The expanding field of community paramedicine faces challenges in all settings, but the programs "that seem to be making significant progress are those that are affiliated with a hospital system," says one researcher.
The push to reduce hospital readmissions is fueling growth in community paramedic programs despite challenges that come with the introduction of a new type of health provider. But, it's unclear whether EMT squads that double as non-emergency primary care extenders will offer a solution to gaps in care opened by rural hospitals closures.
A spring survey of state EMS directors found that 43 of 48 states reported that agencies are actively planning or providing some form of community paramedic (CP) service. Twenty nine reported that EMS programs in their states already offer CP-type services, according to the study by the National Association of State EMS Officers.
And while the approach is growing in rural as well as urban areas, it is unclear whether the programs will allow hospitals to reach beyond their service areas into medically underserved rural communities.
Karen Pearson is a policy analyst at the Maine Rural Health Research Center at the University of Southern Maine. She is one of the authors of a 2014 paper titled 'Evidence for Community Paramedicine in Rural Areas," which concludes that CP programs have the potential to fill gaps in rural healthcare delivery systems, but that "integrating community paramedics into the delivery system is the challenge."
It may be a big problem in communities where the local hospital has shut down. Pearson is currently working on a study of 12 community medicine pilot sites in Maine. Most of the referrals to community paramedics program come from hospital discharge planners, she says. "What we are finding is that the programs that seem to be making significant progress are those that are affiliated with a hospital system."
Readmission Responsibility Extends Beyond Hospitals
In the EMS directors' survey, 40% of the programs reported that they are required to demonstrate "integration with other health services." Of that group, 94% said that they are working with hospitals or health systems. And 64% reported that they are working with hospitals on reimbursement strategies.
And while a lack of hospital home base may be an obstacle in rural areas, the expanding field of community paramedicine faces challenges in all settings. The concept of the community paramedic emerged about 15 years ago, driven by the fact that many 911 callers don't need hospital care.
The push to prevent readmissions gave the field a boost, with paramedics offering non-emergency, in-home monitoring. But, even as CP programs expand, some issues around certification and reimbursement remain unresolved.
Janet Haebler, RN |
'Role Clarity'
The American Nurses Association has been most vocal in raising concerns about the role and training of CPs. Janet Haebler, RN, the group's associate director of state government affairs, says nurses are concerned about the lack of consistent standards for CPs. The programs are run by a range of providers, from hospitals to volunteer squads, and are regulated by state and local agencies with different rules and requirements.
Does Medication Management Really Reduce Readmissions?
"Every state is unique in the way it looks at EMS in general," she says. "In California, they are regulated county-by-county. It is really hard to establish something uniform where there is going to be so much variability between counties or between states."
In some cases, CPs are inappropriately taking on the duties of home health nurses, Haebler says. It is unclear who they should report to, the EMS director or the patient's primary care provider.
The ANA is concerned with "role clarity" and duplication of services, not turf, Haebler clarifies. "There is a place for all of this," she said. "We need to make sure we're all part of an interdisciplinary team and that we are all working together."
Howard Mell, MD, medical director for the EMS program in rural Iredell County, NC, is a spokesman for the American College of Emergency Physicians. He says CP programs are designed to address the needs of newly discharged patients who require monitoring, but don't qualify or have access to home healthcare services.
Howard Mell, MD |
Hospital Cuts Readmissions in Half with Help from College Students
"If we know that certain people have high risk condition, we want to get out there early and say, 'Mr. Jones, Mr. Smith, are you still taking your medicine?' Or, 'We know that there have been storms lately, do you still have power for your medical equipment?'"
The question is: Which patients need a nurse and which patients don't, he says. And when they don't need nursing services that are covered by insurance, who is going to pay the paramedics?
In May, the Nevada legislature unanimously approved a bill outlining certification requirements for community paramedics. While urban communities in the state rely on private ambulance services, many rural hospitals run their own EMS services, according to a state hospital association's spokeswoman.
One of them is the 52-bed Humbolt General Hospital in Winnemucca. Louis Mendiola, the hospital's health systems development manager, told a legislative committee in February that some of their patients have to travel between one and eight hours for routine follow-up care. The hospital's paramedics have been offering non-emergency care informally and at no cost for years, according to a transcript of the meeting.
The hospital justifies the expense because it translates into the savings on readmissions. But, the program would benefit from some form of funding or reimbursement, he told the committee. "There are grants out there, but in the next few years, it is something we are going to want to keep our eye on," he said, according to the minutes.
Collaboration is Key
Buy-in, from hospitals and other providers, is key to the approach and can help rural programs develop funding models, Pearson found. Some rural EMS groups are working with insurance companies and hospitals to develop reimbursement plans. One community set up a "shared savings" program funded by dollars saved by the decline readmissions. Others are experimenting with using Medicaid to pay for some CP care, while some are operating with grant funding.
"Collaboration appears to be an important key for the success of community paramedicine programs, based on our interviews," according to the study. "Additionally, partnering with a hospital may provide more options for reimbursement strategies. "
In the meantime, the EMS directors study reported CP activity in rural communities in Hawaii and Idaho. The Georgia Association of EMS reported a grant from the Georgia Office of Rural Health to study the concept of CPs.
In her study, Pearson surveyed providers in 17 states and found "the majority of the rural community paramedics are in developmental or pilot stages." Minnesota is in the process of expanding urban paramedicine program into rural areas and two of Maine's 12 pilot programs are in rural areas.