Community Paramedic Program a 'No-brainer'

One of the first community paramedic programs is proving that providing in-home, non-emergency care makes sense on many levels, and that it is as "economically viable as another system of care," says the agency's chief of clinical services.

It's been three years since last I wrote about community paramedics. Given the relentless grey tsunami of aging Baby Boomers and the dwindling supply of healthcare providers, especially in rural areas, it's time to circle back and re-examine the program.

The idea is less than 10 years old, but already there are more than 500 community paramedic programs across the United States, says Christopher A. Montera, chief of clinical services at Eagle County Paramedic Services, in Vail, CO. ECPS started its community paramedic program in 2010 as one of the first rural programs in the nation.

"It's going to continue to grow," Montera says. "When we started this, there were no states that had community paramedic legislation and today there are 17 states. More than one-quarter of the states have some sort of legislation for this, and there are another 12 getting ready to come on line in the next few years."

Using paramedics during their down time for in-home, non-emergency care makes sense on many levels.

"We started looking at what we could do as paramedics aren't always responding to calls every day," says Montera. "We thought why don't we use an untapped resource in the community to see patients who are falling through the gaps, or they are homebound and can't see their physicians, but they don't qualify for home care? Here we have a shortage of homecare nurses. It was a no-brainer for us that we see patients."

At ECPS, the care coordination is clinician-driven, and paramedics only visit a patient in their home after a referral. Often, the patients are elderly; about 80% are on Medicare or Medicaid, and many are frequent users of ambulance or ER services.

"We've created a simple form that can be used by any provider in our community, whether they be a nurse, physician or whatever," he says. "They fill out the patient's demographic information, what the patient needs, and they fax it to our office. The patient often doesn't self-identify. The patient is identified by other resources in the community who believe the patient might have an unmet health or social need."

In making the house calls, paramedics are trained to assess potential health threats in the home, including issues with utilities, lack of food, etc.

"The patients, when they go to see their physicians, are typically in their Sunday best. The physician has no idea what the living environment is like in the home," Montera says. "Part of our job is to be the eyes and the ears of the physician in the home. We also can run a myriad of lab test at the patient's home and give those results directly to the physician."

A Self-Funded Money-Saver
ECPS receives no funding for its community paramedic program because the state of Colorado hasn't passed legislation setting up a framework. Montera says the program costs about $110,000 per year. That expense mainly covers the salary of the 1.2 FTEs and an SUV. The program operates four days a week during the day, when the paramedics are not involved in their primary emergency response duties.

Montera says a cost-savings analysis done in 2012 showed that the program saved about $135,000 that year.

"We've proven it works and that it can be [as] economically viable as another system of care," he says. "A lot of it is keeping patients out of long-term care, or keeping them out of the emergency room and getting transported by ambulance, and keeping patients out of areas where they didn't receive unnecessary care."

The ECPS community paramedics see about 200 patients per year, spending on average about one hour in the home. Montera says considerably more time can be spent after the visit helping patients find access to care.

"In fact, last week our community paramedic spent more than 50 hours with one patient trying to place her in the right system of care," he says. "It's not just the one-hour visit, it's all the things that surround that patient's care and the coordination of the care that are as important as the visit itself."

Couldn't a nurse from a federally qualified health center or a county health service do the same thing?

"It is harder to recruit nurses to do this type of work," Montera says. "In our community we have a home care agency that doesn't have the staffing to see patients. We have continual problems with that. We have a federally qualified health center in our community and we partner with them to see these patients."

Filling a Gap
"The other part of it is paramedics are already engaged with the community," he says. "That leap of trust isn't that wide when someone thinks there is a paramedic coming to my home. It doesn't seem as intimidating as having a nurse come in. Also, we are already mobile. It is harder for systems that weren't traditionally mobile to ramp up to mobility. We already have the infrastructure to provide care in a home."

"And frankly, paramedics are not nurses and we are not trying to replace home care nursing, but there are so many patients who don't qualify for home care that we can fill that gap," he says. "It is filling that gap for sub-acute, semi-chronic patients that we can see over several visits and help solve some of their care issues."

Interest in community paramedics has been so strong that ECPS created a free manual to help other communities start their own programs.

"We get calls about five to six times a week asking how to start up. That is why we created the resources, so we could say 'read this and talk to me,'" Montera says.

So how do you start a community paramedic program?

"The first step is community engagement. The community really has to know what you are trying to do, and you have to know what is available in the community," Montera says.

"Secondly you have to have the commitment of a medical director or physician advocate who wants to see change," he says. "If you don't have that in your community, you should consider going to community or county leaders and convince them of the economic benefit of having a healthy population."

"Third, you need the support of the people who run the paramedic system," he says. "It's a little scary to try something new and change your method of operation. You have to be willing to risk a little bit to see some success and to invest in that success before you see it come to fruition."

And finally, everyone in the local care community has to be involved.

"It can't just be the paramedic system saying 'we are going to do this' and then operate in a silo," Montera says. "This program is all about breaking down silos."