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Curious what your opinion is on these programs and paramedic scope of practice in general. This is from the latest issue of the Annals (article is attached to this thread in pdf also). What is particularly insightful to me is the story of a man with an MI being inappropriately triaged to Urgent Care on the basis of complaining about nausea as opposed to chest pain - doesn't leave me with much confidence.
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Paramedicine Programs Making House Calls
But Scope of Practice Under Scrutiny
Annals of Emergency Medicine, 2017-01-01, Volume 69, Issue 1, Pages A13-A16
Loretta Crittenden had been checking her weight daily to watch for any fluid buildup that might signal worsening congestive heart failure. Late one week last fall, the number on the scale began to climb upward, totaling 6 pounds in just 2 days.
By then it was Friday afternoon, and when her family physician’s office was contacted, Crittenden was advised to seek help at a nearby emergency department (ED). So the family contacted 911, and 2 vehicles arrived, an ambulance and another with the same system, staffed by a community paramedic.
After Crittenden’s vital signs were checked, including some blood work, the 89-year-old Fort Worth woman was given the choice to remain at home and determine whether an intravenous dose of furosemide—administered by the community paramedic—would ease the fluid buildup. The family jumped at that option, recounted Joy Gilliam, Crittenden’s daughter, when another paramedic returned to check on Crittenden that evening. “She felt good enough not to go to the ER,” Gilliam said, “but she still needed help.”
Offering paramedic backup for patients like Crittenden is one of a cross section of services that MedStar, the ambulance service for Fort Worth, TX, provides through its community paramedicine program. Through contracts with various health entities, they assist frequent users of the emergency system, patients who have been recently discharged from the hospital, as well as patients in hospice care. Enthusiasts for the model, which is proliferating around the country, say that it can tap the underused skills of paramedics to reach patients who might otherwise not receive medical care or unduly strain the emergency system with low-acuity medical problems.
Historically, ambulances have served as “a taxi service,” only reimbursed if they transport a patient, said Matt Zavadsky, MS-HSA, EMT, MedStar’s chief strategic information officer and that community medicine program’s founder. “So many of the people that we respond to don’t necessarily need to be in an emergency room,” he said, noting that at least one third of MedStar’s calls aren’t deemed urgent enough to activate the siren.
MedStar, which piloted its program in 2009, is one of the earliest pioneers for the concept, sometimes also called mobile integrated health care. By 2014, there were at least 103 such programs nationally, according to a survey by the National Association of Emergency Medical Technicians. Other early programs include those launched in rural areas of Colorado and Minnesota. In 2015, California started a pilot that is testing the concept in a dozen sites around the state, funded through a $1 million grant from the California Health Care Foundation.
But some observers, including physicians, advise a dose of caution. So far, data on these programs’ safety and cost-effectiveness are limited, according to one analysis published early last year in Annals of Emergency Medicine . In California, that state’s chapter of the American College of Emergency Physicians (ACEP) has criticized some aspects of the multisite pilot project there, saying that it gives paramedics too much autonomy to transport a patient elsewhere, such as to an urgent care center.
“I think our main concern is the safety of having a paramedic determine in the field that a patient who called 911 doesn’t need to be seen in the ER,” said Aimee Moulin, MD, president-elect of the California ACEP. “Determining whether an emergency condition exists, we feel like, is the purview of the emergency medicine physician rather than a paramedic.”
Primary Care Versus Navigation
Broadly speaking, the programs adopt one of 2 focuses, depending on where they are based. Rural areas, such as Eagle County in a mountainous region west of Denver, are primarily deploying paramedics to provide in-home services, within their skill set, ranging from postdischarge hospital evaluations to monitoring international normalized ratios for patients receiving warfarin. The program, launched as a 5-year pilot in 2010, has reached more than 900 patients, according to Chris Montera, NREMT, chief executive officer of Eagle County Paramedic Services.
