Published in NDEMS magazine and written by Sean Roed
The day of the Doctor home visits are over, and the chance for our patients to be on home health or hospice are limited to those patients that are terminally ill, or homebound patients that have entered into a largely overtaxed system already. This is where North Dakota EMS can offer assistance for patients and our communities in the form of Community Paramedicine. We have heard of Community Paramedicine, but what does it mean and what do they do?
To put it blatantly, our Community Paramedics fill a much needed gap in the healthcare system, especially in rural North Dakota that is stretched so thin. These trained professionals’ goal is to improve the health and wellness of our communities through collaboration from our Doctors, Hospitals, and Clinics. Community Paramedics help by educating enrollees with the management of their healthcare needs, giving them direct access via telehealth to their primary physicians from the comfort of their own home. It can also help provide prenatal care and assist in senior care services to name a few. They are also able to deliver essential supplies to their patients such as their medications and in some cases, even food. Through the program, the community paramedicine team will work with multiple agencies to establish additional services that a patient might need, such as Meals- on- Wheels or prescription delivery. Care plans will be tailored to each patient, considering their specific home environment, support, and medical needs (Premier, 2019).
The Need:
Our local hospitals and clinics are getting increasing scrutiny from payers and governmental oversight bodies regarding readmission of patients to the hospital, and continuing care of patients. Many ambulance services within North Dakota have already established themselves within the community. By creating a Community Paramedic or Mobile Integrated Healthcare program, our EMS services will be able to play a vital role in assisting our local hospitals and clinics. The Mobile Integrated Healthcare program will focus on patient populations deemed at- risk for hospital readmission, but do not qualify for home health, or just refuse any home health services. The patients seen at our local clinics that need a continuum of care, but do not qualify for home health can greatly benefit from the program. Since most of North Dakota has a high percentage of citizens who are marginally housed, or economically disadvantaged, being enrolled in the Mobile Healthcare program is financially beneficial for them and offers healthcare that would otherwise be unavailable to them.
Many hospice patient family members mistakenly call 911 to have their loved ones transported to the Emergency Department, which is likely to cause disenrollment in the hospice program. If 911 is called, ambulance services would be able to contact the Community Paramedics to assist the hospice patient and assure that they remain in the program, while being able to render care and treatments while the patient remains at home.
With North Dakota’s high percentage of elderly citizens over the age of 65, Community Paramedic programs will be able to offer several services for our elderly patients that are unavailable to many now. Elderly patients enrolled in the program will have affordable healthcare services available to them to ease daily life activities.
A large gap in service for most of North Dakota involves access to behavioral/mental health services. Many of our health services have been overwhelmed and are unable to treat the multitude of patients seeking help. Community Paramedics can help bridge the needs of our citizens and assist in getting the care that they need and desire.
Gap-In-Service Delivery
Community Paramedics could provide gap-in-service delivery for several concepts throughout North Dakota that are difficult for our citizens to gain access to, or even receive help whatsoever. Most North Dakotans see problems within their own communities, and implementing a Mobile Integrated Healthcare or Community Paramedic program in your community will help address some of the concerns and gaps. There are some concepts that can be made available through Community Paramedicine programs to help deliver these gaps-in-service for our communities. Your own Community Paramedic or Mobile Integrated Healthcare programs can incorporate the following goals that the programs provide:
- Post Discharge
- The goal of the post discharge project concept is to avoid as many unnecessary EMS transports, Emergency Room visits, or Hospital Readmissions as possible.
- Alternate Destination
- The goals of the alternate destination project are to ease the burden of our Emergency Departments, reduce medical costs, or avoid Emergency Department overcrowding. Community Paramedics are able to treat patients on scene without transport to the emergency room or offer alternative facilities that are able to care for their needs. This also allows EMS to increase its serviceability and increases options for the community.
- Frequent 911
- The goals of the Frequent 911 project are for individuals who call 911 on a regular basis. Community Paramedics can connect these individuals with services tailored to their needs, further reducing emergency room overcrowding and reducing costs. Typically, these patients are better served by non-emergency aspects of health care, or by social services.
