Different drug regularity bodies in different countries.
Community Paramedic
1. Dana Sechler, NREMT-P
Michael D. Curtis, MD
Chief / EMS Director
Medical Director Emeritus
Baraboo District EMS
Ministry Health Care
1
2. 2
Changes in Mindset
All EMS agencies will not be able to do it
Could possibly decrease call volume—by
which we have measured success in the past
Keeping perspective
When you are up to your butt in alligators, it’s
difficult to remind yourself that your initial
objective was to drain the swamp
3. 3
Public Health Goals
Prevent injury / disability
Prevent illness
Prevent death
Promote births of healthy babies
Promote a healthy lifestyle
Assure health services where otherwise
not provided
4. 4
Health Care Problems
Decreased access to primary care
Growing number of uninsured/underinsured
Uninsured are less likely to seek out preventive
care services and defer care
Increased ED visits/emergency care
High readmission rates
Lack of consistently coordinated, high quality care
All of these lead to high costs of care
5. 5
Rural America
25% of Americans live in Rural America
10% of America’s doctors practice in
Rural America
6. 6
Rural Training Track Program
Program created to attract more Primary Care
Providers to the rural communities
Programs like the Rural Resident Program exist
because typically physicians do not want to practice
in a rural setting due to the special challenges faced
such as:
Poor usage of primary care providers
Poor use of preventive health measures
Patients typically seek treatment for severe cases of
acute or chronic health issues
Poor means for follow-up care, such as home visits
7. 7
Rural Residents
Rural residents:
receive fewer regular medical check-ups
are more likely to report fair to poor health status than
urban residents
more likely to have experienced a limitation of activity
caused by chronic conditions than urban residents
devote more of their income to health care costs
are more likely to engage in risky behaviors
8. 8
Emergency Departments
Not being utilized the way they were designed
Overloaded with non-essential visits
Recent growth of ED visits has helped increase the
cost of health insurance
9. 9
Medicare
Spends $12 - $15 billion a year on hospital readmissions
1 in 5 (20%) of Medicare patients are readmitted into the
hospital within 30 days of discharge
In the case of 50.2% of the patients who were rehospitalized within
30 days after being discharged, there was no follow up with a
physician's office between the time of discharge and
rehospitalization
1 in 3 (33%) of Medicare patients are readmitted into the
hospital within 90 days of discharge
10. 10
Readmission Diagnoses
30-day readmissions for the most common
initial diagnoses in rural hospitals are:
Pneumonia
Congestive Heart Failure (CHF)
Chronic Obstructive Pulmonary Disease (COPD)
Arrhythmia
Kidney/Urinary Tract Infection (UTI)
11. 11
Follow-up Care
Who will provide the follow-up care for these patients?
Doctors?
Chronic shortage
Lack of time for out-of-clinic activities
Nurses?
Chronic shortage
Too many other opportunities for career development
Home Health?