Montera is bullish about the model’s potential for rural areas, which can struggle to financially justify an ambulance service, given the relatively few emergencies in sparsely populated regions. “There are a lot of small rural ambulance services who are closing their doors every day in the United States,” he said. “I’d love to see a paramedic in every community that is dual role, basically doing community paramedicine and responding to emergencies when they need to, and keeping the community healthier and safer.”
Zavadsky described the other approach, more common to urban areas, as the navigation concept. “We’ve got a lot of health care resources [in Fort Worth], but for some reason our patients still can’t seem to find them,” he said. “So we help them find them. We’re not delivering primary care; we’re navigating.”
For many of these programs, though, reimbursement remains a daunting problem because Medicare doesn’t pay for ambulance services that don’t involve transport to a health care facility, said Bryan Choi, MD, an assistant professor at Brown University, who coauthored the recent Annals analysis. “That’s one of the big thorny issues that we have so far,” he said. And Medicare—whose lead commercial insurers tend to follow, he noted—likely won’t change its stance until there are more data, creating a chicken-and-egg situation.
Many of the programs, such as the 12-site pilot under way in California, were launched with public or grant funding. But other reimbursement avenues are being pursued. In Colorado, legislation signed into law last summer designated community paramedics as an endorsed provider with related training requirements, opening the door to directly billing payers for in-home services, Montera said. Minnesota, which has trained community paramedics to support patients in rural areas, already has passed legislation authorizing Medicaid reimbursement.
Zavadsky made the case that the emergence of affordable care organizations and other bundled payment models and incentives to keep patients out of the hospital, such as readmission penalties, paves the way to direct contracting with payers, an avenue that MedStar has followed.
Its program was seeded by worries about the strain of nonurgent calls on the ambulance system, formally called the Area Metropolitan Ambulance Authority and serving Fort Worth and a surrounding region of North Texas.
In a quick search looking at 2008 data, MedStar determined that 21 patients had called 911 at least 15 times in the previous 90 days. Across 12 months, those 21 patients had racked up a hefty bill, some 800 trips totaling more than $950,000. Zavadsky got permission to set up a pilot focused on better supporting those superusers so they didn’t rely as much on the ED.
Patient Care Debate
As he drove through Fort Worth to Crittenden’s house for a follow-up visit, MedStar paramedic Daniel Ebbett, CCP-C, EMT-P, described the various patients today’s much larger program is striving to help: the 90-something woman with dementia-related anxiety who calls 911 when she experiences another panic attack, the obese man who experiences nearly daily falls. They meet with numerous patients, some on strapped budgets, who they brainstorm with about healthier but still cheap food options, even to the point of asking to peek into their cabinets.
Ebbett particularly enjoys working with hospice patients, assisting family members when they become alarmed by a loved one’s condition and call 911. “You go in and identify what is panicking the family and fix it,” Ebbett said. Frequently, a boost in oxygen and easing a patient’s pain can defuse the family’s angst, he said.
When Ebbett arrived at Crittenden’s home Friday evening, she had already shed 4 pounds over numerous bathroom trips and was sitting at the table, eating dinner with gusto. “You all did a great service for me,” she said.
Before they start working in the community, leaders of these programs stress, paramedics receive significant additional training. MedStar’s community paramedics complete approximately 260 additional hours, including clinical rotation, Zavadsky said. In the California pilot, every paramedic receives approximately 200 additional hours and some as many as 250, according to Lou Meyer, project manager for the community paramedicine pilot through the California Emergency Medical Services Authority.
Still, are there cases in which paramedics are wielding too much autonomy? The leaders at California’s ACEP spoke out in letters and testimony against one element of the pilot there—the pilot had needed a temporary waiver from state officials to broaden paramedics’ scope of practice—called alternate destination, which provides paramedics, working under the parameters of a detailed protocol, the option of taking a patient to an urgent care center instead of an ED. As it stands, patients with nonurgent issues might be stranded in a hospital hallway on a gurney anywhere between 1 and 6 hours, with the paramedic nearby waiting for an emergency bed to open up, Meyer said. With alternate diversion, that low-acuity patient gets to consult with a physician, and likely sooner, at an urgent care center. Moreover, Meyer said, it alleviates “having paramedic units just sitting against the wall and not out in the street available for the next emergency call that comes on.”
