The Evolving Practice of Paramedicine

community paramedicine

First responders are seeing an increased role in non-emergent patient care. With legislation regarding the scope of practice anticipated, what might this service line look like?

Traditionally, paramedics and emergency medical technicians take on the exhausting task of rushing patients to the hospital in times of crisis. However, many first responders now find themselves responsible for keeping patients out of the hospital. Instead, they travel with them to other healthcare facilities — albeit at a much more casual pace.

A reverse 911 call

Through the continued growth and evolution of community paramedicine programs, these providers are increasingly involved in the “back lines” of the continuum. These lines entail scheduled visits with patients in their homes after hospital discharge. It also empowers them to remain healthy and to follow their care plans before another emergency room appearance or inpatient stay is needed.

“It’s almost like a reverse 911 call,” said Ryan Overberger, DO, EMT-PHP, medical director of Burholme Emergency Medical Services (EMS), a Philadelphia-based agency that recently received its second grant from the city’s Einstein Healthcare Network to expand upon its existing community paramedicine program. “We’re taking referrals from the emergency department and doing things like medicine reconciliation, making sure that patients have follow-up appointments scheduled, helping patients to have their prescriptions refilled, educating patients about their illnesses, and, yes, serving as a resource to be called on if they have an emergency.”

As best as Overberger and others at Burholme and Einstein can ascertain based on feedback, community paramedicine appears to be headed toward an increasingly stable future.

Related: Essentials of Trauma Nursing, 3rd Edition

Scope of practice

The current Burholme/Einstein program, funded through a grant from the Albert Einstein Society, focuses on patients who are otherwise ready for discharge from the ED but have some care-coordination issues that might land them in the hospital for observation.

ED physicians refer patients to Burholme staff, where they brief them on the program. Patients must provide consent to the home visits before first responders are assigned to them. Patients are not subject to any costs and must be diagnosed with at least one of six acute diagnoses: COPD/asthma, congestive heart failure, hypertension, diabetes, cellulitis, or abscess.

“It’s not long-term care. We follow up on the exacerbation that led to the hospital visit,” said Overberger, who also serves as attending physician in the division of EMS at Einstein Medical Center and medical director for the Einstein Medical Center Elkins Park ED.

Assessment and treatment

Providers write specific pathways for each diagnosis, with assessment and treatment strategies within the scope of practice of the paramedicine team, according to Tim Hinchcliff, RRT, NREMT, managing director at Burholme EMS and coordinator for the community paramedicine program.

Typically, patients who agree to participate in the program receive a phone call the day after discharge. They are also scheduled to have an at-home visit within 3-5 days. Upon arrival, first responders will provide assessment and check vitals. They will confirm that follow-up appointments have been scheduled and that transportation has been arranged. Additionally, they may provide any ongoing education and ask patients about any questions they may have about their healthcare.

“We also do a safety check in the home. This includes looking for smoke detectors, carbon monoxide detectors, and obvious hazards to see if they need us to intervene at all,” said Overberger. “These patients may not always need highly specialized care. They may just need someone to check to make sure that the pharmacy got their prescription orders and that they are able to have it picked up or delivered. Or they may just need someone to remind them that they have a follow-up visit scheduled. They may need help scheduling a visit, or getting them to wherever it is they need to go.”

Breaking down barriers

There may also be extenuating social circumstances that require a higher level of intervention and oversight. These are not easily detectable in the ED for a variety of reasons. Left unnoticed, these situations can exacerbate clinical issues and result in hospital readmission. Overberger and Hinchcliff say that community paramedicine has proven to be a great benefit in this regard.

“Telling someone to ‘Call this number for your follow-up appointment’ may sound like the easiest task in the world. If you don’t have a phone, however, how are you making that call?” Overberger said. “Some people are too proud to let us know those kinds of problems they are dealing with within the hospital. Perhaps they call to schedule an appointment and end up being put on hold for a long time and then give up on that phone call. Maybe they couldn’t find their insurance card at the time, then forget to make the call again. Or they may have no more minutes left on their cell phone plan. They might intend to wait until their new billing cycle, which could be well past the advised follow-up time.”

