Effectiveness of EMS and Community Paramedicine
Nicholas A. Thrash
Point Park University
Abstract
Community paramedicine programs are developing all over the country to help the burden on EMS agencies. These programs are developed to help keep “frequent flyers” out of the hospital and stay home in their residence. These people who are “frequent flyers” are independent enough to still live in their home but not independent enough to take care of themselves 24/7. Together, EMS and Community paramedicine programs are helping eliminate the costs of these patients and ultimately provide better care to patients without transporting them to the hospital.
Keywords: EMS, community paramedicine, mobile response units, frequent flyers
Effectiveness of EMS and Community Paramedicine: What Do I Need to Know?
Picture this: It is a late September night 2016; the air is warm and humid and you are on hour number eighteen of a twenty-four-hour shift. The day has been busy. You are exhausted and are looking forward to laying down in bed to hopefully rest for a few hours. Unfortunately, you are the next due truck for the service area. You text your girlfriend and parents goodnight like you do every other night. You finally close your eyes. All of a sudden “BOOM” the lights turn on and you are jolted out of bed by the loud noise of the bi-tone tones going off identifying your station has a call. You sit on the edge of the bed and listen to the dispatch. The dispatch states the age and gender of the patient along with the address you are responding too. As you hear the address you roll your eyes. Its him. One of your frequent flyers in the area. You get up out of bed, put your boots on and get into the truck and go to the address. You find your patient sitting in a chair very confused. Without any hesitation, you check a glucose level which reads low. You start an IV, administered Dextrose (liquid sugar able to be given through an IV to elevate the patient’s glucose levels quickly). The patient becomes alert, and oriented to person, place, and time after the medication administration. He denies transport to the hospital. You return back to the station and attempt to lay down again. 12 hours later you receive a text message from a co-worker. They are going back to the same address for the same patient. You send an eye-rolling emoji and say “shocker”.
This story I share with you today is not just a story, but a reality for myself along with the other employees I work with at Baldwin EMS. The age, gender, and address of the patient was omitted from this paper due to HIPPA violations (a privacy act that denies care-takers to omit any patient information). An estimated 240 days had past prior to that call this year and that was call number 87 at that noted address for the same patient. The number of times he was transported to the hospital? ZERO. One might ask how is this possible? Why is this person calling 911 and then not going to the hospital? Is that even allowed? What can we as providers do to change this consistent calling and usage of resources for the same thing over and over? The answer? Community Paramedicine programs.
Community Paramedicine programs have been evolving over the last forty years. Since the 1980s, EMS medical directors, system administrators and paramedics have acted to expand the scope of services EMS provides, and, in some cases, the scope of practice as well. These programs have been going in two different directions over the last forty years, both which have a distinct approach for patient care.
The first direction of this program was to increase the skills and capabilities of paramedics to be able to care and transport critically ill patients from facility to facility. Nurses were greatly opposed to his motion but soon came to realize that Paramedics were trained more for emergencies in a medical transportation environment rather than a hospital. This motion then brought on the financial value that Medicare and Medicaid had to start paying these transport companies for their critical care transports (CCTs) within the healthcare system. This system then allowed for EMS agencies to have a greater income along with keeping their patients within the most appropriate facility closest to home.
The second direction the program headed towards, which is the most primarily known direction for those in health care is the expansion role as a paramedic on the opposite end of the spectrum. Currently in the State of Pennsylvania, if a patient calls 911 we have two options for them. The first option is to evaluate the patient, treat them if necessary, and then leave with a non-transport (the patient stays home and does not go in the ambulance for a ride). The other option is to transport the patient to an emergency department. Those are the only two options that we as providers have. That being said, patients that aren’t urgent still utilize an ambulance. Studies place the number of low-acuity transports (sprains or flu-like systems) at 10–40% of EMS transports. The reasons for utilizing an ambulance service for transport to the ED due to a non-emergency condition are many, including lack of access to or availability of primary care, lack of insurance and lack of transportation. Many of these patients could be cared for at primary care physicians' offices, clinics and urgent care centers. In 2006, 24.1% of ED visits were classified as semi-urgent and non-urgent.
This type of program is what is changing the way we know EMS today. Frequent flyer (by definition a frequent flyer is a person who requests 911 assistance 6 times a year) numbers are down along with the number of medical emergencies they are faced with in a yearly basis. The Community Paramedicine program is changing peoples’ lives for the better. Throughout this project I have researched those different agencies while comparing them to the Community Paramedicine program that I am a part of in the Pittsburgh area. The results are shocking and will surprise those who continue to read.
For this paper, I chose to investigate the 911 and Community Paramedicine Program in San Diego along with the health care system at UC San Diego Medical Center. Five years ago, the California Healthcare Foundation Center for Health Reporting and the San Diego Union-Tribune created a five-part report called “Health Care 911” which helped establish such programs like the Community Paramedic Team.
At the UC San Diego Medical Center emergency room, it was approximately 6am where they were treating a 66-year-old-chronic alcoholic who had come in by ambulance. In the last three years, this was call number two hundred forty-two. In the last three years, this homeless man has accumulated a total of $537,000 worth of EMS bills. Unfortunately, when 911 is called, the providers are unable to deny treatment or transport to the hospital. It is estimated that there are approximately over twelve-hundred frequent callers in the San Diego area accounting for 11.6% of ambulance calls. This is an obvious improvement from 5 years ago when that percentage was 17.3%.
Three hours and nine minutes later, this 66-year-old man was found in his wheelchair outside of a business just a few blocks from the hospital. When approached by an employee of the sandwich shop, the man uttered the words “I need help” …call number two hundred forty-three. This time the hospital was to admit him and the community was going to attempt to find a place for this homeless man to stay. Instead, he was released again back out into the public, patiently waiting for call number two hundred forty-four.