But leaders at the California ACEP have questioned whether paramedics can appropriately triage all cases, citing a study published in 2014 in Annals that examined the ability of paramedics and emergency medical technicians to determine who needed to go to an ED. In the 13 studies reviewed, the rates of undertriage ranged from 3% to 32%, the authors wrote.
Dr. Moulin credits other elements of the California pilot, such as posthospital discharge follow-up, with providing additional care to patients. But transporting a patient to another location can undercut care, she said. “You take a patient who has called 911, who is usually in a vulnerable state, and divert them to a lower level of care.”
Dr. Moulin, who sits on an advisory committee formed after the pilot’s approval, said that she’s concerned about a situation she learned about in her committee role: that a man initially taken to an urgent care center was then sent to an ED and required a stent.
The precise circumstances of the patient’s case, as of early fall, were in some dispute. Meyer, the pilot’s project manager, said the man was initially transported to urgent care for suspected food poisoning after complaining of nausea shortly after eating tacos. “He was not described as having chest pains or any other symptoms of a heart attack,” Meyer said.
But the urgent care physician soon recommended transport to the ED because the patient had some shortness of breath and his pulse rate briefly slowed, according to Meyer, who consulted the patient records. Neither the ECG nor the blood tests suggested a heart attack. But the cardiologist took the patient to the catheterization laboratory for further evaluation and identified some partial blockages, which were stented.
The pilot’s protocol has since been changed to include nausea as a reason not to transport a patient to urgent care, Meyer said. But Dr. Moulin, who has not seen the medical record, questions why the patient was steered away from the ED in the first place. Those symptoms in a middle-aged man, she said, could indicate a myocardial infarction. Plus, she added, “Not everyone who eats a bad taco calls 911.”
Soon, more patient care and other data will be forthcoming. Both the pilots in Eagle County and California are being analyzed by academic institutions. If the California pilot is deemed to be effective, the next move would be to submit legislation to change paramedics’ scope of practice, possibly as soon as next year, according to Meyer.
En Route and in Home
These days, MedStar’s program supports more than 500 patients, contracting with various entities, including 4 hospitals, 2 home health care agencies, 2 hospice agencies, and 1 large multispecialty physician practice. The program, which broke even in its third year, projects a total $1.4 million budget for this fiscal year, which began in October 2016, according to data provided by Zavadsky. The projected annual revenue is nearly $2 million.
To cover the various low-level and more urgent crises that might arise, community paramedicine teams operate around the clock. Any 911 call that’s linked to a patient in the community paramedicine program, as Crittenden was, reaps a 2-pronged response, one from an ambulance and the second from a community paramedic.
They also monitor patients who have been recently discharged. An initial assessment can extend 2 hours or more. One Friday afternoon, a paramedic with the program, Kyle Barbour, visited a woman in her late 70s who had congestive heart failure and chronic obstructive pulmonary disease, among other conditions, and had been discharged just a few hours before from a skilled nursing unit.
Once she agreed to enroll in the program, Barbour began to check on her condition, including obtaining a baseline ECG, asking questions about her symptoms as he worked, asking when she’d last eaten, and asking whether she had any family living nearby.
Numerous medications in blister packs, 15 prescriptions in all, filled a bag on a nearby ottoman, sent along from the skilled nursing unit. Barbour returned to his vehicle and brought back a large pill sorter, with each day broken into 4 parts based on dose timing. Lining up the discharge paperwork near the blister packs, he slowly filled the compartments to cover several days, sufficient until he returned to check on her again.
