Essay on community paramedicine (1)

Essay on community paramedicine (1)
Community Paramedicine: The New Frontier Robert S. Cole EMC 380 Eastern Kentucky University
Abstract NAEMT and other stakeholder agencies identifies Mobile Integrated Healthcare and Community Paramedic Programs as “....the provision of healthcare using patientcentered, mobile resources in the out-of-hospital environment.” (2013). The reality of these programs is far more complex. This paper will outline commonalities of MIHCP programs, and show that they are not simply the provision of “patient centered” healthcare, but also “community Driven”; and are not just integrated with the healthcare industry, but also law enforcement, mental health, and other resources not commonly thought of as “healthcare”.
Background Over 20 years ago, The National Highway Traffic Safety Administration (NHTSA) and the Department of Health and Human Service’s Health Resources and Services Administration (HRSA), two federal agencies with a strong history and interest in EMS, released a report outlining strategic goals for the future of EMS. This report, Emergency Medical Services Agenda for the Future , suggested a future where an EMS worker would arrive at a patient's side, assess them, assess their physical and social environment as well, coordinate with the larger healthcare network, and then leave the patient in their home if appropriate or arrange transport to a destination other than an emergency department. EMS would switch from a reactive response to perceived emergencies to an integrated, proactive, community driven service that also responded to emergencies when needed. This report was widely read, debated, and then forgotten by many street level providers in the EMS industry. In the intervening years, many of the measures failed to gain traction in EMS. Other than a handful of isolated programs, this “community EMS” worker failed to materialize on a meaningful scale. EMS in 2008 looked much the same as it did in 1995, isolated, reactionary, poorly understood by the rest of the healthcare community, and mired with no clear identity. Changes in healthcare prompted the resurgence of these concepts with renewed vigor. Accountable Care Organizations (ACO) initiatives, reimbursement changes, and other financial motivators found both EMS and the larger healthcare industry scrambling to restructure their core services for the new century. MIHCP programs are one key part of that evolution. In 2013, the NAEMT and other stakeholder agencies released a vision statement about community EMS initiatives, stating that “Mobile Integrated Healthcare (MIH) is the provision of healthcare using patientcentered, mobile resources in the out-of-hospital environment.” What is Mobile Integrated Healthcare and Community Paramedicine? The terms “Mobile Integrated Health” and “Community Paramedicine” (MIHCP) are still fluid concepts that are somewhat variable depending on the programs reviewed. It is best to view MIH and CP as two sides of the same coin. Mobile Integrated Health reflects the belief that a MIHCP program is integrated not only with the hospital, but throughout the healthcare system. Patient wellbeing neither starts nor stops, with the hospital campus, but is the sum of inpatient, outpatient, preventive, primary, and mental health care, as well as integrating social services, law enforcement, and charitable support when needed. This is a relatively new concept for healthcare in general, but particularly EMS, which is essentially isolated from much of the healthcare industry. In the past EMS has typically only interacted with the emergency department, but that is changing and evolving. The key concept here is not Mobile, nor even Health, but Integration. The other side of this coin, Community Paramedicine, reflects the belief that these programs are community and patient needs driven, not by legislative mandate, reimbursement
motivated, or accreditation. Simply put, the needs of a rural community in Idaho will be far different than that of a community or population need in San Francisco. This is also a shift for EMS, which is often mandated to be provided (in some fashion) by legislation, focused on feeforservice reimbursement, and is often judged by metrics like response times rather than outcomes. A common misconception is that MIHCP is long term or home health primary care. Instead, MIHCP is about short term goals and filling service gaps until the patient can be enrolled in or referred to more long term solutions. “Graduating” from an MIHCP program is almost always the goal, and less than 8% of patients in MIHCP patients remain in the programs after 180 days. One advantage of EMS compared to existing healthcare infrastructure is that EMS already has the means, workforce, and experience, to go truly mobile into the field environment in a quick, timely fashion. In business terms, EMS is “scalable” to meet the needs of