Community Paramedicine Makes Big Contribution to Emergency Medicine—If it’s Given the Support

Editor’s Note: This article kicks off a short series on community paramedicine and the supports needed to get programs up and running—and keep them running.

For more than three decades, community paramedicine programs have experimented with how to address the problems of America’s distressed, fragmented emergency medical care system, including overcrowded hospitals and emergency departments, not enough ambulances or people to staff them—particularly in rural areas—patients going to the ED who don’t need to but lack realistic alternatives, and the gamut of social determinants of health that impact outcomes of emergency interventions.

Depending on state and national regulations and local needs and resources, community paramedicine takes a variety of shapes and emphases. But the ongoing lack of financial support, particularly from insurance coverage for alternatives to unnecessary emergency room transports, makes it hard to achieve these goals. Many programs launched with grant funding or subsidized by their local communities are wondering about their future prospects, despite producing positive results.

Community paramedicine mobilizes specially trained paramedics and EMTs operating in expanded roles, assisting with public health, primary health care, and preventive services for underserved populations and connecting patients with appropriate responses. It’s considered an important component of mobile integrated healthcare (MIH), an emerging model of EMS defined in terms of delivering health services without necessarily transporting patients while decreasing unneeded ED visits, often incorporating a component of telemedicine.

James McLaughlin directs the MIH team and its community paramedics for Ute Pass Regional Health Service District, a rural ambulance service based just west of Colorado Springs in Woodland, CO. It covers portions of four counties in a mountainous region that has limited access to urgent care and just one critical access hospital.

“We have six or seven FTEs of dedicated community paramedics, and our goal is to make sure that they have the tools and resources they need for their work and to create opportunities for resiliency for them,” McLaughlin said.

The nearest behavioral health facilities, mental health crisis stabilization units, or substance abuse treatment and detox facilities can be two hours or more away in Denver or Colorado Springs.

“What we’ve found is that we can reduce cost and improve access and client satisfaction by doing medical screenings in the field. And the clients have better outcomes,” he said. “We are also the mobile crisis team that comes in and provides crisis services in our community.”

Based on Community Need

McLaughlin said every community paramedicine program is different, because its role is to address the needs of its community’s marginalized populations, and every community’s population in need is different. In some areas it’s unnecessary emergency room visits for patients who lack access to primary care. In other areas it’s prenatal care or post-partem care, because the local hospital has closed its labor and delivery unit.

Roughly 40% of the time, community paramedics in the Ute Pass community are able to intervene without needing to transport to an ED, he said. They work with an embedded psychiatric nurse practitioner who is part of the team and able to either join them on-site or do a tele-behavioral health evaluation to determine whether or not that person is safe to be left at home.

“We follow up within 24 hours to set them up with additional resources, counseling, substance abuse disorder treatment, medication-assisted treatment, things like that. We also have partners that we work with in the community, people who have recovered from substance abuse disorder or a behavioral crisis who will come and offer peer support for that person longer term as they start their recovery process,” McLaughlin said.

The program is supported by local government through property and sales taxes, patient billing, grants and a contract with the state’s Behavioral Health Office, McLaughlin’s boss, Timothy Dienst, MPA, NRP, CEO of the Ute Pass Regional Health Service District, explained during a workshop at the recent conference of the Association of Health Care Journalists in Los Angeles.

“We were one of the first rural EMS services to establish a mobile crisis response team. We put these patients on a safety plan and connect them to mental health providers and follow up,” he said. “We engage with them at home, then connect via telehealth to physicians or mid-levels, get their prescriptions filled, and the patient never has to leave their home.”

Key challenges for the Ute Pass program include workforce issues, a large coverage area with limited resources, and a poor payer mix, with 80% of its calls either Medicare, Medicaid or uninsured.

“Medicare, Medicaid and commercial payers won’t pay for treatment-in-place or for community paramedicine, even when paying for such services would save them money,” Dienst said. “A lot of our bills are denied, delayed, or reduced. Paying for it is our biggest challenge.” EMS is based on a failed economic model, he added. “Many of our calls never needed to go to the hospital in the first place.”

Bringing ‘Mobile’ Into the Health Space

Reuben Farnsworth, MBA, CP-C, CCP-C, NRP, Deputy Chief of Delta County Ambulance Service in Delta in rural southwestern Colorado, one hour from Grand Junction, offers another illustration of innovative response to local needs.