- Hospice
- The goal of the hospice project is to provide hospice patients with the medical care and support necessary to remain at their residence or location instead of being unnecessarily transported to the emergency department. This also allows the hospice patient to remain in hospice care and avoid potential disenrollment.
- Public Health Collaboration
- The goal of the public health collaboration project concept is to provide more efficient and effective healthcare for those individuals that are being treated under local District Health programs and partnering them with our Community Paramedics through the public health department case workers.
- Behavioral Health
- The goal of the behavioral health project is to provide patients with the ability to be evaluated in a timely manner and provide more appropriate care. Community Paramedics can provide a more effective, efficient, and timely service by again avoiding the emergency department, reduce the unnecessary out of town interfacility transports, and lowering costs. Community Paramedics can work closely with social services and other support agencies to provide the best care available through direct provider contact, or telehealth assessments with other mental health professionals.
- Sobering Center
- The goals of the Sobering Center project are to assist patients that suffer from alcohol or drug addiction by offering them alternatives to going to the emergency departments for routine care and provide them with treatments and transports to more appropriate facilities that are capable of administering the appropriate medical care (Meyer, 2022).
- Elderly Assistance
- The goals of the Elderly Assistance project are to provide our elderly population with assistance on routine tasks, such as setting up medications, education on procedures, and providing alternative transport options to facilities that are more appropriate for the elderly, while avoiding overcrowding the emergency department.
- Telehealth
- The goals of the Telehealth project are to offer enrolled or referred patients the ability to have Community Paramedics respond to their residence or location and set up telehealth communications with the patient’s primary care providers. Community Paramedics will be able to take vital signs, perform 12 lead EKGs, draw labs, and act as the primary care provider’s eyes and ears to help perform patient assessments. This program will help patients remain in the comforts of their own homes while still communicating with their primary care provider. The Community Paramedics would even be able to bring any prescribed medications to the patient’s location, making this project very effective, proficient and lowers healthcare costs.
Community Paramedicine in Rural North Dakota --Qualifications and Education Requirements
Community Paramedics are advanced paramedics that work to increase access to primary and preventive care, while decreasing the use of emergency departments, decreasing unnecessary hospitalizations, and decreasing the total costs of healthcare. Community Paramedics are not meant to replace any existing healthcare programs, but will supplement and enhance other programs, while providing a gap in medical services for North Dakota. Several programs are available to teach potential Community Paramedics and are typically a few semesters in length. Some programs even allow EMT’s to take the beginning portion of the classes as they are looking to eventually advance their careers.
Most Community Paramedic programs have a pre-requisite for entering the program. For example, some programs require that the Paramedics have worked for an Advanced Life Support (ALS) for a minimum of 2 years prior to enrolling in the program. Community Paramedic programs will allow students to get specialized training, which consists of lectures, labs and clinical rotations. Their studies provide advanced clinical assessment and treatment of patients with specific and chronic illnesses. Areas of study include:
- Disease of the Eye, Ears, Nose, and Throat
- Hematologic Diseases
- Immunologic Diseases
- Endocrine Emergencies
- Infectious Diseases
- Abdominal and Gastrointestinal Diseases
- Special Challenge Patients
- Genitourinary Diseases
- Geriatrics
The Community Paramedic will also have advanced education in traumatic injuries which include assessment and management of:
- Blunt Trauma
- Soft-Tissue Trauma
- Burns
- Penetrating Trauma
- Musculoskeletal Trauma
- Trauma to the Head, Face, and Neck
- Spinal Trauma
- Thoracic Trauma
- Abdominal Trauma
- Epidemiology of Trauma
- Hemorrhage and Shock
The Community Paramedic is educated in aspects of community-based care in the pre-hospital environment, the needs assessments of their patients, the healthcare needs of the community, patient monitoring and interventions, as well as utilization, and coordination of community health with the major stakeholders and social services in the area (Kahout, 2022).
