Sarah Calams, Associate Editor
An ever-popular phrase from Kelly Grayson is – "if you've seen one Fire and EMS agency, then you've seen one Fire and EMS agency."
The same can be said for community paramedicine programs.
When you talk to anybody that either has a community paramedicine program or is considering implementing one, you'll quickly realize that all programs are different because they're driven by a needs assessment.
But at its base, community paramedicine is a program that ultimately aims to use a paramedic in an expanded role to cover more ground and more needs. The concept itself advocates an expanded use of the paramedic certification, but it's not just an excuse to expand what a paramedic does and doesn't do.
In fact, Chip J. Portz, assistant chief of EMS with Central Jackson County (Mo.) Fire Protection District, says his department's program, CJCares, which started in Sept. 2016, seeks to right-size the care that's given to patients.
No easy definition of mobile integrated healthcare
CJCFPD employs five community health workers with non-medical certification for the resource management component of community paramedicine and has two certified community paramedics on staff. CJCares piloted for six months while data was collected to assure administration and fire board officials that the program was a good use of permanent money.
The program assists in clinical care coordination between patients and providers; and provides medication inventory and compliance; community resource navigation; and home safety checks, such as fall risk assessments and post-discharge education.
Portz, who has served as assistant chief of EMS for three years and with the CJCFPD for 26 years, said sometimes, how a community paramedicine program is intended to be used isn't how it ends up being utilized based on the community's needs at the time.
CJCares, an acronym that stands for Central Jackson County/Community Assessment and Resource Evaluation Service, aims to reduce emergency call volume by applying a fire prevention model to an ever-increasing emergency call volume. CJCFPD's call volume has increased by more than 20 percent over the last four years, Portz explained.
"Our original goal was to reduce the usage of the emergency crews by targeting the superusers," Portz said.
CJCFPD first identifies the cause of frequent calls for assistance and then assists patients in finding non-emergency solutions. As a result, their interventions reduce the need for unplanned Fire and EMS trips to the hospital and increase the availability of emergency resources.
In order to track their success, Portz starts documenting at the first point of contact on a repeat patient.
"We start counting how many times we see them after we contact them," he said. "If it's been six months since we've contacted them, and we may have contacted them multiple times, I'll go back six months before and compare those two sets of numbers."
By using that method, CJCFPD has seen a decrease of 54.6 percent in superusers.
Portz says it's mostly not a matter of 911 abuse, but more so a matter of trying to identify what a patient needs and how to provide it.
"A good portion of our population that's calling frequently actually has chronic medical problems that aren't being solved by being transported to the emergency department," he said. "The reduction in frequent callers is our biggest documentable success."
The CJCares crew follows up with patients referred by Fire and EMS systems to help curb subsequent unplanned ambulance usage.
"We take references from a lot of different places, but some of the most important ones are the emergency crews that are out all the time on these calls," Portz said. "An emergency crew might have been to an address one time, but they may call and say that the patient looks like they have a chronic medical problem and that their needs aren't being met."
Portz clarified that even though a patient may not pop up on a frequent caller list, it doesn't mean that crews cannot identify those patients that may need more help.
"The interaction with the crews and the acceptance of the concept that maybe just taking someone to the emergency room isn't how we solve their problem is another hard-to-document success. It does demonstrate that we can sometimes do more than just transporting them to a hospital and dropping them off."
The biggest hurdle so far, Portz said, is that the CJCares program still doesn't have any reimbursement for its services.
"Some say that if you reduce your emergency calls and your transports, that as a transporting agency, you're actually reducing your revenue. And that's true, you can look at it that way. But by reducing those emergency transports, we're actually keeping the emergency resources available for true emergencies."
And right now, the program isn't marketed – it's mainly word of mouth.
"We do as many educational outreaches as we can, but one of the things that I insist on is that we go slowly. It frustrates the crew sometimes, but I still only have one crew to do all these things."
Portz reminds his team to focus on why the program was started – to reduce superusers and to make emergency resources more available.
"If we expand very quickly and don't put the brakes on, then we lose sight of why we started. I think the worst thing in the world we could do is promise something that we can't deliver.
Putting community healthcare first
If anyone can explain the benefits of going slow when it comes to community paramedicine programs, it's Fire Chief Steve Orusa. Chief Orusa, who has been a paramedic for 20 years, has served as chief for Fishers (Ind.) Fire and Emergency Services since April 2011.
In 2016, the department started its community paramedicine program. The department has one community paramedic on duty at all times.
