A machine’s cogwheels work together to create a mechanical advantage. Deviations to this structure, such as helical gears, change the configuration, orientation and production of the machine. Today, there’s a new world of epicyclical gears in motion: “community paramedicine.”
Every healthcare-related problem varies in size and rotates around a non-fixed point, which creates various moments with random speeds while still mandating interconnected patient solutions. Therefore, all healthcare systems and processes are constantly moving and each are interdependent on each other. Each patient issue within those systems has its own unique root cause, which must be solved.
It can be a moving target, but our new role is to manage all these moving parts and find solutions. In this environment, EMS can no longer say, “It’s the hospital’s problem now.” We’re in this with the patient for the long haul and need to achieve results.
As community paramedics, we examine each identified patient issue by analyzing the root cause; we have accountability and responsibility for all aspects of patient care. Our basic process at Montgomery County, Texas, Hospital District (MCHD) is three steps:
1. Evaluate. Do a comprehensive assessment on the patient’s:
>> Physical, mental and psycho-social health;
>> Ability to independently perform the basic activities of daily living; and
>> Living arrangements, social network and access to support services.
2. Navigate. Make a care plan that:
>> Addresses areas of concern; and
>> Provides suggested interventions or actions and recommendations.
3. Link. Coordinate care by:
>> Managing healthcare and communication;
>> Providing support services and resources; and
>> Continuing evaluation and monitoring.
This process of managing the multiple components of care requires much more dedicated time, resources and integration than solely providing acute emergency prehospital care.
The MCHD community paramedicine program is being funded for a three-year period through the Texas 1115 Transformation Waiver Program. This system allows for incentive payments based upon the achievement of mutually agreed-upon metrics and milestones between the Health and Human Services Commission and Montgomery County Public Health District, the performing provider. Services are then contracted to MCHD EMS to deliver the program to qualifying residents of Montgomery County.
The community paramedicine team is comprised of five paramedics (including the program coordinator), a registered nurse (RN) case manager and the EMS medical director. The paramedics work in the field with the patients and collaborate with the RN case manager to deliver an individualized care plan. The RN case manager collaborates with the patient’s primary care physician (PCP), home health or other services being received so the approach is interconnected with all facets of the patient’s healthcare. The EMS medical director oversees all aspects of program delivery.
MCHD is also in the process of adding a physician’s assistant to the group, who will provide direct clinical oversight, make home visits with the paramedics, treat conditions in the home, prescribe immediate-needs medications and collaborate directly with healthcare specialists.
The objective of the MCHD program is to improve the patient’s overall quality of life; reduce the need for emergency services and return hospitalizations; reduce disparities by assisting in navigation of medical and social services; and empower and enable individuals to manage their health and welfare. Understanding linkages between socioeconomic inequity and health is essential to reducing exposures to environmental hazards as well as disparities in health.1 Delivering health services to this at-risk population attempts to bridge these gaps.
MCHD’s community paramedicine team consists of a program coordinator, an RN case manager, three community paramedics and a medical director.
Elbert Greenwood is a 59-year-old male who was identified as a potential enrollee in the community paramedicine program based solely on his extensive 9-1-1 use. After the first meeting it was quickly determined these multiple emergency calls were a manifestation of many social, medical and educational access problems. Each identified issue appeared to originate from a basic lack of transportation and a perceived lack of social support.
Elbert always called 9-1-1 for one of two reasons: he had abdominal pain or shortness of breath because he needed a paracentesis, or he had altered mental status associated with liver failure (i.e., high ammonia levels). The typical chain of events included an ED visit, 2—5 days of in-patient care and sometimes a transfer to a medical rehabilitation facility–all on a roughly two-week rotation.
When discharged, he would be given prescriptions for his medications for one month and instructions to follow up with a PCP and multiple specialists. However, he was never able to accomplish any of these tasks because he didn’t have transportation or the essential tools to access other resources. Elbert had no PCP, was 100% medication noncompliant, had no phone, and was receiving no specialized care for any of his chronic conditions. He used 9-1-1 and the ED as treatment for all of his ongoing medical needs.
A patient with a PCP is more compliant because they trust the doctor’s advice and are more likely to follow it. Furthermore, having someone coordinate your care can be critical if you have multiple providers.2 Elbert had very little synchronization regarding his medical care and multiple chronic conditions that required medications, long-term monitoring and clinical interventions, so our first challenge with Elbert was to obtain a PCP to allow him to gain access to medications, referrals to specialists and preventive care for his chronic conditions.
The second challenge was transportation; Elbert has no wife or kids to ask for a ride, no vehicle, no money for taxis and no access to public transportation. Two-thirds of rural America–60 million people–are almost wholly unserved by public transportation.3 Elbert also didn’t feel comfortable asking his family members for support.
