Community Paramedicine: A Value-Oriented Strategy

Community paramedicine appears promising as a population health management tool, but payment strategies loom as a barrier to widespread adoption.

In Chico, Calif., paramedics receive a daily list of patients discharged from Enloe Medical Center with a diagnosis of heart attack or heart failure. Within 72 hours of a patient’s arrival home, a paramedic is on the phone.

“They call to make sure the patients understand their discharge instructions, that they have filled their prescriptions, that they have their follow-up appointment, and that they understand what the follow-up appointment is,” says Marty Marshall, managing director of Butte County Emergency Medical Services (EMS). “If it sounds like the patient is confused or would benefit from some help, they try to make an in-home visit.”

Meanwhile, in Robbinsdale, Minn., paramedics are part of a multidisciplinary care team that targets Medicaid patients who do not qualify for home healthcare services or who refuse long-term care. Their goal is to help patients understand and follow care plans. 

“We are going to be part of this person’s life for 30 days,” says Pete Carlson, manager, community paramedicine, North Memorial Health Care.  “Do they know how to follow their low-sodium diet? Where to grocery shop? What to do when their insurance doesn’t cover the durable medical equipment?”

In fact, the influence of community paramedics does not end at 30 days. Care then transitions to community-based providers, including those that provide nonclinical social supports, with community paramedics visiting on an as-needed basis.

The two programs are part of the fast-growing community paramedicine (CP) movement, in which specially trained EMS personnel are deployed to help reduce avoidable emergency department (ED) visits and inpatient admissions while improving patients’ health status and experiences of care.

Despite many barriers to widespread adoption, community paramedicine holds great promise, says Kenneth W. Kizer, MD, MPH, director of the Institute for Population Health Improvement at the UC Davis Health System and a former state EMS director in California.

“CP is an important component of population health management and the emerging value-based healthcare economy because it fills gaps in the local healthcare delivery infrastructure that are directly germane to value-based payment,” he says.

The Pilot Phase

Still in its infancy, community paramedicine is emerging around the country. Kizer estimates that at least 150 programs are established or being piloted in nearly 20 states.

He is the author of a 2013 report, “Community Paramedicine: A Promising Model for Integrating Emergency and Primary Care,” that assessed the feasibility of developing CP programs in California. Commissioned by the California HealthCare Foundation and California Emergency Medical Services Authority, the report said CP programs may result in:

• Decreased use of EMS services by individuals who do not have a medical emergency and would be better served in a setting other than an ED
• Increased access to primary care for medically underserved populations
• More opportunities for EMS staff, especially those that have a low volume of calls, to develop and maintain their skills

No comprehensive database exists, but researchers at the University of Washington identified 86 CP programs operating as of December 2014, including 49 serving urban areas, 27 in rural communities, and 10 serving both rural and urban patients. ^a

Focusing only on the rural programs, the researchers found that:

• The most common goals for CP programs are improving management of chronic diseases, reducing ED visits, reducing hospital admissions or readmissions, reducing costs, improving patient satisfaction, and reducing EMS use.
• The most frequently targeted populations include chronically ill patients, recently discharged patients, frequent EMS users, and elderly patients.
• The most common services are assessment (ranging from vital signs to home safety checks to administering EKGs); testing of blood glucose or other variables; preventive care for chronic conditions; and post-discharge services, such as medication inventory and monitoring compliance.

Minnesota in Action

CP has developed most quickly in Minnesota, courtesy of 2011 state legislation directing the Minnesota Department of Human Services to determine CP services that should be covered by Medicaid. The CP concept got another boost in 2013 when Minnesota received a $45 million grant from the Center for Medicare & Medicaid Innovation to test new healthcare ideas.

As of early 2016, Minnesota had 16 CP programs in place, with another eight in development. One of the first was launched in 2012 by North Memorial Health Care. Working as part of a team that includes social workers, nurses, pharmacists, case managers, and other professionals, North Memorial paramedics seek to provide better primary care access for patients discharged from the hospital who are not receiving home healthcare services and those with chronic conditions who need in-home monitoring.

Most of North Memorial’s paramedics work as traditional 911 responders on some days each week and as community paramedics making home visits on other days, Carlson says.

Since the program began in 2014, North Memorial has documented that CP patients more frequently keep their follow-up primary care appointments and report greater confidence in their ability to manage their health problems. Moreover, Carlson says ED visits and inpatient admissions for patients served by CP have been reduced by at least 40 percent since the program began.