"We had a conversation with our EMS division and we quickly realized that it's everyone's responsibility to put the health and wellness of the community first," Chief Orusa said.
The community paramedicine program began with four parts – blood pressure screening, CPR training, home safety surveys and a hospital discharge program. The department, which partnered with Community Hospital North, followed up with congestive heart failure patients for a year and was able to reduce CHF patients' readmission rate by 15 percent.
As a result, the program has been able to capture some grant funding from hospitals to help defer costs. Furthermore, the department is looking to expand the community paramedicine program with a mental health component.
The impetus to incorporate mental health in community outreach came from a midnight ride-along with the police department. After his experience, Mayor Scott Fadness came to Chief Orusa and said, “'What are we doing for mental health in our community?' I said, 'You know what, we're not prepared.' So he started us on a journey over the past three years to get educated on mental health and really try to create a community that embraces mental health before the crisis occurs."
The department is working to embed a licensed clinical social worker in the community paramedicine program.
"For example, one of the things we were successful in doing this past year was improving the mental health program in our schools," Chief Orusa said. "If a kid had a mental health issue, and that kid was immediately detained at Community Hospital North, that child was discharged and the school never knew about it. The community paramedicine program never knew about it."
Chief Orusa identified that gap in the local mental health and wellness system. Since then, the program has hired a full-time mental health coordinator and was able to hire mental health counselors to be in every school starting in January.
"At the hospital, parents can sign a release, so now the schools can get the kids services that they need and the community paramedicine program can follow-up at home with services as well. We have a continuum of care for that child's health and wellbeing, where before we had breaks in the chain."
The department is also working on a program for adults.
"We realize that it's going to be a marathon, not a sprint. We have a lot of things in play. It starts at the top – we can want to make progress and get better, but if we don't have the resources and leadership support, then it doesn’t happen and we become frustrated," Chief Orusa related.
Paramedics can redirect care
Kurt Krumperman, executive director with Albuquerque (N.M.) Ambulance Service, also prefers a community paramedicine program that grows slowly.
"It doesn't mean going 100 mph is a bad way to go, but it has a lot of risks," Krumperman said.
Krumperman, who has been with AAS for 6.5 years, has been involved in EMS since 1982. He spent most of his career in Syracuse, New York, where he was first exposed to paramedics playing a role in taking people to the right level of care.
"We had a snowstorm of 48 inches in less than 24 hours, and suddenly the idea was to take patients to the closest urgent care center rather than the ED. The idea of having paramedics redirect patients seemed to be an acceptable concept during a snowstorm. That's what got us started looking at the issue of the role paramedics play in determining what the right level of care is."
AAS' community paramedicine program started three years ago and it has four full-time community paramedics and one half-time community paramedic.
The department obtains a list of patients who frequently go to the ED from insurance companies. Representatives visit the patients and educate them on the difference between the ED, urgent care and primary care. The department also visits patients who are at high risk for readmission after discharge from the ED or a hospital.
"The program has been amazingly successful. We've reduced the frequent users' utilization of the ED by 70 percent," Krumperman reported.
Sometimes, crews find out during visits that patients really are doing poorly.
"There have been a few times that we've called 911 for an ambulance to pick them up and take them to a hospital because they weren't doing well," Krumperman said. "But it's with a definitive diagnosis, not a question. We know they aren't doing well because of our assessment."
AAS has maintained its community paramedicine program by developing relationships with both its hospital system and insurance companies.
"We've been able to do this in collaboration with them and with reimbursement from them. We haven't relied on grants at all. We are self-sustaining financially," Krumperman said.
AAS currently has contracts with three insurance companies and Krumperman said they're hoping to add a fourth in the near future.
And even though funding hasn't been a barrier, AAS has had difficulty with redirecting 911 patients away from the emergency department.
"Initially, we had a pilot project where we were redirecting low acuity callers into the 911 system to a nurse advice line, but that didn't work so well. We might try it again, but not in the near future."
AAS is currently working on creating a project where certain low acuity patients, if they qualify and are willing, will participate in a telemedicine consult with a physician who can redirect them to urgent care if they meet the criteria. Krumperman said AAS will most likely pilot the project in early 2018.
"We believe our program has been very successful to date. The main successes are people that are able to get the care they need without having to go into the hospital."
Establishing pilot program parameters
While all community paramedicine programs differ in goals, successes and roadblocks, Daniel Gerard's community paramedicine pilot program at Alameda (Calif.) City Fire Department has its own unique characteristics, accomplishments and obstacles.
