP roundtable sessions. During this intimate, dynamic and highly interactive session, participants received very candid responses to some of the most pressing questions about MIH-CP programs. Here’s what we learned:
What’s the best way to kick-off an MIH-CP program?
Start with the end in mind. Most successful MIH-CP programs start after assessing for gaps in the local healthcare delivery system. Whether in an urban or rural area, there will likely be gaps that EMS agencies can fill. In some cases, it may be serving in a primary care/physician extender model with community paramedics embedded in the local community, while in other areas, it may be using EMS resources to navigate patients through the healthcare system to the most appropriate healthcare resource.
Determining the gaps typically requires either a formal or informal community gap analysis with local healthcare stakeholders. Once the gaps have been identified, local EMS leaders can then tailor the program to bring valuable resources to the local community. That value will help make the program sustainable over time.
What are the sustainable funding models for MIH-CP programs?
The good news is that there are a growing number of MIH-CP programs beginning to generate revenue for EMS agencies. Some of the more prevalent economic models are fee-for-service payments for patient contacts and patient enrollment fees.
In the patient contact model, agencies are paid a predetermined amount for each patient contact, or paid an hourly rate for the time the community paramedic is working with patients. Third party commercial payers and state Medicaid offices are the most common sources of funding under the fee-for-service model.
Enrollment fees are designed to reimburse EMS agencies for the duration of a specified enrollment period for specific programs such as high utilizer and readmission prevention. In this model, the EMS agency is at risk for the utilization of the community paramedic during the patient enrollment. Since the agency gets the same amount for each enrollment, a patient who requires 20 visits over 30 days to achieve the desired outcome will be more expensive to the EMS agency than a patient who requires nine visits to achieve the same outcome.
A less common, but growing, economic model is a per-member/per-month payment for MIH-CP services. In this model, the EMS agency is paid a set amount per month for each patient enrolled in the program. This model is attractive to payers since it helps them budget monthly expenses and shifts some of the utilization risk to the EMS agency. In some rare instances, the payer may include the payment for traditional ambulance service into the same per-member/per-month rate.
Are there any uniform processes for measuring the outcomes of MIH-CP interventions?
This has been one of the most exciting things about the evolution of MIH-CP programs. Over the past two years, a large group of providers, national EMS associations, external stakeholders and even healthcare accreditation and quality organizations have made great progress in formalizing and standardizing outcome measures for MIH-CP programs.
Outcome measures have been finalized and published for the domains of program structure, patient safety and quality, utilization, cost savings, patient satisfaction and health status, and healthcare system balancing measures for the community paramedic and 9-1-1 nurse triage interventions. These measures are very specific with detailed descriptions of the measure goal, what data to query and the actual formula to use in calculating the measure are specifically described in the measures tool. The group is currently developing process measures for the community paramedic intervention and outcome measures for ambulance transport alternatives.
The measures tool and accompanying Excel workbook can be accessed at the National Association of EMTs MIH-CP Toolkit.
Are there any educational standards for Community Paramedics?
The responses to this question were very diverse, based largely on the geography of the respondent. In the United States, there are a few community paramedic educational models, the most prevalent being the curriculum developed by the Hennepin Community College and the Paramedic Foundation. This curriculum is provided free of charge to accredited colleges or universities to conduct local programs, or through distance education. Generally, this training course is 200–300 hours for didactic and clinical components and are taught to currently certified paramedics.
In other countries, such as the United Kingdom, Australia and Canada, the base paramedic training program could be up to three years and include a formal degree. Many of the concepts of community paramedicine is included in that training requirement. In some cases, additional community paramedicine or “advanced care practitioner” courses, could be an additional two to three years of education. The main difference is that in those countries, the community paramedic or advanced care practitioner is an independent practitioner, meaning they don’t require clinical supervision by a physician, like a nurse practitioner in the U.S.
Another development in the U.S. has been the completion of a standardized certification process for community paramedics developed by a team of experts working with the International Board of Specialty Certification (IBSC). This exam was based on the actual core competencies most commonly used by existing community paramedics across the country through a survey process of program leaders and those functioning as community paramedics. The group then developed specific questions to test the understanding of these competencies and conducted beta tests of the exams over the past year.
There was also discussion about the potential role of community health worker (CHW) training for community paramedics. CHW is an evidence-based intervention that trains local community members who are knowledgeable about the culture of the local community. CHW training is generally nonclinical, but rather focuses on concepts such as social determinants of health, patient education and motivational interviewing. In many states, CHWs are already reimbursable by Medicaid and other payers. Perhaps CHW certification would be a logical component of community paramedic training due to the evidence-based and economic models. If paramedics gain additional certification as CHWs, we would be using CHWs who have the added value of being able to provide clinical care.
The Future …
The roundtables concluded with several of the agency leaders predicting that the role of MIH-CP services will continue to evolve and expand. Many interventions and service lines being conducted by MIH-CP programs today weren’t even contemplated a year ago and system leaders outlined programs they have been asked to consider by healthcare partners, such as palliative care partnerships, bundled payment partnerships for joint replacement and cardiac patients, as well as expanded roles for clinically appropriate alternative destinations for 9-1-1 callers. Experts cautioned participants that mission creep continues to be a challenge. Local agency leaders should continually evaluate requests for service expansion based on whether they can provide service that demonstrates value while staying within the traditional scope of services for an EMS agency and paramedics.