What’s Working in California

Butte County EMS’s CP program is one of 12 pilot projects authorized by the California state legislature following recommendations by Kizer and his colleagues in their feasibility study. State law regarding scope-of-practice for paramedics will need to be changed to permit community paramedicine, and the pilots are generating the safety, efficacy, and outcomes data that are needed before that can happen.

The goal of the Butte County pilot is to determine whether readmission rates for patients discharged after a diagnosis of acute myocardial infarction (AMI) or congestive heart failure (CHF) would be reduced if paramedics provide follow-up calls and/or home visits.

Although the pilot is still in progress, Marshall can see what is happening. The follow-up calls are helping AMI patients—in 2016, AMI readmissions were 53 percent lower than the baseline level in 2014. But a phone call is insufficient for CHF patients; indeed, the readmission rate for that group actually increased during the last half of 2016.

That’s because CHF patients often have trouble complying with the lifestyle changes that are required to control their condition, and they need considerable support to consistently weigh themselves to monitor for fluid retention. Because no additional paramedics were added to the EMS staff, the pilot is designed to reveal whether the current staff has adequate time to provide the requisite follow-up care.

“What we’re going to find in the end is that we need to have more dedicated resources to consistently make home visits to those more difficult patients if we are going to make a positive impact on the readmission rate,” Marshall says.

Based on his staff’s experience to date, he thinks other diagnoses—chronic obstructive pulmonary disease and pneumonia, in particular—might be better suited to CP follow-up than are CHF cases. But he thinks the CP movement could have the most impact on health care if paramedics were authorized to transport patients to the most appropriate setting.

“So often, they don’t need to come to the ER,” Marshall says. “If paramedics have the authority and the latitude to redirect patients, they can make a real difference in the cost and the outcomes of our patients.”

Some of the California CP pilots are allowing paramedics to transport patients to urgent care or mental health clinics, while others are providing hospice support, follow-up treatment after a tuberculosis diagnosis, and other interventions.

Who Pays?

As health systems pivot to population health management and value-based contracts, CP offers a lot to like.

“There’s face validity for the underlying concept of using an existing pool of healthcare workers who already possess most of the needed skills and are an established and trusted part of the community infrastructure to expand access to basic services,” Kizer says. “And it fills a clear and demonstrated need to bridge primary care and emergency care and fill gaps in the underlying healthcare delivery infrastructure that exist in so many communities across the country.”

But two big barriers stand in the way of rapid adoption. One is lack of evidence about which CP strategies truly add value. While various programs have demonstrated that they reduce 911 calls, ED visits, or emergency transport charges, the field is so new that almost every program is an experiment and no standard protocols have been developed or tested.

“The data are not as compelling as either Medicare or other healthcare payers want to see before deciding whether they are going to cover this as a service,” Kizer says.

Some programs are supported by grant funding, which means their long-term viability is uncertain. Other programs work only because of particular circumstances. For example, Butte County EMS is a joint venture between Enloe Medical Center and a private EMS provider.

“In our case, if I can save the hospital money, that makes this financially worthwhile,” Marshall says. “But stand-alone ambulance providers aren’t going to get into this business if they don’t get paid for it.”

In general, neither public insurers nor health plans pay for CP services, with Minnesota as a notable exception. That state’s Medicaid program has covered CP services since 2012.

Blue Cross and Blue Shield of Minnesota thus reimburses community paramedics who serve its Blue Plus managed Medicaid subscribers. In keeping with state regulations, CP services are covered only if they are part of a patient care plan developed in coordination with the patient’s primary physician and relevant local healthcare providers, according to a Blue Cross spokesperson.

Carlson, a longtime CP leader in Minnesota, expects CP will advance only in states in which widespread payment reform forces health systems to develop new care delivery models. EMS organizations cannot afford to provide CP without payment, and payers are unwilling to cover CP because the value has not been quantified.

“The challenge right now is the traditional fee-for-service structure,” he says. “Until bundled or value-based payments become more entrenched, it’s going to be challenging for people to make that leap.”

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Lola Butcher writes about healthcare business and policy topics for several HFMA publications.

Interviewed for this article: Peter Carlson, manager, community paramedicine, North Memorial Health Care, Robbinsdale, Minn.; Kenneth W. Kizer, MD, MPH, director, Institute for Population Health Improvement, UC Davis Health System, Sacramento, Calif.; Marty Marshall, director, Butte County Emergency Medical Services, Enloe Medical Center, Chico, Calif.).  

Footnote

a. Patterson, D.G., et al, “What is the Potential of Community Paramedicine to Fill Rural Health Care Gaps?” Journal of Health Care for the Poor and Underserved, November 2015.