As hospitals fill with patients and the cost of medical care rises, the use of community paramedicine also may increase. To fill the gap between routine doctor visits and emergency transport to hospitals, communities have the opportunity to expand the use of highly trained paramedics to better serve their populations’s urgent-care needs.
A number of states – including California, Colorado, and Massachusetts – have established community paramedic programs. Community paramedics, who are selected based on experience and additional training above standard paramedic requirements, receive additional training on their expanded roles.
Individual programs vary, but the first step is a gap analysis for providing care under the current system. Emergency medical services (EMS) cannot fill some gaps either because the medical techniques required are too far outside the current scope of paramedics or because the equipment required is not easily portable. The provision of “urgent services” is an extension of the traditional emergency role of the paramedic, taking pre-existing skills and adapting them to a new task.
One of the gaps identified in the current system is that it has two modes: (a) scheduled visits; and (b) transport to the emergency room. In urgent cases, patients have needs that are not immediately life-threatening (therefore, not emergencies), but available visiting nurses or primary care physician visits are hours or days away. In such situations, patients may be reluctant to go to the hospital by EMS, especially considering that emergency rooms and the hospital rooms beyond them are finite, expensive resources that are stressful for some patients.
By partnering and coordinating with local Visiting Nurse Association providers, primary-care physicians, and EMS resources, the community paramedic is able to bridge this gap by providing on-demand staff that can cover the urgent need. In addition, community paramedics can help reduce the re-hospitalization rate. According to a 2009 study in the New England Journal of Medicine, this rate is 19.6 percent of Medicare patients within 30 days and 34 percent within 90 days of discharge. As an extension of the traditional EMS systems, community paramedics are able to provide coverage for these urgencies.
Traditional EMS systems staff and equip their services based on the type and volume of work already allotted to them. Although community paramedic programs would add extra costs, paramedics already have knowledge and skill sets that would allow them to fill these gaps effectively without the cost of training new staff for the task.
As with many good ideas, community paramedic programs must have a financially viable model to follow. A number of models would be effective in covering the costs of such programs. In the staffing model, for example, the homecare agency contracts with the EMS agency to provide urgent services when needed outside the homecare agency’s routine visits. Another model, the cost-savings share model, has the hospital system paying for the program with money saved by decreased overuse of their resources. In this model, the money comes not from the hospital, whose census would decrease, but from the Medicare system, which would reap the benefits of decreased hospitalization payments.
By providing community paramedics with additional equipment suited to their tasks, such as i-STAT blood-analysis devices, and training them on in situ care rather than focusing on stabilization and transport, these pioneers can help patients stay out of emergency rooms and hospitals, which in turn would improve patients’ health, quality of life, and survival, while strengthening the medical system overall.
Joseph Cahill is the director of medicolegal investigations for the Massachusetts Office of the Chief Medical Examiner. He previously served as exercise and training coordinator for the Massachusetts Department of Public Health and as emergency planner in the Westchester County (N.Y.) Office of Emergency Management. He also served for five years as citywide advanced life support (ALS) coordinator for the FDNY – Bureau of EMS. Before that, he was the department’s Division 6 ALS coordinator, covering the South Bronx and Harlem. He also served on the faculty of the Westchester County Community College’s paramedic program and has been a frequent guest lecturer for the U.S. Secret Service, the FDNY EMS Academy, and Montefiore Hospital.