Prepared to service “homebound” and “hospice” patients only
12. 12
Possible Solution
Community Paramedics
Trained specifically for field medicine and home visitation
Mobility and flexibility are hallmarks of EMS orientation
Scope of practice includes many advanced medical skills
complimentary to clinical nursing
Advanced communication methods allow for “telemedicine” type
of patient care management with close supervision by primary
care providers
13. 13
Emergency Medical Services
EMS ≠ Prehospital
EMS = Healthcare
EMS Services will need to address the needs
of all patients who present with a Healthcare
condition or need, throughout the continuum
of the Healthcare system
i.e.: prevention — rehabilitation
14. 14
Solution
Non-competitive program that is designed to fill in
healthcare gaps
Provide primary healthcare, improve emergency
response capabilities, and strengthen community
healthcare collaborations in our community
A Community Paramedic is part public health, part
disease management, part prevention, part social
worker, part patient educator, and part treatment
15. 15
Advantages
Eliminating health disparities to rural areas
Decreasing overall healthcare costs
Proper referrals to primary care physicians
Decreasing misuse of emergency departments
Proactive EMS care verses reactive EMS care
16. 16
Advantages
Decreasing nonessential ambulance transports
Decreases workload and increases quality and
efficiency of managing patients in a primary care
setting by utilizing EMS personnel through nontraditional methods
EMS personnel currently have a good basis of
training, expertise and scope of practice to provide
essential primary care services
18. 18
Case Study – Mrs. Jones
Mrs. Jones is in her mid-70’s, and lives alone
Has new onset of symptoms to a chronic condition
Physician debating sending pt to floor for observation
The PCP requests a Community Paramedic visit and
evaluate the patient once a day for a week
CP writes a report in patient’s chart after each visit
19. 19
Case Study – Mrs. Payne
66-year-old female recovering from abdominal
surgery for small bowel obstruction
Discharged to her residence after 2 days of post
surgical observation
Developed complications due to internal leakage of
intestinal contents into her abdominal cavity
Patient had one phone call 3 days after discharge
with her surgeon and was assured that pain was
normal
20. 20
Case Study – Mrs. Payne
911 called after 5 days at home due to fever and pain
Patient and surgeon were unaware that she was febrile
and septic or that the appearance of her suture site was
not “normal”
Transferred to UW where she underwent emergency
surgery but died 3 days later
Could a Community Paramedic follow-up to augment
written discharge orders have saved this person’s life?
21. 21
Readmissions Reduction Program
The Affordable Care Act of 2010 requires
HHS to establish a readmission reduction
program.
Effective October 1, 2012
Designed to provide incentives for hospitals to
implement strategies to reduce the number of
costly and unnecessary hospital readmissions.
Readmission = “an admission to a hospital
within 30 days of a discharge from the same
or another hospital.”
22. 22
Readmissions Reduction Program
20% of Medicare patients are readmitted to a
hospital within one month of discharge
CMS considers this number excessive and
believes that readmissions are an indicator of
quality of care, or lack thereof
Provides an incentive for hospitals to
decrease readmissions by coordinating
transitions of care and increasing the quality
of care provided to Medicare beneficiaries
23. 23
Readmissions Reduction Program
Part of CMS’ goal to transition to value based
purchasing
paying for care based on quality and not just
quantity
These incentives are escalating penalties that
decrease a hospital’s payments from all of its
Medicare cases
Purpose is to improve quality and lower costs for
Medicare patients
Ensure that hospitals discharge patients when they are
fully prepared and safe for continued care at home or
at a lower acuity setting
24. 24
Predicted Costs to Hospitals
Total number of discharge patients at local hospital:
2,792 (patients)
Percentage of annual admissions at local hospital that are
Medicare insured: 42%
1,173 (patients)
Percentage that are readmitted within 30 days:
20%
Total patients that are non-reimbursable by Medicare:
235
Average amount charged (non-reimbursed) per patient:
$15,318
Annual projected non-reimbursable funds:
$ 3,599,730
(patients)
25. 25
Community Paramedic Programs
International:
Programs in Australia, New Zealand, the United Kingdom,
and Nova Scotia
Several across the U.S.
Red River project – New Mexico (1990’s)
Colorado
Minnesota
Huge explosion of others attempting some type of program
across the U.S.
Already starting to diversify
inner city EMS agencies are adopting CP concepts
applying them to 9-1-1 calls
26. 26
Community Paramedic Programs
The Community Healthcare and Emergency Cooperative (CHEC)
formed in July 2007
addressed critical health care shortages in rural and remote areas—
specifically by developing a new community health provider model
From this partnership, the Community Paramedic Program emerged
CHEC members based the Community Paramedic model on the best
practices of similar initiatives around the world, including the Alaska
Community Health Aide, the Nova Scotia Community Paramedic model
and the Australia Rural and Remote Paramedic Program
CHEC has a standardized training curriculum that is consistent
internationally, yet can be modified and customized for each
community, province and nation
27. 27
Value to the Local Hospital
Patients can be discharged earlier with proper
continuation of care and no decrease in Medicare
compensation
Better patient retention due to higher patient satisfaction
as hands-on care follows through home recovery period
Positive publicity of participating in this unique program
Overall community health improvement as care plans
include prescheduled home follow-ups
28. 28
Goals
Decrease hospital readmission rates
Decrease non-essential ED visits
Improve patient outcomes
Improve continuum of care
Decrease overall healthcare costs
29. 29
So, what have we been doing?
