1. The recognition of EMS as an active partner in community needs assessment;
2. The ability of EMS to fill community healthcare gaps;
3. The avoidance of service duplication; and
4. The strengthening of health infrastructure by improving access to health services.

The Iowa EMS Association has agreed to post articles relating to Community Paramedicine/Mobile Integrated Healthcare on its website to improve access to this important information for EMS providers.
 

Paramedics Step Up to Cut Hospital Readmissions
Emergency medical workers find a new lucrative line of business: helping hospitals potentially save millions of dollars.
By Alan Neuhauser USNews.com Oct. 9, 2014

The cupboards were bare, so he did what anyone would do – he went grocery shopping.

Except this wasn’t his home. He wasn’t even buying food for himself.

Instead, the man is a paramedic with the Carmel, Indiana, Fire Department, a fast-growing town of 86,000 just north of Indianapolis. Carmel Fire Chief Matt Hoffman said his staffer wasn't responding to an emergency – he was preventing one, visiting one of the 80-plus former 911 patients participating in the department’s new Mobile Integrated Health Care program.

A community paramedic with Colorado's Eagle County Paramedic Services checks on a patient.

“All she had was Campbell’s chicken noodle soup, which is really high in sodium and really bad for congestive heart patients like her – that’s the last thing in the world you would want that person to eat,” Hoffman recounts. “So of his own volition, this paramedic provided some better menu options so that she would not fall into another congestive-heart-failure episode and be transported back to the hospital.”

In the past decade, according to the Joint National EMS Leadership Forum, close to 300 fire departments, ambulance services and hospital systems nationwide have launched programs like Carmel’s, initiatives commonly known as community paramedic or community paramedicine.

Under President Barack Obama’s Affordable Care Act of 2010, hospitals can be fined if a patient has to be treated again for the same condition shortly after being discharged. Last year, 18 percent of Medicare patients who were hospitalized and then discharged had to be readmitted, Kaiser Health News reported. The return visits cost the agency about $26 billion.

Last year, a program that saw 739 patients in rural Colorado helped save an estimated $313,834 in costs between hospitals, insurers and patients. A small pilot program in Minnesota reduced ER readmissions for high-risk patients from roughly 20 percent to just 3 percent. And of the roughly 80 patients that Carmel's community paramedics have seen since July 1, just two have called 911 again for the same condition.

And one week after Medicare announced it would fine more than 2,000 hospitals for readmitting too many patients last year, Hoffman hopes that community paramedicine's apparent success rates will attract millions of dollars in funding from local hospitals eager to reduce future Medicare penalties. That money, he says, could support operations budget for the entire fire department, without a single cent of taxpayer money.

“It’s looking at the delivery of health care in the community in an entirely new way,” says Michael Kaufmann, medical director for the Carmel Fire Department and St. Vincent Carmel Hospital's Emergency Department.

Community paramedicine, in one sense, brings back the black-bag home-doctor visits of yore: rather than wait for a call to 911, paramedics swing by former patients' homes. They’ll check vital signs, make sure patients are taking their medications, look for potential hazards like mold in the home or tricky stairs. In some programs, the paramedics may administer vaccines, draw blood for tests, and drive patients to the pharmacy or local clinic rather than the emergency room.

The Carmel Fire Department boasts more than 50 firefighter-paramedics who cover the city's roughly 50 miles, plus nearby Clay Township.

The Carmel, Indiana, Fire Department, seen here battling an apartment fire in 2008, launched its community paramedic program this summer.

“We have people that we run on, on a regular basis, dozens of times a month, and there has to be a system to help them take care of themselves or at least find them other options than the emergency room,” Hoffman says. “If we can take that preventative measure, it saves our resources for the times we desperately need them.”

Plus, adds Susan Long, director of clinical services for Allina Health EMS in Minnesota, which has implemented its own community paramedic program, “hospitals don’t get dinged for the re-admissions.”

And that, fire and EMS agencies hope, could be a potentially lucrative opportunity for their cash-strapped ambulance corps.

“I run about a $3 million budget, and about half of that is supported from ambulance fees,” Hoffman says. “My goal is that my entire operations budget would be based on user fees” from the three hospitals in his jurisdiction that could pay his department for the community paramedicine program, instead of forking over millions more to the government for excessive ER visits.

Last week, Medicare declared it would penalize 2,610 hospitals, docking them a portion of every Medicare payment that goes toward a patient’s stay – fines expected to total about $438 million, Kaiser Health said.

Those penalties, as intended, has created huge interest in preventative care. As Chris Montera of Colorado’s Eagle County Paramedic Services describes, paramedics have “come in to help them [the hospitals] fill those gaps.”

Eagle County founded the country’s first rural community paramedicine program in 2009. The service covers 1,692 square miles and helps bring basic care to hundreds of far flung patients who might otherwise have trouble getting to a clinic or pharmacy. The patients, referred to the program by a physician, are chiefly the elderly – the median age last year was 60 – but those with mobility or behavioral issues also use the service, too.

Other programs, like Carmel’s, are based in cities: community paramedics in Fort Worth, Texas, and Wake County, North Carolina, also keep an eye on patients.

“The physician in the clinic or the hospital doesn't necessarily see what the patient is doing at home,” says Allina’s Long. "So having the paramedic see that the patient is going up three flights of stairs every day or eating high-sodium food, it’s another connection point to really improve the health of the patient.”

Many if not most of the programs are still figuring out the best way to pay for them. There are two different models; some, like Eagle County, hire community paramedics exclusively for the program while others, like Carmel, ask their paramedics to see patients between emergency calls.

"We're using our extra capacity," Carmel Mayor James Brainard says.

Minnesota is the only state to have authorized reimbursements through Medicaid. Programs in other states, like Carmel's and Eagle County's, want partnerships with hospitals.

For now, though, Eagle County's Montera says, "it's still very entrepreneurial."

There are skeptics, too. Nursing groups, for example, have voiced some concern that community paramedicine programs could eliminate some home health-care jobs. Members of the International Association of Firefighters also initially argued that the program might unfairly impose additional duties on firefighters and paramedics. In July, though, the union adopted a resolution in favor of community paramedic services.

"Engaging our members, our firefighter-paramedics and EMTs, to be even more integrated into the community and to be even higher value and importance – we really see it as expanding our service as we have in so many areas," IAFF general president Harold Schaitberger says.

Hoffman agrees.

"In the 1970s, fire departments only fought fires, and then we really started working on fire prevention," he says. "Now because of the Affordable Care Act, we're pretty much doing the same thing. We're trying to cure these patients or treat these patients before they need treatment."