The community paramedicine team provided encouragement and offered support in his decision to reach out to his sister and brother. Concurrently, we identified a family practice with nurse practitioners (NP) who perform in-home mid-level provider medical assessments. Elbert now only had to travel to the PCP’s office once and then the NP would perform the continuing in-home visits.
Initially, we had problems getting him into this PCP because Elbert had lost his wallet; he didn’t possess a hard copy of his insurance card nor driver’s license. As patient advocates, we reached out to his insurance office to get him expedited through the system. At the same time, Elbert had to save enough money to get a renewed license and wait the required six weeks for new Medicare/Medicaid cards. It’s unfortunate, but if the community paramedics hadn’t been part of his integrated healthcare team, he would still be waiting for his initial appointment–assuming he would’ve identified the program providing in-home visits. His lack of access to transportation hindered his ability to seek traditional physician’s visits, but his low socioeconomic status and lack of access to technology made it impossible to seek or identify any possible alternatives.
Elbert is on social security disability and his fixed income “is mostly for utilities.” When we first met Elbert in his home, although very clean, it was a small, poorly constructed trailer with many homespun plywood repairs. There were gaps in the floor, walls and doors, and no central heat; there were also recent problems with plumbing and water.
Our first encounter and immediate concern included education on the dangers of his homemade heating unit–a camp stove with a propane bottle. We explained to him the dangers of carbon monoxide poisoning with such a setup, but he didn’t think he had another option. We again encouraged him to seek help from his family to replace the heating unit while we looked into public resources. To our surprise, on our next visit he had installed an old wood-burning stove that was properly ventilated to the outside. This small upgrade made his home safer and showed us his willingness to self-manage if given education and explanation; we also no longer needed to seek additional public resources for heating. But it also showed the community paramedicine program coordinators that although Elbert’s medical needs were extensive, there were basic amenities that needed to be addressed to decrease the risk of potential hazards that could lead to further 9-1-1 calls.
Elbert’s fixed income didn’t afford him the ability to do any basic home repairs, buy over-the-counter medications not covered by Medicare/Medicaid, call taxis to get to appointments or attain a healthier diet. He was only able to walk two driveways from his house to the local rural corner store for prepackaged foods. The community paramedicine team worked with Elbert to get him linked to resources to support with home repair, to cover utility costs and to get food stamps. This will give Elbert the ability to purchase necessary items that are prescribed but not covered, and eat a more balanced diet with healthier food choices.
In the time leading up to the PCP appointment, we concentrated on Elbert’s access to required medications. He wasn’t able to get any of his medications from medical rehabilitation filled because the rehabilitation facility sent the prescriptions to a local chain pharmacy close to his home–but “close” for Elbert was over seven miles one way. He was unable to walk this long distance, unable to afford a taxi and didn’t have access to a phone. Additionally, he didn’t have a computer to request mail order; even if he did, he was unable to afford the copay on mail-order medications.
Our team researched potential options and located a pharmacy in his area that delivered medications to his home free of charge. He now had his needed medications, but this unearthed another problem with his access.
Besides having chronic liver disease and hepatitis C, Elbert had recently been diagnosed with Type II Diabetes. The team discovered this diagnosis by looking at his record from the rehabilitation facility. Elbert said he was unaware of this information and had never received any direction on the newly identified chronic condition. He told us he’d never thought to even look into the folder that came home with him every time he was admitted. “That’s for the doctor when I get one,” he said. He didn’t know he needed insulin and oral diabetes mellitus medication, to be checking his blood glucose levels (BGL) or that he needed to augment his diet. We worked on basic diabetic education, got him food logs, read food labels with him and worked on nutrition questions as they arose. But, when his insulin arrived with his other medications from the new pharmacy we discovered he didn’t have a glucometer.
Since Elbert has Medicare/Medicaid, the cost of a glucometer and diabetic testing supplies should’ve been covered, but the delivering pharmacy didn’t fill medical equipment. Because he wasn’t taking insulin, we urgently needed for Elbert to monitor his BGL. We contacted a local major chain pharmacy to get the supplies; that pharmacy needed a prescription for it to be covered. We asked our medical director to write the required medical equipment prescription (glucometer, lancets and strips), which we submitted to the major chain pharmacy. It was subsequently denied the following day for lack of prior approval.
Elbert was now at risk of a new set of 9-1-1 calls because he had diabetes medication but no way to check his BGL. In most instances, unplanned readmissions to a hospital indicate bad health outcomes for patients.4 The community paramedics were the only ones taking his BGL during their in-home visits. Since the prescription through the medical director had been denied, we ultimately donated to him one of our service’s surplus devices while we waited for the PCP to approve a glucometer through Medicare/Medicaid. This way, Elbert could immediately check his BGL prior to every insulin administration.
He now keeps a written record of his BGL because he “just feels better” when his sugar isn’t consistently over 350 mg/dL.