Past:
Baraboo is the 3rd Nationally approved CP Program
Consortium with the North Central EMS Institute
http://www.communityparamedic.org
Approved as a pilot program through WI State EMS Office
Appointed Captain Lori Spencer to administer the CP program
Began working with Dr. Marv Birnbaum and Jan Beyer
UW Emergency Education Center
Goal is to collect data over 3 years to prove the validity of CP
30. 30
So, what have we been doing?
“It is important to note that such studies have
not ever been done for evaluation of the
impacts of EMS, especially regarding ALS
—and we do not want the CP programs to
go down the same path.
Current CP efforts around the U.S. are not
collecting data to determine the value of
the program.
This process must be better and must show
its worth.”
~ Dr. Marvin Birnbaum
31. 31
So, what have we been doing?
Partnerships:
Created a Steering Committee with the following entities:
UW Madison Medical School &
Emergency Education Center
Sauk County Public Health
State EMS Office
Office of Rural Health
St. Clare Hospital
Home Health
Ho Chunk Nation
Ambulance Commission members
Others
32. 32
So, what have we been doing?
Curriculum:
Colorado Community Paramedic course
Dr. Birnbaum sits on the oversight committee
Lori took the course
Didn’t take the clinical portion, as she is an RN
Marv, Lori, and Jan took curriculum and ‘Wisconsinized’ it
The revised curriculum is specific to primary care
Intent is to be taught by UW Medical School
around 200 hours with didactic and clinical portions
Other staff are ready to take the course though UW
waiting for…
33. 33
So, what have we been doing?
The intent was to fund the CP Program through grants
For the first 3 to 5 years
After that, we believed that Medicare and insurance
companies will reimburse for these services
Based upon perceived cost savings
Reality:
Applied for numerous grants
Scored over 93 points in all the grants
Denied for numerous reasons
34. 34
So, what have we been doing?
Grants—
UW School of Medicine & Public Health grant
Health Resources & Services Administration (HRSA)
Innovation Grant from Center for Medicare & Medicaid Services
Also applied as a consortium with North Central EMS Institute ($27 million)
No CP programs were granted any funds with the CMS grant
Robert Wood Johnson Foundation
Reasons for denial
Physician comment, “EMT’s shouldn’t be doing this in the field.”
“Great idea(s), but too cutting edge—come back in 3 to 5 years.”
35. 35
So, what have we been doing?
Present:
Minnesota passed law to recognize CP as a practicing
level of EMS
Services can bill, and get reimbursed
Program administrator took new job as a Hospice nurse
Still applying for grants
Changed focus
CHF
Wound care
Include partnership with Madison FD
37. 37
What’s next?
Future:
New Name: Mobile Integrated Health Care
Telemedicine
Locally, we will continue working with Partners to:
Finish State curriculum
Send additional staff to CP training
Implement actual field program
Collect data
Work on Legislative initiatives
Work on permanent funding
Hospitals?
38. 38
What’s next?
Future:
National / State perspective will look at Scope of profession
Similar to RN licensure
A Paramedic will be credentialed (endorsed) based upon training
ACLS, PALS, TEMS, Critical Care, Community Paramedic, etc.
State will regulate the service that provides the level—not necessarily
the individual
EMS Office will host a Stakeholder meeting at the State the level, to
begin discussions with partner groups
Appears that there may be support at the National level
Grassroots effort from the bottom up
National acceptance from the top down
39. 39
Questions?
Contact info:
Dana Sechler, NREMTP
dsechler@bdems.com
Office: 608-356-3455
Michael D. Curtis, MD
Michael.Curtis@ministryhealth.org
Cell: 715-498-2240