At one point, Barbour asked the woman whether she was typically so short of breath. She was supposed to be receiving oxygen, she responded, looking around. “I was trying to find it. I don’t know where it ended up.” Barbour located the oxygen tank, situated behind her armchair, and connected it to her, easing her breathing.
-----------------------------------------------------------------------------------------------------------------------
Paramedicine Programs Making House Calls
But Scope of Practice Under Scrutiny
Annals of Emergency Medicine, 2017-01-01, Volume 69, Issue 1, Pages A13-A16
Loretta Crittenden had been checking her weight daily to watch for any fluid buildup that might signal worsening congestive heart failure. Late one week last fall, the number on the scale began to climb upward, totaling 6 pounds in just 2 days.
By then it was Friday afternoon, and when her family physician’s office was contacted, Crittenden was advised to seek help at a nearby emergency department (ED). So the family contacted 911, and 2 vehicles arrived, an ambulance and another with the same system, staffed by a community paramedic.
After Crittenden’s vital signs were checked, including some blood work, the 89-year-old Fort Worth woman was given the choice to remain at home and determine whether an intravenous dose of furosemide—administered by the community paramedic—would ease the fluid buildup. The family jumped at that option, recounted Joy Gilliam, Crittenden’s daughter, when another paramedic returned to check on Crittenden that evening. “She felt good enough not to go to the ER,” Gilliam said, “but she still needed help.”
Offering paramedic backup for patients like Crittenden is one of a cross section of services that MedStar, the ambulance service for Fort Worth, TX, provides through its community paramedicine program. Through contracts with various health entities, they assist frequent users of the emergency system, patients who have been recently discharged from the hospital, as well as patients in hospice care. Enthusiasts for the model, which is proliferating around the country, say that it can tap the underused skills of paramedics to reach patients who might otherwise not receive medical care or unduly strain the emergency system with low-acuity medical problems.
Historically, ambulances have served as “a taxi service,” only reimbursed if they transport a patient, said Matt Zavadsky, MS-HSA, EMT, MedStar’s chief strategic information officer and that community medicine program’s founder. “So many of the people that we respond to don’t necessarily need to be in an emergency room,” he said, noting that at least one third of MedStar’s calls aren’t deemed urgent enough to activate the siren.
MedStar, which piloted its program in 2009, is one of the earliest pioneers for the concept, sometimes also called mobile integrated health care. By 2014, there were at least 103 such programs nationally, according to a survey by the National Association of Emergency Medical Technicians. Other early programs include those launched in rural areas of Colorado and Minnesota. In 2015, California started a pilot that is testing the concept in a dozen sites around the state, funded through a $1 million grant from the California Health Care Foundation.
But some observers, including physicians, advise a dose of caution. So far, data on these programs’ safety and cost-effectiveness are limited, according to one analysis published early last year in Annals of Emergency Medicine . In California, that state’s chapter of the American College of Emergency Physicians (ACEP) has criticized some aspects of the multisite pilot project there, saying that it gives paramedics too much autonomy to transport a patient elsewhere, such as to an urgent care center.
“I think our main concern is the safety of having a paramedic determine in the field that a patient who called 911 doesn’t need to be seen in the ER,” said Aimee Moulin, MD, president-elect of the California ACEP. “Determining whether an emergency condition exists, we feel like, is the purview of the emergency medicine physician rather than a paramedic.”
Primary Care Versus Navigation
Broadly speaking, the programs adopt one of 2 focuses, depending on where they are based. Rural areas, such as Eagle County in a mountainous region west of Denver, are primarily deploying paramedics to provide in-home services, within their skill set, ranging from postdischarge hospital evaluations to monitoring international normalized ratios for patients receiving warfarin. The program, launched as a 5-year pilot in 2010, has reached more than 900 patients, according to Chris Montera, NREMT, chief executive officer of Eagle County Paramedic Services.
Montera is bullish about the model’s potential for rural areas, which can struggle to financially justify an ambulance service, given the relatively few emergencies in sparsely populated regions. “There are a lot of small rural ambulance services who are closing their doors every day in the United States,” he said. “I’d love to see a paramedic in every community that is dual role, basically doing community paramedicine and responding to emergencies when they need to, and keeping the community healthier and safer.”
