As healthcare organizations work toward greater integration, one key player has rarely been mentioned. Emergency medical services (EMS), which play a crucial role in the health of our communities, were largely ignored by the Affordable Care Act.
It's true that in some ways, EMS stands apart from the rest of the Acute Care Continuum. After all, these services are funded not by hospitals but by local governments (e.g., fire departments), foundations and/or private ambulance companies. However, this distinction is somewhat artificial in practice, because EMS usually maintains close ties with local emergency departments (EDs) and the providers working there.
As former paramedic coordinator for the Oregon Board of Medical Examiners and physician director of four different ambulance services, I have a lot of experience with paramedicine. I've even coauthored a clinical book for EMS personnel. And I've seen firsthand how these professionals can play key roles in delivering quality, cost-effective care. For example, in some of Oregon's rural hospitals, the EMS unit is actually stationed at the ED and assists with patient care between 911 calls.
So I really believe that by leaving EMS out of the conversation, we're missing a golden opportunity to further the goals of healthcare reform.
Lately, I've been pleased to see growing interest in the concept of community paramedicine (CP), or "mobile integrated health" as it's sometimes called in the literature.
What Exactly Is Community Paramedicine?
Community paramedicine (CP) is a model of EMS practice that encompasses community-based care. Most CP programs are designed to bridge existing gaps in the Acute Care Continuum (for example, post-hospitalization care or chronic disease management in rural areas). Programs are tailored to local needs and are designed to complement (rather than compete with) existing services.
CP programs are directed by "community paramedics" — certified paramedics who have completed 200 hours of additional study in the specialty. The fact that paramedic salaries are significantly lower than those of hospital-based providers and nurses allows them to deliver community-based care in a cost-effective manner. In addition, many CP programs work closely with local healthcare and social services organizations to fulfill their mission.
Community Paramedicine Comes of Age
CP isn't exactly a new concept. But as the healthcare system strives for greater integration, there's been renewed interest in the role EMS can play.
Just a few recent developments:
- Community paramedicine pilot programs are now operating in several states, including California, Colorado, Minnesota, Maine, North Carolina and Texas.
- The Journal of Emergency Medical Services published an article series on community paramedicine.
- The Institute for Population Health Improvement (IPHI) at University of California, Davis released a landmark report on community paramedicine, which led to the commissioning of a 12-site pilot program.
- The National Conference of State Legislatures published a brief on community paramedicine for policymakers.
- The US Department of Health and Human Services developed a comprehensive evaluation guide for community paramedicine programs.
The IPHI report identified six gaps in the healthcare system that could potentially be filled by community paramedicine:
Treat and release. Up to 35 percent of EMS calls are nonemergent. In these cases, community paramedics can provide on-the-spot care for minor injuries and illnesses, which reduces costs and frees up valuable ED resources.
Patient navigation. Community paramedics can also help non-emergent callers reach appropriate care by transporting them to non-hospital destinations like primary care, urgent care, substance abuse treatment and behavioral health centers.
Addressing ED "frequent fliers." Community paramedics can work with local healthcare and social service organizations to assist people who chronically overuse ED resources. For example, these patients often benefit from access to primary care, housing, disease management and treatment for substance abuse.
Preventative care. In underserved areas, community paramedicine programs can partner with primary care providers and social service organizations to deliver needed screenings, education and immunizations. For example, one program in Chicago paired community paramedics with public health nurses. These teams reach out to families in at-risk neighbors in order to increase childhood vaccination rates.
Post-acute care. Community paramedics can help reduce unnecessary hospital readmissions by following up with recently discharged patients, assessing the home environment and helping patients to comply with discharge instructions and follow-up appointments. They can also facilitate communication between members of the care team.
Chronic illness management. Community paramedics can make regular visits to people with congestive heart failure, diabetes and other chronic conditions to support them in complying with their treatment regimen.
Challenges and Opportunities
So why hasn't CP been more widely utilized? In addition to its many benefits, there are some formidable barriers to its practice.
Perhaps the biggest obstacle is scope of practice. Most state regulatory codes are quite specific in spelling out the procedures paramedics can and can't perform. Here in California, the laws also limit paramedics' practice to pre-hospital care (with an exception for small and rural hospitals). So in many places, significant regulatory changes would be necessary to move CP into the mainstream.
Reimbursement is another major hurdle. At present, payment for EMS services is episode-based. What's more, Medicare and most private payers will only reimburse if the patient is transported to an emergency department. This doesn't allow community paramedics to decide that an alternate destination would be more appropriate — even when these paramedics are highly trained and practicing under medical control.
To get around this limitation, some CP programs have sought alternate funding through strategic partnerships and grants. However, I think the ACO model, with its emphases on innovation, collaboration and quality, could be the most viable framework for bringing CP into the Acute Care Continuum.
Integrating CP into ACOs could significantly accelerate the development of these programs. It would almost certainly create opportunities for research and follow-up studies that would allow us to formulate best practices for this emerging field.
I also think that physicians — particularly emergency physicians — can play an important role in the development of effective CP programs. By advocating for such programs and offering to provide medical control, we can accelerate the integration of EMS into the Acute Care Continuum. And we can also help to remove many of the access barriers our most vulnerable patients face.