MIHCP programs far easier than the rest of healthcare. There seems to be more emphasis in the “MIH” side of the MIHCP initiatives, largely due to greater funding possibilities, and a greater comfort of EMS leaders working in the healthcare world than in the community. MIHCP programs are becoming more about extensions of the healthcare industry's needs, and less about the patient. Community driven initiatives, which focus on the needs of the patients in the community (while likely to be less funded) are no less important. There is a real danger in some programs as the focus shifts to the “integrated healthcare” aspect of MIHCP programs, that the community paramedicine focus will be lost. How widespread is MIHCP? MIHCP programs are difficult to identify because they will often look very different across the country. According to the NAEMT vision statement, to be considered an MIHCP program, it must be fully integrated; collaborative; datadriven; patientcentered and teambased. What does that mean, exactly? ● Fully integrated. Lack of integration between different levels, types, and organizations in healthcare is a major contributor to poor healthcare and increased healthcare costs. MIHCP programs are designed to close the gaps in patient care. If a program does not integrate fully with the local healthcare community for both admissions, follow up, and discharge, then it is not fully integrated into the broader healthcare system and not a true MIHCP program. ● Collaborative. MIHCP programs cannot exist in a vacuum. They require stakeholder buy in, assistance from legislators, and reaching out to very diverse (nonEMS and nonhealthcare) organizations to identify and meet needs. A program that decides to purely “go it alone”, is not a MIHCP program. ● Datadriven. Data is vital to making decisions, and the better the data, the better the decision. It is not enough to speculate on a community's needs, a good program has to have hard facts to support its assessments.
● Patientcentered. In the middle of capitated payments, contracts, stakeholder meetings, interagency politics and grant writing; there is still a patient. Some programs may lose sight of this in the rush to be on “the bleeding edge”. A MIHCP program remains patient centered, including using home visits and other direct patient interaction. ● Teambased. Some of the best MIHCP programs are multidisciplinary in their initiatives. More than collaboration, these programs involve social workers, law enforcement officers, home health care providers at the street level in point of care actions. The NAEMT identified 103 confirmed MIHCP agencies in 2014, with many more in early stages of development. Currently the overwhelming majority are in suburban and urban communities, though there is substantial interest in rural and “super rural” organizations. Rural programs may present the most unique challenges, but also the most levels of creativity in MIHCP. Over half of MIHCP programs identified by the NAEMT started in 2014, with a bare minimum more than three years old. This illustrates both the level of interest and uncharted territory that is community paramedicine. Community Needs Assessments One of the single most important parts of forming (and continuing) a MIHCP program is a formal needs assessment. A needs assessment is a data driven period to identify gaps and needs in the local patient population. Performing (and repeating) formal, well constructed needs assessments is perhaps the single best predictor of program success. Most EMS agencies rely primarily on their own EMS data set, or the larger NEMSIS database for this task. Unfortunately, this may miss a substantial opportunity to look at patients whom a MIHCP program can impact, but who are not normally transported by EMS or seen in the ER (and therefore are not in those databases). A prime example would be a patient population seem primarily by another discipline, but with a medical “gap”, like mental health patients. Education Considerations Education criteria for MIHCP programs are still being conceptualized. Most MIHCP programs are made up of paramedics with a wide variety of educational backgrounds, including nursing, social work, or no degree at all. According to the NAEMT, experience is the single most common requirement to be a community paramedic. Additional areas of emphasis include clinical topics (i.e. expanded knowledge on COPD, ESRD, and CHF), patient communications, and integration with community resources. That said, several university based degree paramedic programs are beginning to offer a “Community Paramedicine Track” at the Bachelor level. Idaho State University is enrolling its first class of paramedics who will be eligible to obtain a Bachelors of Science with an emphasis on Community Paramedicine this year. Other programs, such as Hennepin College, simply offer a technical certificate as an addon credential to already certified EMS providers.
