Community Paramedics Aim to Lower Health Costs via Home Care

Primary care providers and other clinicians have long recognized the importance of home-based healthcare services as a cost-effective and proactive means of monitoring vulnerable patients to keep them healthy and out of the hospital.

Unfortunately, home health nursing uses a strict and narrow set of eligibility guidelines that often disqualify many people who could otherwise benefit from those services.

With that in mind Minnesota has become a national leader in a movement to create and use certified "community paramedics" to monitor and provide non-emergent care for patients in their homes.

Barb Andrews, RN, a veteran EMT, was one of the first providers in her area to achieve certification as a community paramedic. She now serves as the manager of the Urgency Center & Community Paramedic Program at North Memorial Clinic in the Twin Cities suburb of Robbinsdale, MN.

"Our healthcare structure is broken and people are falling through the cracks every day. We need to figure out who we can use to catch these people as they are falling," Andrews tells HealthLeaders Media. "Because regulations and the expense of home health nurses make it difficult to get people the services they need community paramedics offer extensive background experience and abilities at a fraction of the cost of a nurse."

North Memorial's community paramedic program has been operational since Oct. 15, 2012, with nine certified EMT/CPs on staff and five more EMT/CPs trainees prepping for certification in May. The hospital operates the program for eight hours a day, seven days a week. Each EMT/CP continues to serve primarily in the traditional role on emergency calls in the ambulance. But for one shift a week they change uniforms and drive their own cars to visit patients as CPs.

Because the program has no funding and can't bill for the services, it is limited to patients of North Memorial Clinic primary care physicians. "If we tried to see everybody the amount of requests would be astronomical. There are a lot of people interested in it," Andrew says. "We do not put restrictions on insurance or age. We don't want to duplicate services, so if they are eligible for home health nurses then we wouldn't go."

So far, Andrews says the typical patients "seem to be a lot of elderly people who don't have good family or social support."

"They aren't eating very well and they get confused about their medications," she says. "We set up their medications a week at a time so that they know for sure what to take and when to take it. We have helped people get set up with Meals on Wheels to make sure they're getting food delivered. Technically, if they are not homebound, that is what makes them ineligible for home healthcare. But we can draw the blood anyhow so they don't have to scramble to get to the clinic."

The CPs will spend from 30 minutes to two hours in each home discussing a variety of care concerns. Andrews says one patient receives a call from CPs every morning reminding her to take her meds before breakfast. "It's tailored to each individual patient, which is what I think is so neat about it," she says. "We don't try to fit the patient into a template of care. You set up what works around the patient."

To become certified by the state of Minnesota, community paramedics must have at least two years of experience as an EMT, and provide a letter of recommendation from a medical director. They must also go through more than 300 hours of training in the classroom and in clinical settings, where they learn how to assess patients in their homes and guide them to available services within the community.

The time spent in patients' homes can prove invaluable to providers because they're able to better assess the health challenges their patients confront beyond clinic walls.

"When the patient comes into the doctor's office you get a picture, but you can present anything you want in a picture," Andrews says. "When you go to the home you can't stage that. You are going to see things the way they really are. We learn a lot more about community assessment and how to hook people up with the available services in the community and turn the focus away from emergent care and toward managing long term chronic care and identifying people's needs in their homes. Even beyond their medical needs: do they need help getting their driveway shoveled? Do they need a ride to the grocery store?" 

"With some patients, the doctors will send us out just to check on their living situation. There doesn't have to be a specific need. Every patient is just as different in the clinic as they are in their homes so there isn't a template to follow because everybody has different needs."

Because the program is only about five-months old, Andrews says it's still too early to determine its cost-effectiveness. "We are absorbing the cost of the program but hopefully gaining in that we are keeping people out of the hospital," she says.

"We are keeping our patients in a better state of overall health and well being. But that is why we haven't extended it beyond the North Memorial community, because it can get expensive very quickly. We are all for helping people, but we have to keep our own boat afloat as well."

Minnesota officials are now crafting a framework for a fee schedule that will allow providers to bill for community paramedic services. Rather than looking at the program as "a pure source of revenue generation," however, Andrews says it's more likely that the value will come from the money saved by providing proactive, non-emergent care in the least-expensive environment—the home.

"If we can keep people healthier and prevent them from utilizing extra sources that saves money and keeps the patient healthier—which is really the ultimate goal."