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 (EMTs) have had the exhausting task of caring for patients during times of crisis and rushing them to the hospital. However, more of today’s first responders are finding themselves responsible for keeping patients out of the hospital and instead of traveling into other healthcare facilities — albeit at a much more casual pace. Through the continued growth and evolvement of community paramedicine programs, these providers are increasingly involved in the “back lines” of the continuum, conducting scheduled visits with patients in their homes after hospital discharge and empowering 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 (ED) 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 not just the continued funding they’ve received but positive patient feedback from their patients and insight into current legislation that aims to define scope of practice and credentialing of those who work in this capacity, community paramedicine appears to be headed toward an increasingly stable future.

SIRENS & 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. Patients are referred to Burholme staff by the ED physicians and patients are briefed on the program and are required to 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 at medical director for the Einstein Medical Center Elkins Park ED. There are specific pathways that have been written 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 and are scheduled to have an at-home visit within 3-5 days. Upon arrival, first responders will provide assessment and check vitals, confirm that follow-up appointments have been scheduled and that transportation has been arranged, provide any ongoing education as necessary, and asks patients about any questions they may have about their healthcare. “We also do a safety check in the home of some critical-type stuff, such as smoke detectors, carbon monoxide detectors, and obvious hazards to see if they need us to intervene at all,” said Overberger. “And 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 or to help them schedule a visit and get them to wherever it is they need to go.”

BREAKING DOWN BARRIERS

Then again, there could be extenuating social circumstances that require a higher level of intervention and oversight that 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, but if you don’t have a phone, 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. Or 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. Or perhaps they could not find their insurance card at the time and forget to make the call again. Or they may have no more minutes left on their cell phone plan and 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, or food insecurity, defined as being without reliable access to a sufficient quantity of affordable, nutritious food, poses barriers that are difficult to address without at-home intervention.

“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 by getting them partnered with resources to either help with medication costs or other charities that help with food because, if you’re not worried about where your next meal is coming from, it’s going to be much more easy to treat the condition. These are the types of challenges that can only be discovered when you go into someone’s home and have an honest discussion with them. It is basic medical empowerment and helping people to be partners in their care.” Medical equipment such as glucometers and CPAP (continuous positive airway pressure) devices are also evaluated and, if needed, replacement is facilitated or education on usage is given. Overberger said that assistance is also provided for durable medical equipment, as needed. “Some of these neighborhoods, people are stealing the equipment that gets delivered to patients’ homes, or 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’s a full-blown emergency and discuss 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, and we can transition to a 911 response, transporting the patient before their condition becomes critical.

MEANING & METRICS

The current Einstein/Burholme paramedicine program stems from an initiative that was also supported by a grant from the Einstein Society from 2014-17 for patients being discharged from an inpatient hospital stay. Once the funds were depleted and analytics were conducted, the benefits were easily seen.

“For instance, we had learned that many COPD patients were running out of oxygen, and we were finding that, for any number of reasons, those patients who did not have their 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, a comparison was conducted on patients who were eligible for the program but declined it for various reasons with those enrolled in the program, and “we found that, compared with patients we did not visit, patients who had paramedicine visits typically had a ‘scheduled next encounter with care, more often than an unscheduled encounter’ he continued. “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. 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. “And 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.”

LEGISLATION LIFELINE

Also buoying the program, and others like it, is existing legislation that seeks to more strongly define clinical parameters and reimbursement. “In Pennsylvania, there’s a lot going on in the legislative pipeline in terms of codifying 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 with getting that 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.”

AN ALLIED COLLABORATIVE?

One of the ongoing uncertainties of the existence of community paramedicine remains how it fits into the continuum as a collaborative service line, particularly among visiting nurse services. Those lines are becoming less blurry, however, both Overberger and Hinchcliff said. “There was a lot of consternation nationally about the inception of programs like this among allied health staff, but most of that does not exist anymore,” Overberger said. “There have been nursing agencies that have come out and vocalized their support of community paramedicine because it helps them to reach patients that they historically have had trouble reaching.”
Hinchcliff stresses the collaborative intent of these types of programs and that in many instances its conceivable to think that the community paramedicine professional could be operating alongside the home nurse or coming into the home after the nursing visits have been completed. 

Even if accredited education programs and credentialed personnel appear to be imminent, Hinchcliff and Overberger said it’s unrealistic to think that first responders would ever be the sole provider presence in a patient’s home. Specifically, chronic wound care would be an example of a high-level, long-term patient need that community paramedicine would not oversee.  

“Wound care nurses and other specialists are always going to do better chronic wound care than first responders,” Overberger said. “I don’t see any benefit in trying to train a paramedic or an EMT in such a highly specialized area of care. We help to manage the acute infection by ensuring antibiotics are refilled, or that patients are going to the wound clinic or making sure their wound is being observed by a specialist in the home. We aren’t built to keep people out of the hospital forever. We are built to bridge them to home.”

As Hinchcliff sees it, community paramedicine is one of the ultimate examples of where today’s healthcare is headed from a quality-based structure. “We really believe that what we are doing is a best practice that it is in line with the Pennsylvania governor’s [Tom Wolf] objective to provide more in-home care and less facility care,” he said. “In order to do that you have to be able to provide this level of support in patients’ homes or they are going to chronically return to the hospital.” 

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