Eventually, just as the EMS profession will have to move as a whole to a minimum degree requirement, it seems likely that community paramedicine will require an academic component to take MIHCP programs into the future. Failure to address these issues will leave room to question the safety and qualifications of Community Paramedics compared to other degreed professionals like Registered Nurses. Scope considerations When discussing MIHCP programs, the topic of scope of practice invariably comes up. Many of the informed picture newly minted community paramedics suturing wounds, administering antibiotics, and waving the magic wand of new skills in the execution of their jobs. It is easy to understand this when you see other “advanced paramedic” initiatives like critical care paramedic (CCEMTP) or tactical paramedic (TEMS) programs that are very skills and medication intensive. As a profession, EMS tends to be very skill and procedure focused. The reality is that the idea of a “scope of practice” as it applies to MIHCP’s is a huge and illfitting concept. Many of the MIHCP functions do not depend on the administration of a new medication or performance of a new skill, rather EMS is taking a new role in patient advocacy. The few instances of “scope of practice” issues often involve traditional “nursing skills” such as basic wound care/checks, administering antibiotics, and immunizations; none of which are outside of a paramedics skill set or ability, often with little or no additional training. There are some processes that are new to EMS, such as breathalyzers, point of care testing, and field drug screening. Again, these are often performed in other settings by providers with far less training than a paramedic, and therefore are well within the realm of possibilities. When one looks at the opposition to MIHCP programs raised based on scope of practice, one can usually find they are instead based on fear of “role creep”. “Role Creep” is a fear of losing one’s position due to the expansion into another field. For example, Nurses may fear a cheaper paramedic workforce taking traditionally nursing positions, not only in the ER, but in home health, and other settings. Paramedics may fear being forced to do jobs other than emergency calls (ignoring that less than 20% of calls are emergencies in most systems) and believe that MIHCP work is not “real” EMS work. There are some limited cases where the labor unions (i.e. IAFF) have opposed MIHCP expansion in the fear it will be “forced” on their members or detract from core functions in the fire service. In the end, MIHCP will certainly result in some redefining of what “scope of practice” really means in EMS, although the actual “skills list” probably won't change much. What will, what must change is the idea of a narrowly defined role for the EMS provider solely on an ambulance.. As long as paramedics are limited to so called “emergency response” and medical transportation . the whole profession (not just MIHCP) is doomed. Can there be a Community EMT? The idea of a community EMS health worker other than a paramedic (CEMT) is an interesting discussion. The overwhelming majority of MIHCP programs utilize paramedics, with
a few using nurses or physicians assistants in one role or another. All these options are somewhat resource intensive for small communities classified as rural or superrural (i.e. frontier). It may be hard to imagine whole regions of the country that do not have any paid EMS at all, much less paid paramedics. In some communities, the only “advanced care” is by helicopter or fixed wing, and over an hour or more away; so the idea of employing paramedics in any capacity may only be a pipe dream. Such is the reality of many regions in rural America. It is particularly true in states such as Montana, Wyoming, Idaho, Oregon,and Alaska. These same regions are often the same ones lack health care accessibility of all types, not just EMS. Any community needs assessment would show a need for a MIHCP, but the advanced level providers simply are not in the communities for this role. But EMT’s (often volunteer) may be. Recall the cinematic example of Michael J. Fox being driven around in the Cadillac ambulance doing house calls between the rare emergency in the 1991 movie “Doc Hollywood”. The CEMT would require quite a bit more education to do medication reconciliation, and other programs, and perhaps an additional module on immunizations, but this is not inconceivable either. In many states EMTs already administer IM injections for anaphylaxis and hypoglycemia. Considering the alternative, abbreviated closely monitored CEMT programs may be a success in underserved superrural programs where there simply are no other options. There is some discussion in rural communities in Idaho that using MIHCP initiatives may bring paramedics to region who have never had advanced life support capability before. The region (typically a large, rural county) would conceivably hire two or three paramedics for the entire area, and these would perform MIHCP duties as their primary function; and respond to the occasional EMS call with the indigenous volunteer EMS agencies as needed. Funding would be provided through a complex series of grants, partnerships and contracts. Common initiatives within Community Paramedic/Mobile Integrated Healthcare programs System Supplementation Several of the most successful MIHCP programs keep their CP’s integrated into the 911 system, believing that the ability to supplement 911 response helps justify the expense of deploying the program into the field.