Zavadsky described the other approach, more common to urban areas, as the navigation concept. “We’ve got a lot of health care resources [in Fort Worth], but for some reason our patients still can’t seem to find them,” he said. “So we help them find them. We’re not delivering primary care; we’re navigating.”
For many of these programs, though, reimbursement remains a daunting problem because Medicare doesn’t pay for ambulance services that don’t involve transport to a health care facility, said Bryan Choi, MD, an assistant professor at Brown University, who coauthored the recent Annals analysis. “That’s one of the big thorny issues that we have so far,” he said. And Medicare—whose lead commercial insurers tend to follow, he noted—likely won’t change its stance until there are more data, creating a chicken-and-egg situation.
Many of the programs, such as the 12-site pilot under way in California, were launched with public or grant funding. But other reimbursement avenues are being pursued. In Colorado, legislation signed into law last summer designated community paramedics as an endorsed provider with related training requirements, opening the door to directly billing payers for in-home services, Montera said. Minnesota, which has trained community paramedics to support patients in rural areas, already has passed legislation authorizing Medicaid reimbursement.
Zavadsky made the case that the emergence of affordable care organizations and other bundled payment models and incentives to keep patients out of the hospital, such as readmission penalties, paves the way to direct contracting with payers, an avenue that MedStar has followed.
Its program was seeded by worries about the strain of nonurgent calls on the ambulance system, formally called the Area Metropolitan Ambulance Authority and serving Fort Worth and a surrounding region of North Texas.
In a quick search looking at 2008 data, MedStar determined that 21 patients had called 911 at least 15 times in the previous 90 days. Across 12 months, those 21 patients had racked up a hefty bill, some 800 trips totaling more than $950,000. Zavadsky got permission to set up a pilot focused on better supporting those superusers so they didn’t rely as much on the ED.
Patient Care Debate
As he drove through Fort Worth to Crittenden’s house for a follow-up visit, MedStar paramedic Daniel Ebbett, CCP-C, EMT-P, described the various patients today’s much larger program is striving to help: the 90-something woman with dementia-related anxiety who calls 911 when she experiences another panic attack, the obese man who experiences nearly daily falls. They meet with numerous patients, some on strapped budgets, who they brainstorm with about healthier but still cheap food options, even to the point of asking to peek into their cabinets.
Ebbett particularly enjoys working with hospice patients, assisting family members when they become alarmed by a loved one’s condition and call 911. “You go in and identify what is panicking the family and fix it,” Ebbett said. Frequently, a boost in oxygen and easing a patient’s pain can defuse the family’s angst, he said.
When Ebbett arrived at Crittenden’s home Friday evening, she had already shed 4 pounds over numerous bathroom trips and was sitting at the table, eating dinner with gusto. “You all did a great service for me,” she said.
Before they start working in the community, leaders of these programs stress, paramedics receive significant additional training. MedStar’s community paramedics complete approximately 260 additional hours, including clinical rotation, Zavadsky said. In the California pilot, every paramedic receives approximately 200 additional hours and some as many as 250, according to Lou Meyer, project manager for the community paramedicine pilot through the California Emergency Medical Services Authority.
Still, are there cases in which paramedics are wielding too much autonomy? The leaders at California’s ACEP spoke out in letters and testimony against one element of the pilot there—the pilot had needed a temporary waiver from state officials to broaden paramedics’ scope of practice—called alternate destination, which provides paramedics, working under the parameters of a detailed protocol, the option of taking a patient to an urgent care center instead of an ED. As it stands, patients with nonurgent issues might be stranded in a hospital hallway on a gurney anywhere between 1 and 6 hours, with the paramedic nearby waiting for an emergency bed to open up, Meyer said. With alternate diversion, that low-acuity patient gets to consult with a physician, and likely sooner, at an urgent care center. Moreover, Meyer said, it alleviates “having paramedic units just sitting against the wall and not out in the street available for the next emergency call that comes on.”