To continue the coordination of care, the community paramedics began working with Elbert’s NP to better manage the long-term situation of his chronic conditions. Utilizing resources available through MCHD’s pharmacy benefits coordinator and case managers with MCHD’s Health Care Assistance Program, Elbert was enrolled in a drug company payment program for medication to treat his Hepatitis. This lowers his out-of-pocket medication costs, which currently are his second-largest monthly expense.
He’s also now a patient of an interventional radiology (IR) team that has set weekly appointments for a preventative paracentesis, which should reduce the need for emergent intervention in the ED. The clinic has ambulatory transportation services sponsored by Medicare/Medicaid, so Elbert has a backup transportation plan if his family can’t drive him to these scheduled appointments.
Reduced out-of-pocket expenses, case management and patient education with behavior support all improved Elbert’s medication adherence.5
We initially intervened with Elbert to decrease his 9-1-1 usage. One may have thought that just referring him to a PCP would have solved a lot of his issues, but that was just the superficial problem. Each new issue stemmed from lack of a perceived social support system and lack of transportation. As we tackled his issues, we kept uncovering problems (gears) that needed to be solved (turned). Everything was and is intertwined, and the only way to make Elbert healthier on the whole is to operate knowing that one intervention affects those that come before and after.
None of this would have been accomplished if Elbert wasn’t an active participant in his healthcare. The key factor in this entire process was Elbert and his desire to change his situation. It wouldn’t matter if we found him a PCP if he refused to go to appointments, it wouldn’t matter if we’d delivered his medications if he didn’t take them as prescribed, it wouldn’t matter if he had a glucometer if he was unwilling to use it. His compliance and participation with the community paramedicine team and program made him a self-manager in his own health, welfare and, ultimately, life. With some of his basic needs met and his full compliance, we’ve been able to switch gears with his aid, converting to more education, maintenance and monitoring. When our interventions started to fall into place, Elbert stated in reference to our team, “I didn’t realize I’d gotten a Rottweiler that wouldn’t let go.” We reassured Elbert we indeed were here for the long haul.
A Year in Review
During the first fiscal year of MCHD’s community paramedicine program, 26 patients were enrolled. Of those patients, 16 (61.5%) showed a decrease in 9-1-1 use. This group collectively went from a pre- enrollment figure of 236 emergency calls to a post-enrollment figure of 132, resulting in a large savings for both the hospital and MCHD EMS. (See Table 1, below.)
Interestingly, eight (30.8%) patients increased their usage of 9-1-1 from 79 emergency calls collectively to 150 calls. This supports our initial belief that patients who show non-compliance won’t benefit from these programs.
Of the 26 patients, one showed no change and one moved away.
Table 1: Cost savings from decreased resource usage from community paramedicine patients
The lack of overall basic strategies and mechanisms for patient integration in our current healthcare system touches both the patients and the providers. To understand comprehensiveness–a common ground to the definition of integration–we must understand the relationship of elements that constitutes the whole. Therefore, if we don’t get to the underlying cause of each patient issue, the patient doesn’t have a chance for success and the issues will reoccur. When providers analyze the root cause, they’re able to identify and modify issues. Vulnerable individuals have complicated and ongoing needs (which frequently are part medical, part physical, part psychological and part social), experience difficulties in everyday living, require a mix of services delivered sequentially or simultaneously by multiple providers, and receive both cure and care in the home, community and institutional settings.6
The process of providing healthcare, social services and other related reinforcements at the right time, the right place and within the right setting to this group of high-risk patients becomes very difficult or sometimes just impossible with today’s current environment and resources. However, just like prehospital EMS, healthcare providers must continue finding new remedies, answers and solutions to the numerous problems and hurdles we’re faced with. Only then will these discoveries lead to new, safe and effective quality methods for the improvement of patient outcomes for citizens and the community.
1. Srinivasion S, O’Fallon LR, Dearry A. Creating healthy communities, healthy homes, healthy people: Initiating a research agenda on the built environment and public health. Am J Public Health. 2003;93(9):1446—1450.
2. Gorman C. (Sept. 1, 2010.) How primary care heals health disparities. Scientific American. Retrieved Feb. 5, 2015, from www.scientificamerican.com/articleclosing-the-health-gap/?page=2.
3. Community Transportation Association of America: Atlas of public transportation in rural America. National Transit Resource Center: Washington, D.C.,1994.
4. Walraven CV, Bennett C, Jennings A, et al. Proportion of hospital readmissions deemed avoidable: A systematic review. CMAJ. 2011;183(7):391—402.
5. Viswanathan M, Golin CE, Jones CD, et al. Interventions to improve adherence to self-administered medications for chronic diseases in the United States. Ann Intern Med. 2012;157(11):785—795
6. Kodner DL, Spreeuwenberg C. Integrated care: Meaning, logic, applications, and implications–A discussion paper. Int J Integr Care. 2002;2:e12.