Community Paramedicine in Rural North Dakota -- Funding the Program, Equipment Needed, and Estimated Program Results
Several models that will help provide the funding necessary to effectively finance such an operation. One of the models will require the formulation of an Ambulance Tax District to help alleviate the expenses. Direct billing of the patient’s insurance companies for services will help sustain the project, but will need supplementing as the goal is to keep costs affordable and provide services to citizens that are low-income, near, or at poverty level and the elderly. A pilot program in your service area can be considered a shared risk model with partnership with the local hospitals, clinics and with the communities they serve. CMS currently does not have a reimbursement model set up for these services, but those changes can happen quicker than we think.
Sustainability Plans:
Long-term plans include sustainable program funding to savings accruing to system payers from readmission rates such as from local and regional hospitals and clinics. Community Paramedics will be able to develop a sustainable fee structure for post discharge patients after demonstrating cost savings to the local and regional hospitals. With support from the community, tax levies can be reevaluated and increased as necessary to provide the community services.
Technology Used:
Standardized Advance Life Support (ALS) Medical Equipment, 12 lead EKG, Digital Scale, electronic Patient Care Repot (ePCR) platform for medical records, Telemedicine equipment, telemonitoring equipment, Central Square Computer-Aided Dispatching of our current infrastructure. A special 1-800 number that can be called 24 hours a day, seven days a week for any concerns or if the enrolled patients need to talk to their primary care paramedic.
Estimated Program Results:
In 2011, the United States per capita healthcare expenditures were $8,608, and the average life expectancy was at 79 years. It has been predicted that if the current pace of expenditure growth continues, costs could reach $13,330 per capita by 2030, consuming 28% of total national gross domestic product (Healthcare, 2014). With further development and guidance from the State Emergency Medical Services System, Community Paramedics may be able to transport patients to other locations, like clinics, be evaluated and treated at their residence, and avoid some of the high costs added to the healthcare system. Community Paramedics is a provision of healthcare that uses patient-centered, mobile resources in an out-of-hospital environment, as well as being a social service resource available to the whole region (Healthcare, 2014). Hospitals can use these services to reduce readmission into their facilities providing a very beneficial asset for their finances. Community Paramedic programs can receive reimbursements for their services, but overall will be minimal amounts, and it is the most economical way for facilities to not receive readmission fines, saving the healthcare facilities money. Here in rural North Dakota, we have low populations, large areas of coverage, and tend to have lower socioeconomic backgrounds in the region. Most insurance companies and the Centers for Medicare and Medicaid Services (CMS) are currently looking at moving away from fee-for-services towards a pay-for-performance reimbursement models, Community Paramedics are financially more adaptable for the future of EMS (Goodwin, 2013). As we shift strategy to more patient centered medicine, Community Paramedics can provide maximum value, improved quality patient care, and medical professionalism throughout our community.
Community Paramedic programs will not only reduce the total cost of care, but it will also increase the health of our citizens, well beyond CMS beneficiaries. They will be able to treat patients in their own homes, or even transport them to alternative locations such as a clinic. The citizens of our community deserve a full system approach to healthcare, and Community Paramedics can provide this for our state.
References
Premier Health, city of Dayton launch community Paramedicine Initiative. Premier Health - Dayton, Ohio. (2019, June 1). https://www.premierhealth.com/your-health/articles/premier-pulse/premier...
Meyer, L. (2022). Community Paramedicine. EMSA. Retrieved from https://emsa.ca.gov/community_paramedicine/
Kohout, S. (2022, December 9). Paramedicine - Community Paramedic - Certificate of Specialization. OTC Programs. Retrieved from https://programs.otc.edu/certificate-of-specialization-in-paramedicine-c...
Goodwin, J. (2013, July). Finding a New Seat at the healthcare Table. Hmpgloballearningnetwork.com. Retrieved from https://www.hmpgloballearningnetwork.com/site/emsworld/article/10957645/...
Healthcare, M.M. (2014). Mobile Integrated Healthcare: Approach to Implementation. Jones & Bartlett Learning. http://online.vitalsource.com/books/9781284091713