But leaders at the California ACEP have questioned whether paramedics can appropriately triage all cases, citing a study published in 2014 in Annals that examined the ability of paramedics and emergency medical technicians to determine who needed to go to an ED. In the 13 studies reviewed, the rates of undertriage ranged from 3% to 32%, the authors wrote.
Dr. Moulin credits other elements of the California pilot, such as posthospital discharge follow-up, with providing additional care to patients. But transporting a patient to another location can undercut care, she said. “You take a patient who has called 911, who is usually in a vulnerable state, and divert them to a lower level of care.”
Dr. Moulin, who sits on an advisory committee formed after the pilot’s approval, said that she’s concerned about a situation she learned about in her committee role: that a man initially taken to an urgent care center was then sent to an ED and required a stent.
The precise circumstances of the patient’s case, as of early fall, were in some dispute. Meyer, the pilot’s project manager, said the man was initially transported to urgent care for suspected food poisoning after complaining of nausea shortly after eating tacos. “He was not described as having chest pains or any other symptoms of a heart attack,” Meyer said.
But the urgent care physician soon recommended transport to the ED because the patient had some shortness of breath and his pulse rate briefly slowed, according to Meyer, who consulted the patient records. Neither the ECG nor the blood tests suggested a heart attack. But the cardiologist took the patient to the catheterization laboratory for further evaluation and identified some partial blockages, which were stented.
The pilot’s protocol has since been changed to include nausea as a reason not to transport a patient to urgent care, Meyer said. But Dr. Moulin, who has not seen the medical record, questions why the patient was steered away from the ED in the first place. Those symptoms in a middle-aged man, she said, could indicate a myocardial infarction. Plus, she added, “Not everyone who eats a bad taco calls 911.”
Soon, more patient care and other data will be forthcoming. Both the pilots in Eagle County and California are being analyzed by academic institutions. If the California pilot is deemed to be effective, the next move would be to submit legislation to change paramedics’ scope of practice, possibly as soon as next year, according to Meyer.
En Route and in Home
These days, MedStar’s program supports more than 500 patients, contracting with various entities, including 4 hospitals, 2 home health care agencies, 2 hospice agencies, and 1 large multispecialty physician practice. The program, which broke even in its third year, projects a total $1.4 million budget for this fiscal year, which began in October 2016, according to data provided by Zavadsky. The projected annual revenue is nearly $2 million.
To cover the various low-level and more urgent crises that might arise, community paramedicine teams operate around the clock. Any 911 call that’s linked to a patient in the community paramedicine program, as Crittenden was, reaps a 2-pronged response, one from an ambulance and the second from a community paramedic.
They also monitor patients who have been recently discharged. An initial assessment can extend 2 hours or more. One Friday afternoon, a paramedic with the program, Kyle Barbour, visited a woman in her late 70s who had congestive heart failure and chronic obstructive pulmonary disease, among other conditions, and had been discharged just a few hours before from a skilled nursing unit.
Once she agreed to enroll in the program, Barbour began to check on her condition, including obtaining a baseline ECG, asking questions about her symptoms as he worked, asking when she’d last eaten, and asking whether she had any family living nearby.
Numerous medications in blister packs, 15 prescriptions in all, filled a bag on a nearby ottoman, sent along from the skilled nursing unit. Barbour returned to his vehicle and brought back a large pill sorter, with each day broken into 4 parts based on dose timing. Lining up the discharge paperwork near the blister packs, he slowly filled the compartments to cover several days, sufficient until he returned to check on her again.
At one point, Barbour asked the woman whether she was typically so short of breath. She was supposed to be receiving oxygen, she responded, looking around. “I was trying to find it. I don’t know where it ended up.” Barbour located the oxygen tank, situated behind her armchair, and connected it to her, easing her breathing.