Additionally, language barriers may cause confusion or fear that delays or outright prohibits a patient from following discharge instructions. Food insecurity, i.e., being without reliable access to affordable, nutritious food, poses barriers that are difficult to address without at-home intervention.

Addressing social needs

“Food insecurity is a huge issue for some of our patients,” Overberger said. “Many patients are faced with choosing between buying the new medicines they’ve been prescribed or a meal for their family. We try to help people address these social needs that go beyond their medical care. This may include partnering them with resources to either help with medication costs or other charities that help with food. If you’re not worried about where your next meal is coming from, it’s going to be much easier to treat the condition.”

These are the needs and challenges that only emerge after an honest, one-on-one discussion with the patient. This forms the basis of basic medical empowerment.

Evaluating medical equipment

During a visit, healthcare professionals also evaluate medical equipment such as glucometers and CPAP (continuous positive airway pressure) devices. If needed, they facilitate replacements or educate patients on proper use and care.

Overberger said that his first responder team also provides durable medical equipment as needed. “Some of these neighborhoods, people are stealing the equipment that gets delivered to patients’ homes. Some companies won’t deliver to the area at all,” he said. “I never cease to be amazed by some of the things we find on these visits. We’ve seen patients prescribed the same medication by two different doctors, and so they’re taking double the dosage.”

There are other advantages to first responders going into patients’ homes for scheduled visits, Overberger said. “Our paramedicine teams sometimes identify patients whose conditioning is worsening despite treatment. We can identify this worsening before it becomes a full-blown emergency. We then discuss it with their physician, or with Einstein physicians, and adjust their treatment plan accordingly. Sometimes it’s clear the patient needs to go to the hospital. We can then transition to a 911 response, transporting the patient before their condition becomes critical.

Meaning and metrics

The current Einstein/Burholme paramedicine program stems from an initiative supported by a grant from the Einstein Society. Once the analytics were conducted, the benefits were easily seen.

“For instance, we had learned that many COPD patients were running out of oxygen. We were finding that, for any number of reasons, those patients who did not have appointments made for them at the time of discharge were much less likely to see the specialist or their primary provider,” Overberger said. “We also conducted data that found our patients felt that they benefited from the program and that it kept them from having additional ED visits and re-hospitalizations.”

Additionally, the team compared patients who were eligible for the program but declined it with those enrolled in the program. Compared with patients they did not visit, patients who had paramedicine visits typically had a ‘scheduled next encounter with care, more often than an unscheduled encounter.’

“Our theory was that, if we can help to get the patients to their scheduled follow-up appointments, then we are helping them to navigate the health system process,” said Overgerger. “And that was something that we saw as one of our major successes.”

Patient satisfaction surveys have also been part of both programs’ evaluation and assessment. “Our feedback has been very positive,” Overberger said. “From what patients are telling us, they are getting something out of the program. They feel better overall and in their ability to take care of themselves. They are connecting with physicians.”

A legislation lifeline

Also buoying the program is legislation that seeks to strongly define clinical parameters and reimbursement.

“In Pennsylvania, there’s a lot going on in the legislative pipeline. These proposed bills will codify who is supposed to pay and at what levels and at what circumstances,” Overberger said. “That’s why many of these programs exist because of grant funding or hospital funding.”

According to Hinchcliff, House Bill 1113, or the Community Paramedicine Services Act, “is going to create a standard of care and finalize the certification for pre-hospital care personnel to be recognized as community paramedicine providers.”

“In order for it to become something that would be reimbursable by insurance companies, it has to go through complete legislative review,” he continued. “The Pennsylvania Emergency Health Services Council is taking the lead in Pennsylvania’s certification, scope of practice, and standards through the legislative process currently. Down the line, the department of health and the bureau of EMS will have set standards for different types of community paramedicine programs.”

 

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