Mental Health Diversion MIHCP program may partner and respond with law enforcement and mental health workers to help mental health patients bypass the ER, saving time, resources, and money. Discharge Follow Up/Readmission Prevention Hospitals have begun to be penalized with reduced reimbursement for patients readmitted to a hospital within 30 days of discharge. These penalties are designed to incentivise hospitals to keep patients healthier, and decrease the revolving door of healthcare facilities. A hospital would contract with an MIHCP program to follow up with high risk patients to use home and telephone visits to reduce readmission. Medication Reconciliation Much research has shown that many patients and their families do not understand their discharge instructions or their medication regimen. MIHCP programs would do a home visit and review the medications with the patient, look for unanticipated interactions or unintended problems with the medication at home. One recent study by Ada County Paramedics found about 128 medication reconciliation deficiencies per patient in the program. Reducing these gaps would theoretically improve compliance and reduce errors and adverse outcomes. “EMS Loyalty” (Frequent Flier) Programs Frequent users are a common problem in any EMS system, no matter how big or small. What happens, however, when the frequent flyer becomes not just a bother, but an articulable drain on the taxpayer on a meaningful scale? MIHCP programs have had some success in reducing frequent fliers, and some failures too. To be successful, MIHCP programs must define what makes a frequent flier, what are the probable causes, if an MIHCp program can actually impact those causes, and finally, if the patient will accept help. The definition of a frequent flier is community dependant definition. Typically, calling 911 in excess of 10 times a month is sufficient. MedStar (Texas) found that 21 patients had been transported to local EDs a total of 800 times over a 12month period, whereas the Tucson Fire Department identified 50 individuals who accounted for more than 300 nonemergency 911 calls over a similar period. Some frequent fliers are ideal for a MIHCp intervention. The diabetic with frequent hypoglycemia, or the frequent fall patient with no other resources for help. MIHCP programs can intervene, and subsequently connect these patients with meaningful programs that will help them manage their underlying disease over the long haul. Conversely, some frequent fliers are poor fits for an MIHCP program. This is particularly true of many with substance abuse issues, particularly persistent and repeated alcohol intoxication. These patients may be reluctant to accept help, and refractory to MIHCP intervention. A well designed multidisciplinary approach may be useful for some of this population, but efforts in this area have met with limited results.
Hospice Revocation Avoidance Most seasoned paramedics can recount a call or three where a hospice patient's family, unable to reach the oncall hospice team, called 911. This puts EMS in a difficult situation. The patient with an end stage, often complex disease process needs help, but traditional transport disenrolls the patient from the very program best designed to help him at the end of the patient’s life. MIHCP programs may contract with certain hospice agencies to provide urgent response 24/7 to meet the needs of the patient, and still prevent transport. The MIHCP can administer expanded analgesia for pain control, provide assessment, and give reassurance to the family in a more timely fashion than a hospice staff responding from home after hours. Funding Considerations Some sources estimate that for every one dollar invested in MIHCP programs, between five and ten dollars are saved “downstream”. Unfortunately, downstream savings are a hard sell to strapped county commissioner's budgeting tax payer dollars. Currently over 60% of MIHCP programs generate no revenue, and very few generate substantial revenue. None are completely selfsupporting. Currently, MIHCP services are largely nonbillable, with a few exceptions. So the question is, who will pay for MIHCP programs? Fee for service EMS is largely a service industry, and that service is almost exclusively based around transport. Therefore, reimbursement is largely based around feeforservice and transport as well, and an EMS service is therefore dependant on a volume business. Contrary to everyday EMS, needless transport is the antithesis of MIHCP programs. Therefore, before a substantial revenue stream is realized, alternative reimbursement for MIHCP functions must be developed. This typically starts with legislation changing Medicare and Medicaid rules. Both Idaho and Minnesota have been successful in passing legislation allowing state funded Medicaid to reimburse MIHCP programs, though the actual revenue stream is still modest. That said, several national organizations have been lobbying the federal government to follow suit in their Medicare legislation, opening the potential for private insurance reimbursement as well. Capitated Payments The concept of a capitated payment scheme is a contractual allowance per patient, prepaid on a set schedule (typically monthly). For example, General Community Hospital may pay Rural County EMS MIHCP program a capitated fee of $500.00 per month for three months to enroll a patient in a readmission prevention program. The MIHCP program promises to perform functions to prevent readmissions. No matter how many visits the program makes, nor how