Gerard, the EMS coordinator for the department, was a paramedic and EMT for 20 years in northern New Jersey. He has also been a professor of emergency medicine at George Washington University, orchestrated the ambulance redesign for Hong Kong Fire Services Department and worked with Pan American Health Organization in the Bahamas. He has been with ACFD for five years, went to the city of Oakland for six, and returned to ACFD to help run the community paramedicine pilot program.
The pilot program, which began in 2015, includes eight community paramedics. However, only two are in the office at the same time; they come in for three- to six-month rotations. They report all of their program data to the University of California, San Francisco.
The pilot is currently limited to the frequent user and the post-discharge Medicare patients. The pilot focuses on the patients who have a higher probability of readmission 30 days post discharge.
"Once we're past the pilot phase, we will be providing all of the services that the state of California will empower us with," Gerard said. "It's going to be based on community needs."
So far, the pilot program has been able to reduce hospital readmissions for the primary Medicare diagnosis by 75 percent; for the frequent users, they've reduced their admission to the hospital by 50 percent.
"The frequent user population is more challenging because they move around from community to community," Gerard said. "Because we're a pilot project, there's no way to pass those people off by giving another community a head's up."
Once the department moves from the pilot phase to a permanent program, Gerard said it will be able to come up with a better methodology to track those patients to make sure their needs are met wherever they live.
In the meantime, Gerard said the department is focusing on ways to fund to program.
"Every year, we have to scramble to put together the money to continue the pilot. We get measure money from the county, our city puts some money in and the EMS agency puts some money in. Getting everyone together on who's going to provide what dollar amount can be difficult."
Another issue they've run into – mainly because they're a pilot program – is having patients referred to the department that fall outside the boundaries of the pilot.
"These are vulnerable populations, but they may not meet the parameters of the pilot that we have set up. We made a commitment early on to try and work with these people the best that we could."
In one instance, a disabled man, who had a fire in his home, was in the hospital less than a day but needed help finding housing and food.
"All of his things were destroyed. We worked with him for a 48 to 72-hour period, where normally he would have been referred to the Red Cross and he would have had very limited housing options. There really wasn't a lot of support for him. We try to work with people the best that we can – even though they technically fall outside the pilot's parameters."
The other issue that the pilot program has encountered is coordination with other hospitals and medical facilities.
"When one of our patients ends up in Kaiser or Alta Bates Summit, there's a bit of a hurdle trying to work with them because they don't understand our role. But that's just evolved over time by building those relationships," Gerard noted.
Because Alameda is bound by the lines of geography, when patients leave the island and an incident occurs, sometimes that information doesn’t get back to the department in a timely manner.
"Our community paramedics have to remain diligent. They work hard and work the program really well. They're well-known with the social workers at the different hospitals."
Providing keys for success
At Alameda Hospital, Gerard said the social workers internally promoted the pilot program, which has contributed to its overall success. However, outside of the hospital, community paramedics have to make those relationships on their own.
"They really care about the patients and they want to make sure they get the care and the service that they need."
Gerard, reflecting on his favorite success story, said one community paramedic's desire to help his patient above and beyond the call of duty stood out the most. "We had an elderly female, who had CHF and diabetes, and she didn't have a lot of family support," he explained. "She was really at risk."
Community paramedic Patrick Corder worked diligently with the woman to get her the support that she needed.
"It was everything from Meals on Wheels, to get her back and forth to the doctor's office, he put her into a community group so that she could get active and wouldn't be in her house all the time."
And even after she successfully completed the program, Corder still worked with her.
"She had his phone number and would call him up once in a while and he continued to work with her to maintain that success. She was successful because we gave her all the tools she needed."
Corder also went with her to a doctor appointment in San Francisco to be an advocate for her and explain her issues to her primary care physician.
"He didn't say, 'OK, you're done' after she graduated the program. He continued to work with her. We're really proud of the program. The success of the program is wholly due to the community paramedics that we have."
The common link that binds all four community paramedicine programs together is the idea of a service that meets the needs of the community to ensure the people who need emergency services have them readily available. Each community has its own distinctive rhythm – including a variety of healthcare needs for people who call 911.
Services the programs provide, like mental healthcare for children and adults, and long-term care for people with chronic illness, are not readily available or provided by other emergency medical professionals. The programs may run differently, but slow and steady work will win the race.