Stories like this are what prompted San Diego EMS departments along with the hospitals to change the way patient care was delivered and change the health care system. They introduced programs like PATH (people assisting the homeless), Project 25 (a program at St. Vincent de Paul Village that seeks to improve frequent users’ lives by providing housing and care), have saved tax payers almost four million dollars in ambulance, jail and social services. These programs are funded by grants that are paid for by the United Way, Affordable Care Act, and Medi-Cal Managed Care. As one member said, who regularly helps with this project, “Healthcare is becoming shelter. If you don’t have shelter the next place you think of going is the hospital”.
One of the biggest programs that have changed healthcare in San Diego, along with changing the 911 system and assisting the community paramedicine program is called “Street Sense” This software tracks 911 calls throughout the city and allows providers, especially the community paramedics, to see where frequent calls come from. Then, the providers are able to go to those residents and offer the help that these people need.
An example of this program was shown by Anne Jensen and Shawn Percival, both community paramedics through San Diego. They approached a female, who appeared to be homeless sitting at the intersection of Sixth and University avenues. The paramedic crew approached the female who promptly rejected treatment. Moments later, the crew was approached by a male who was in tears and ragged clothing. His name was Richard Collins, forty-two years old who had been living in the streets for some time and has called 911 eighteen times this summer. While Jensen and Percival never met Collins in the flesh, they had felt that they had known him for some time now due to the frequent calling of 911 when they are working on the trucks (working on the trucks refers to working on an ambulance and running emergent 911 calls) and not working the SUV of the community paramedic team.
Jensen and Percival are two of six members of the newly established community paramedicine team in the area. In a single year this team has dropped the number of mega users (a person who calls 911 twenty-five times or more within a single year) from ten to three. They also are approaching targeted areas who are deemed to eventually be mega users.
Dr. James Dunford, the medical director for the city stated, ““We’re demonstrating that targeted intervention, using real-time data, can create a surgical strike beam to focus on people who need help the most. t’s a surveillance model with the ability to intercept patients in the field,” he added. It can surround people with social services, people who never had any help around them before.”
The best part of this program is it not only can, but is proven to save money. The community paramedicine program took the cost of 50 frequent users before and after they were assisted in some sort of way by the community paramedicine program and found that there was a $314,000 savings in just one year.
Not only San Diego has success stories of community paramedicine programs. Right here in Pittsburgh alone there are two major community paramedicine programs, one being with Allegheny Health Network, and the other through the University of Pittsburgh called CONNECT. I fortunately have been a part of the CONNECT program since its foundation in 2013. In the four years that it has been established, we have represented all 45 EMS agencies in the county and all 36 municipalities in the urban core of Allegheny County.
Our team of 12 community paramedics are casual employees who work one to two days a week at the Center for Emergency Medicine located in McKee street in Oakland. During the days we work, we help approximately four to five patients at a time. Referrals come in by EMS agencies or the local hospitals. After we receive the referral we then go and contact the patient and attempt to visit the residence for a few hours to discuss with them their choices instead of the constant 911 call and transport to the hospital.
Over the last few years we have seen significant results. These results not only shocked out team, but when presented at the Regional EMS Conference, State EMS Conference, and I was fortunate enough over the last 2 years to present this information at the National EMS Conference in Baltimore, MD, and in Salt Lake City, Utah. The reaction we receive when we tell people are incredible.
As of now we have a total of 269 patients. 42% of our patients live alone. 54% of our patients have some sort of mental health diagnosis. Of those 269 patients, the average age of them is 64.4 years old. Since 2013 we have received 1,372 referrals and these numbers continue to rise every year.
The outcomes that we have had with our patients are phenomenal. Since we have been assisting these patients, there have only been 7 emergency department visits this year. Of those 7 visits, 5 of them have resulted in hospital admission for either surgery, or evaluation for an extended time due to the circumstances of the medical emergency. 3 of those visits have resulted in a diagnosis of a chronic illness. That being said these visits are “true” emergencies and are requiring immediate attention and care for an extended period of time. This year alone our patients have totaled a savings of $8,560 and saved the health care system a total of $1.8 million dollars this year alone.
The CONNECT program is hoping to expand to become a multi-county program with funds from Medicaid, health insurance, and other health initiatives. We look to help people all over the area and continue to grow the program until it becomes a state-wide program. Our patients are our mission in both their health and saving them financially
As one can see, millions and millions of dollars are spent into healthcare for these frequent flyers. Those users continue to, what we call in EMS, “Abuse the system” and continually rely on us to treat them and transport them to the hospital at any given time. The EMS system in this country is getting burnt out due to the number of frequent calls that providers are going on each and every day. These Community Paramedicine programs are helping providers from getting burnt out. They are helping patients with their quality of life. They are helping the cost of health care stay at a semi-reasonable level instead of constantly driving the prices up. They are helping the whole system we call health care. With the continuation of these programs, the way we see health care now will be completely ratified for the good, and us as future health care administrators in this country are going to be a part of the greatest revolution of health care that the system has seen yet. The patient I referred to at the beginning of this paper has first handedly seen the effects of this program. In one year’s time, he has cut his personal expense on health care by a total of $3,636 and generated an approximate 90% savings in avoidable healthcare costs.
So, one day…just one day, that time at work when you go to lay your head down after a long morning and afternoon, you will wake up to the sound of your alarm clock and not the sound of the station tones going off. Because Community Paramedicine programs will have provided the residences of the community the necessary needs to live happy and healthy lives without the constant need for 911.