many phone call follow ups, the $500.00 is all the service will receive. Therefore it is incumbent on the MIH agency to be as effective as possible to pocket the excess, if any, of the capitated payment. Shared Savings Arrangements There are certain classes of patients that present a financial burden on governmental agencies and hospital systems. An example of this is the mental health patient. A governmental parent agency of a law enforcement officer who places a patient into “protective custody” (i.e. a mental hold) assumes some financial responsibility for that patient’s medical care. If that same patient requires a screening in the emergency department prior to moving to another location (i.e. a mental health facility), the taxpayer is on the hook for that too. In addition, both an ER bed and an officer are often tied up for hours waiting for this low acuity patient to be screened. A properly designed MIHCP program would involve a screening process in the field, allowing properly assessed patients to bypass the local ER, going directly to “detox” or the local mental health resource for further care; saving thousands of dollars in terms of manpower off the street and real expenditures to the ER. Conceivably, a MIHCP program would partner with an Law Enforcement agency to perform screenings on a fee for service basis, with the fees based on a faction of the estimated savings the agency saves by not transporting the patient to the ER. Fee structure would have to be set up so as not to present a conflict of interest that might compromise patient health. Grants Grants are a promising funding stream for new MIHCP programs, though EMS agencies may have to delve into new territory to find them. Grants from nongovernmental organizations, public health concerns, and philanthropic trusts are more likely to invest in MIHCP programs than SAFER grants and other traditional EMS programs. System Savings Another approach to the funding obstacles in MIH is an internal funding approach. Reducing “frequent flyers”, who are typically a drain on resources and staff, can be viewed as freeing up resources (both manpower and real dollars) for other patients and functions. Therefore, a MIHCP program that shows it can save taxpayer dollars by reducing call volume to these patients may be in a way selfsupporting. This MIHCP concept is probably the most appealing to many street level EMS providers, but also the most difficult to validate in terms of real cost savings. Summary MIHCP programs remain a great variable in the future of EMS as a whole. MIHCP programs have been on the horizon of EMS for decades, but have been largely dependant on changes to the healthcare landscape in the past five years.
These changes have provided momentum for the concept, but also run the risk of MIHCP programs becoming extension of powerful healthcare network’s agendas, and losing touch with the communities and the patients they should serve. MIHCP programs have expanded and developed some novel programs that even the pioneers of the concept did not envision in 1995. In the end, MIHCP programs depend on data, integration both with the community and with the larger healthcare industry, a heavy dose of out of the box thinking, and a willingness to go where no paramedic has gone before. Today, the “cat” is out of the proverbial bag in terms of this new specialty in EMS. It is clear it is gaining momentum, and is ripe for expansion; or exploitation, by the new world of healthcare. The only question is what type of mischief the “cat” will get into next? References MIHCP Vision Statement. (2013). Retrieved November 15, 2015, from http://www.naemt.org/MIHCP/MIHCPVisionStatement.aspx 2014 NAEMT report on Mobile Integrated Health care and Community Paramedicine: A National Survey. (2015). Retrieved November 16, 2015, from https://www.naemt.org/docs/defaultsource/MIHCP/naemtmihcpreport.pdf?sfvrsn=2 Par, R. (2015, August 13). Nurses Balking About Proposed Calif. Paramedicine Program. Retrieved November 16, 2015, from http://ems.sinaiem.org/wpcontent/uploads/2014/09/NursesBalkingAboutProposedCalif.pdf Samantha, M. (215, March 25). Idaho law would allow EMS to bill for nonER transports. Retrieved November 14, 2015, from http://www.ems1.com/legislationfunding/articles/2142923IdaholawwouldallowEMStobillfor nonERtransports/ Wingrove, G. (n.d.). Communityparamedic.org. Retrieved November 16, 2015, from http://communityparamedic.org/ Trained Paramedics Provide Ongoing Support to Frequent 911 Callers, Reducing Use of Ambulance and Emergency Department Services. (2009). Retrieved November 14, 2015, from http://communityparamedic.org/Portals/CP/NCCCP/AHRQ%20Updated%20MedStar%20Innova tion%20Profile%202013.pdf

Essay on community paramedicine (1)

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Essay on community paramedicine (1)