At-home care services are receiving a facelift. The nurse’s role is among the many questionable aspects of this service line.
The calls come in seemingly constantly, day in and day out. At all hours of the morning, afternoon, and evening. At an unpredictable frequency, 9-1-1 dispatchers and first responders can rely on only one certainty — that they will be needed for a variety of reasons ongoing and in an instant, all at once, at any given time. Surely, trying to anticipate the next call would be a lesson in futility. From cardiac arrests, strokes, and drownings to gunshot wounds, burns, and broken bones, these lifesavers have seen it all and must be prepared in an instant to respond to instances that simply cannot be anticipated. Still, every time a call comes in from someone who wants help adjusting the settings on their air conditioner or has bugs in their home, Larry Atteridge, NRP, director of emergency medical services at Natchitoches (LA) Regional Medical Center, is reminded of the reality that not every call into 9-1-1 is going to be a matter of life and death — not even close. That doesn’t change the mentality that every time the dispatch radio sounds, however, that every call must be treated as such, even if one-third of the calls that come in monthly are non-emergent and really unnecessary as far as 9-1-1 standards go.
“That’s a huge burden on our system,” said Atteridge, a nationally registered paramedic who has served more than 30 years in emergency medical services (EMS) and oversees three ambulance system stations for the largest rural hospital in Louisiana. “And I’m absolutely sure that it’s a huge burden on every EMS system throughout the United States.”
Judging by the ongoing trend of community paramedicine programs, an evolving healthcare service line that allows paramedics and emergency medical technicians (EMTs) to operate in expanded roles by assisting with public health, primary healthcare, and preventive services to underserved populations in the community,1 he’s onto something. As of 2015, more than 100 EMS agencies in 33 states and the District of Columbia had launched community paramedicine programs or mobile integrated healthcare programs,2 a movement that aims to deliver higher quality and more cost-effective medical care by coordinating resources among EMS providers, hospitals, in-home carers, and insurance companies.3 As part of these initiatives, first responders are more likely to conduct scheduled visits in the home setting to provide services such as blood pressure checks and wound care in an attempt to keep patients out of the hospital. Of course, the goal here is to also reduce the volume of 9-1-1 calls that could hamper the response to true emergencies—but could this impact the role of the visiting nurse? While few would argue against the benefits to offering more patients more exposure from trained healthcare professionals when they otherwise would not be able to rely on them, this is just one of the various questions that are being raised by the increasing integration of these programs. Questions raised are also related to everything from where funding may come from to how protocols will be written and managed.
In Natchitoches, the concept of community paramedicine is just that — an abstract idea that does not yet have concrete evidence to substantiate the need, but something that is being evaluated in order to determine real evidence. Atteridge, however, predicts that in the next three years his community will be among the growing number of those utilizing these programs. He also doesn’t envision that it would be a service line devoid of nurses, especially when considering the proliferation of chronic wounds in this country and the impact and expertise that nurses have in this area of healthcare.
“At some point, a nurse’s visit [to the patient’s home] might be more appropriate than a paramedic visit, depending on the complexity of the patient,” he said.
Caroline E. Fife, MD, FAAFP, CWS, FUHM, isn’t so sure. The medical director of CHI St. Luke’s Wound Care Clinic in The Woodlands, TX, Fife, a former EMT herself, believes the cost of employing a nurse in the home could preclude them from having a strong presence when compared to an appropriately trained community paramedic. When compounded by the number of patients who do not qualify for Medicare visiting nurse services due to a certain level of independence and considering that many of these people could yet still also be among those calling into 9-1-1 for reasons that don’t amount to emergencies, and the math does not work in nursing’s favor.
“These people do not need a home nurse — it’s too expensive, and this is not a good utilization of our tax dollars,” she said. “They don’t need skilled nursing. But they do need somebody to check on them and to let them know when they are sick — that’s the other thing that is a growing need.”
Despite where this trend leads to clinically in the home, both Atteridge and Fife believe the nurse’s role in assisting the development of protocols for first responders, particularly when it comes to wound care, will be essential as the trend continues.
“Without that nursing piece of the puzzle, if we were a standalone service, I would have huge reservations about letting a paramedic go out and assess a wound without extraordinary training and credentialing,” Atteridge said. “I don’t think the nurses are ever going to lose their strength in this.”
The nurse’s role could also be reinforced by those working within outpatient wound centers, where many patients would conceivably be referred to without qualifying as hospital readmission. “We don’t need people to be [in the home] all day, but we do need people to go into the home [and perform basic wound care] for these patients, including triage,” Fife said. “So I need to ask these patients if they can afford to hire somebody to take care of them because if they can’t, the only other option I have is to call adult protective services and report them for neglecting themselves because I cannot allow that to go on. That’s a horrible thing to have to do to someone. And this is where community paramedicine can come into play.”
- Community Paramedicine. RHIhub. 2018. Accessed online: www.ruralhealthinfo.org/topics/community-paramedicine#definition
- Over 100 community paramedicine programs launched in 33 states. EMS1.com. 2015. Accessed online: www.ems1.com/community-paramedicine/articles/2174134-Over-100-community-paramedicine-programs-launched-in-33-states
- McGrath MK. What is mobile integrated healthcare? RAVE Mobile Safety. 2018. Accessed online: www.ravemobilesafety.com/blog/what-is-mobile-integrated-health