Community Paramedicine

Picture this scenario: You respond to a 35-year-old male with insulin-dependent diabetes mellitus complicated by alcoholism and near-homelessness. You find him at his home, a daily hotel, without complaints.  Other family members (who don’t live with the patient) visited and called 911. They are worried about him because his home is very unsanitary, and the patient drinks too much. This is the second time this week you have responded on this guy at this address. He never wants help. You arrive to confirm that he is slightly intoxicated, slightly intoxicated, and he hasn’t checked his blood sugar in months. Just like last time. His appearance is generally normal, if slightly dirty and malodorous, and the patient once again has no complaints. His vitals are normal, outside of a blood sugar reading of 188 mg/dL. He is intoxicated, but is in his own home. So you call for community paramedics to add this gentleman and his family to their daily visit list. The CPs can come make sure the patient and his family don’t abuse the 911 system with calls like this. Maybe the CPs can explain to the patient why he needs to quit drinking and check his sugar more often. They can also explain to the family why the patient isn’t a 911 candidate. While calling to set up the CP visit, you tell dispatch to mark this address as one the CPs need to respond to, rather than 911 resources. You leave the patient at home with instructions to wait on the community paramedics. [Clapping-style hand brush off motion.]

Awesome, right? Like a big, amazing EMS dream!

Something came up recently that got me to thinking about community paramedicine; more specifically, how a community paramedic program would work. The scenario above generally describes the way that a lot of street medics envision community paramedics. In short, community paramedics are other responders who take low-acuity calls so the “real medics” don’t have to. They can do suture removals, well-baby visits, and such while waiting for street medics to find patients for them to commun-isize. 

Commun-isize my boring calls, so I don't have to!

This community paramedic model will probably never happen. Sorry to be the one to tell you.

There are two viable options for community paramedicine. Neither involves 911 responses. The first is to operate as an adjunct to primary care in rural areas without sufficient primary care physician (PCP) access. Most rural counties don't have enough PCP/family medicine/internal medicine physicians willing to take on new patients. I see this CP model as a follow-up post PCP visit to answer patient questions, provide follow-up test results, check medication understanding, and such. 

The second option for community paramedics is to reduce hospital readmission rates for specific types of patients. Medicare monitors 30-day unplanned readmission and death rates for COPD, MI, heart failure, pneumonia, stroke, and hip or knee replacement patients. Medicare then links those quality measures (readmission rates) to financial reimbursement*. Thus, hospitals are incentivized to find ways to continue caring for patients after discharge. Like, say, sending a community paramedic to their house to weigh them, run a 12-lead, maybe draw some blood, and check to make sure they are working off their updated medication list. Concerning findings at the home visit would result in a clinic visit, rather than waiting until the problem worsens to the point of needing an ambulance to the ED and hospital readmission. Those kinds of CP actions would potentially enhance the care received and increase patient satisfaction.

The most likely scenarios for a community paramedic call is for a medic to visit a house to weigh a CHF patient. The medic checks to make sure the patient has and understands her meds. Then the community medic goes to a STEMI patient who was released from the hospital two days previously. The main goal of this visit is to dispose of all the patient’s old medications and explain the new ones. Patients are comfortable with their old medication lists and will stick with them, even after a big event changes their prescription list. They need the new list, not the old/comfortable one. Then the medic goes to COPD patient’s house to make sure they are using oxygen. The medic finds the patient’s supply of oxygen to be running low and helps get more delivered. And so on...

Nobody can see the future, so it will be interesting to see if community paramedicine is a fad or an EMS paradigm shift. But it is unlikely to have a large effect the acuity of calls in a 911 system, however it works out.

* Hospital Readmissions Reduction Program (HRRP) in Section 3025 of the Affordable Care Act