Community Paramedic: Starting with Hospice

Nationally, healthcare is rapidly trending toward more community health and home health in order to help decrease unnecessary ED visits, admission and re-admission, and to continue treatment beyond discharge. The impetus for this came from patients, hospitals, insurance providers and public policymakers and is the future of healthcare. Since EMS has been providing medical care to the community in homes for decades, it is on the forefront of this push. This new area for EMS is becoming known as community paramedicine.

 

At Albuquerque Ambulance Service (AAS), we began to investigate how we can be a part of this change.

 

“Initially, our focus for the community paramedic (CP) was on navigating low-acuity patients away from EDs and to [prevent] high-risk patients who were just discharged from a hospital from being re-admitted,” says Kurt Krumperman, executive director for AAS. High-risk patients include patients with cardiac, neurological, respiratory or diabetic complaints. “But then, we broadened our view and looked at how we could prevent unnecessary ED visits and continue treatment for patients who already have in-home healthcare,” he says.

 

In January, we met with Presbyterian Healthcare Services (PHS) Hospice program in Albuquerque to discuss how AAS could assist with in-home hospice patients. The hospice team stated that during overnight hours, their patients were at risk of unnecessary ED visits and delays to in-home nursing care due to limited staffing. Only one triage nurse is available to answer phone calls from families and another nurse is available to responds to the patient’s home. When the overnight nurse is not immediately available, the family will ultimately call 9-1-1.

 

To address this, AAS and PHS developed a plan for CPs from AAS to be on call daily from 5 p.m. to 7 a.m., serving as backup to the lone overnight hospice nurse. The goal for the CPs is to respond to the home and provide care to the patient or comfort the family until the nurse is available to respond, if needed. They anticipated that the CP could respond to between five and 10 calls per month.

 

The CP responds in his or her personal vehicle equipped with a cell phone, laptop for patient care reporting and a jump bag equipped with a variety of basic medical supplies. The CP is dispatched by the hospice triage nurse with all necessary information, including past medical history, current complaints and current treatments performed at home by the patient’s family. The CP also has telephone access to the on-call hospice medical director. Hospice estimated that the average on-scene time for the CP would be 30 minutes to an hour.

 

As we began the paramedic selection process at AAS, there was a palpable level of excitement among paramedics for the CP program. As a new program with a large potential for expansion, it represented a different form of paramedicine, especially because the focus for hospice patients is more on comfort care and not treatment and transport. Our only requirement for the CP position was a minimum of one year of experience as a paramedic in a full-time capacity.

 

We received a large number of inquiries and each applicant had a different reason for wanting to join the CP hospice program. Joy Sturm, a paramedic for AAS, states that “hospice nurses are absolutely wonderful and really go out of their way to provide comfort care for the patient and the family, and I want to be a part of that.” At the age of 13, Strurm had firsthand experience with a hospice team when her mom was a patient.
Once the team of paramedics was selected, they underwent four hours of classroom training and eight hours of on-the job-training in the inpatient hospice unit at Presbyterian Kaseman Hospital in Albuquerque.

 

The program went live on June 1. During the first month, AAS responded to five requests from the hospice triage nurse.

 

Paramedic Tiffany Linne responded to two of those five calls. “My first call was at 11 p.m. It was weird to be responding solo to a call. I had difficulty finding the address, as there were no street lights and no partner to help me navigate,” she says.

 

Linne’s first patient was a 50-year-old female with a hospice diagnosis of chronic obstructive pulmonary disease. The hospice triage nurse advised Linne of the family’s concerned that the patient’s oxygen saturation was low, her heart rate was irregular and slow and she had a decreased respiratory rate. The triage nurse also told Linne that the family had been directed to administer the patient morphine from the home medication kit prior to her arrival.

 

“When I arrived at the home, the patient was awake and talking with normal vital signs,” Linne says. With family already rendering comfort care, Linne spent 40 minutes on scene comforting the family and reviewing the home medication kit and the steps of the dying process.

 

Sturm’s experience was similar.

 

“My first call was for a 90-year-old-female with a hospice diagnosis of COPD and cancer metastasized systemically. The family was concerned about the change in the patient’s condition,” Sturm says.

 

Prior to Sturm’s arrival, the hospice triage nurse directed the family to administer oral atropine, Ativan and morphine. The patient presented with signs that he was actively dying, including increased sleeping, increased oral secretions and slight crackles while sleeping

 

“I spent 30 minutes on scene, initially assessing the patient for signs of discomfort, and then spent the majority of the time comforting the family and reviewing the dying process,” Strum says.

 

AAS and PHS Hospice continue to grow and learn from this new program. Frequently, articles in the news highlight community health and home health services and how healthcare is moving more toward out-of-hospital care.

 

AAS continues to evaluate where the CP program can expand, solidifying it as a permanent business model in EMS. Since the start of this program in June, AAS has been approached by an assisted living facility that houses a number of hospice patients from a variety of hospice companies and is interested in learning if the CP program would benefit them and its patients.

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