“We cover six counties. Our big focus is advanced clinical care,” he said.

The program manages very complex patients so they don’t have to make long-distance trips for acute care such as the infusion of experimental drugs, which would be either in Salt Lake City or Denver, a drive of four to five hours at minimum.

Farnsworth leads Delta’s community paramedic program, which is in the rare position of operating entirely in the black, thanks to a significant contract with local insurer Rocky Mountain Health Plans, among other financial supports, because its treatment-in-place approach has demonstrated ER avoidance.

“I’d say for our most complex patient, at best estimate, we saved the insurer a half-million dollars since last November. So, they see the value,” he said.

For Farnsworth, the terms MIH and community paramedicine are interchangeable, although MIH can also involve nurses and other professionals. “Community paramedics are a big piece of this. We bring ‘mobile’ into an integrated health space, whether it’s hospital at home, readmissions avoidance, or chronic and acute community paramedicine. But we also help reduce people’s dependence on the ER because our mobile team meets them where they’re at,” he said.

“We take a marginalized population and get them in touch with what they need. In our area, that’s primarily mental health, but this model can be whatever the community needs.”

People get a myopic view of community paramedicine, Farnsworth said, thinking of it primarily in terms of medical reconciliation or fall risk assessment. “That’s almost an insult. Community paramedics are the crisis responders for their communities. We’re very versatile.”

One of its biggest contributions is evaluating and supporting social determinants of health, he said. “Before we started this program, I didn’t realize how many patients were failing to keep their primary care appointments because they just didn’t have access to transportation.”

Areas of Greatest Need

Michael Juntunen coordinates the community paramedicine program at Mayo Clinic in Rochester, Minnestoa. This program employs 12 FTEs of community paramedics and deploys three to five in the field every day of the week, along with community EMTs.

The program started with a hospital-based approach, Juntunen said, “Asking where can we help, what can we do, identifying any barriers out there and trying to help fill the need—helping patients to be able to be successful outside the confines of a hospital or ED.”

To determine areas of greatest need for Mayo’s community paramedics, Juntunen approached different areas of the hospital and clinics, as well as leaders in the community.

Cardiology was the first department to partner with the community paramedics.

“We worked with cardiology to determine whether we could discharge patients earlier from the hospital, so that Mayo could serve more patients who needed our specialized cardiovascular care,” Juntunen said. The service started with lower acuity, community-dwelling patients who could complete their diuretics in their homes, with oversight from a cardiology advanced practitioner.

There were also phone-based consultations with cardiology providers, who already knew the patients, had seen them in person, and developed their care plans when they were still in the hospital.

“Then we did home visits one to two times a day,” Juntunen said.

After the success of the pilot with cardiology, community paramedics are now an open referral source for any provider, clinic, or hospital-based department at Mayo Clinic in Rochester., available for anyone in the system to refer to. 

“And that was huge for us,” he said. “We see quite a few patients where other services might not have the capacity, or else need to focus on higher level care. There’s this kind of No Man’s Land where people can get stuck, not getting what they really need to thrive at home. We have the advantage of being part of a large healthcare system in which the majority of our clients are somehow tied into that system. We carry our electronic health record with us and document directly into the EHR chart.”

If You Build It

“We are not paid adequately for the healthcare we provide,” McLaughlin argued. Even when insurance pays for community paramedicine, it’s not paying enough. “We are paid to provide expeditious transport from the scene of an emergency to a hospital, and until we can start to transition away from being merely a supplier of healthcare to a provider of healthcare services, we are going to continue to struggle with getting the compensation we deserve over the long term.”

If you want to know what community paramedicine really is all about, he said, look at your EMS staff who have the longest dispatch times.

“Go to those people and ask what kinds of patients are they working with—such as people with diabetes or behavioral crises. That will give you a clue. These are your providers on the scene of emergency calls. They’re doing community paramedicine, they just don’t use the term. By developing MIH, you’re enabling them to do the right thing. And if we can take that patient and treat them on scene, that’s a force multiplier. It helps to keep more ambulances on the road.”

McLaughlin believes if you build community paramedicine, they will come. “We took a huge leap of faith to do this program,” he said. With EMS stepping up to do a lot of new things, it can be hard work. “We do it because no one else will.”

What are the answers to the dilemmas of community paramedicine? Next month we will explore some possible solutions, including HR 2538, a bill now being considered in Congress to authorize reimbursement under Medicare for treatment in place by EMS.