Emergency Medicine Advocacy Handbook

Ch. 25 - Community Paramedicine and EMS Policy Issues

Alexander T. Yang, MS, NRP; Muhammad Durrani, DO, MS; Tristan Simmons, DO, MBA; Richard Pescatore, DO

Community paramedicine is a facet of the evolving integrated health care system that proposes to expand the role of paramedics and emergency medical technicians (EMTs) beyond that of traditional emergency care. The uninsured, chronically ill, elderly, homeless, and disabled are often referred to the emergency department because there are no other options available for them to receive care. Community paramedicine can potentially address this gap by offering services such as management for chronic disease, substance abuse, and mental health, as well as support for hospice care, injury prevention outreach, medication reminders, and patient advocacy.¹ The uniting facets of mobile integrated health care are visualized in Figure 1, which demonstrates how the diverse skillsets of many different disciplines can be
harnessed by the community paramedic.

Many pilot programs in community paramedicine are already seeing success in improving community health needs by training paramedics to work with patients’ primary care providers and provide expanded care coordination services.

Diversion to Alternative Care Centers

According to the National Center for Health Statistics, the number of ED visits crested at 136.9 million in 2015, a steady rise compared to the prior 5 years.^2,3 Frequently, when emergency departments have exhausted their resources because of overcrowding or boarding, the hospital is put on “ambulance diversion” to steer emergency services toward hospitals with appropriate capacity.

However, in the wake of increasing utilization of EDs by increasingly ill patients, many systems have opted to move lower acuity patients to primary care settings, essentially preemptively diverting these patients from the ED. Defining an appropriate population of “non-emergent” or lower acuity patients has proven challenging. A study conducted by the RAND Corporation estimated that 14–27% of all ED visits can be handled at alternative care and urgent care centers, saving up to $4.4 billion annually.⁴ However, a recent retrospective analysis which conservatively defined “avoidable” ED visits as discharged ED visits not requiring any diagnostic tests, procedures or medications, found a much lower incidence of 3.3%.⁵ Programs to transport “non-emergent patients” to alternative sites of care are seen as a potential intervention to target this group.

The Emergency Room Diversion Grant Program, part of the Deficit Reduction Program of 2005, allocated $50 million to states to extend hours of clinics, educate patients about appropriate usage of the ED, and establish new community health care centers.⁶ Upon the program’s completion in 2011, CMS used the findings to identify strategies to reduce ED use, which can be condensed to the following approaches:⁷

• Broaden access to primary care centers
• Target frequent ED users with interventions aimed at diversion to appropriate outpatient care
• Target patients with behavioral health problems by increasing access to comprehensive mental health care

ED visits for behavioral and substance abuse problems continue to skyrocket, increasing 55.5% from 2006 to 2013.⁸ Several pilot programs have utilized EMS to divert these patients to urgent care and sobering centers and have been successful in reducing overall ED use. For example, the STOP program in Providence, Rhode Island, allows EMS transport services, staffed with an EMT and a social services outreach worker, to identify and transport intoxicated persons to sobering centers rather than to the ED or prison.⁹

As EMS transport services strive to engage in alternate destination diversion, a major barrier for agencies has been highlighted: current CMS payment policy reimburses for ambulance transport exclusively to emergency departments, but not to other destinations.^10,11 The result is a strong financial incentive for ambulances to continue exclusively transporting patients to EDs. It has been estimated that an annual $283–$560 million could be saved if CMS reimbursement for out-of-hospital services allowed for more flexibility in transport destinations.¹²

While diversion to alternative care centers may reduce “non-emergent” ED utilization, one must also be cognizant of potential dangers in tasking EMS personnel with making decisions involving ED diversion. Without the full arsenal of diagnostic tools available in the emergency department, and the expert training of an emergency physician, patients may be incorrectly triaged as “non-urgent” when in fact they require further emergency medical care. While paramedics and EMTs are trained to recognize patients requiring emergency
medical attention, specifically identifying “non-emergent” patients is beyond their normal scope of care. It remains unclear if pre-hospital triage protocols can reliably guide paramedics to make appropriate field decisions regarding “nonemergent” transport destinations.¹³

Another obstacle involves EMTALA, which mandates a medical screening exam and the provision of emergency care to patients who present to the ED requesting evaluation, regardless of ability to pay. To fulfill their EMTALA obligations, hospitals must provide an MSE to every patient who seeks it before diverting them elsewhere. Diverting non-urgent patients prior to evaluation by an emergency physician may be a violation of these obligations, if done in the ED setting. While certain provisions of EMTALA allow for physician surrogates (in this case, pre-hospital professionals) to perform an MSE, there are strict requirements for phone consultation with an ED physician. Even where EMTALA requirements are met, private clinics and urgent care centers have no EMTALA constraint requiring evaluation, and thus could chose not to accept low-income, underinsured, or uninsured patients who are deemed to be “non-emergent.” This could result in progressive destabilization of payer mixes as EDs are forced to take on a larger percentage of uncompensated care while the adequately-insured are diverted to alternative care sites.

In 2014, the Houston Fire Department launched the Emergency Telehealth and Navigation (ETHAN) program, which employs real-time, audiovisual communication directly between a pre-hospital patient and an emergency physician. After EMS personnel arrive on scene and identify a non-emergentappearing patient that meets inclusion criteria, a tablet PC is used to connect with an ETHAN Project call center emergency physician, who can then remotely interview and visually assess the patient. If appropriate, non-emergent
transport (ie, free taxi voucher) is provided to an ED or a primary care clinic.¹⁵ A retrospective analysis of early data from the ETHAN Project shows some promise. During the 1-year study period, there was a 44% decrease in ambulance transports to the ED, and there were no deaths in either the low-risk control group or the low-risk group with ETHAN physician assessment.¹⁶ While early results from ETHAN are encouraging, it is currently unclear if this program has had an impact on crowding in the 60+ EDs — accounting for 1.4 million ED visits per year — in the Houston area. Certainly, further legislative activism concerning diversion to alternative care centers must provide for the obstacles presented by diagnostic uncertainty and EMTALA requirements to ensure patient safety.

The Push for Alternative Providers in the Field

Since the publication of the “EMS Agenda for the Future” in 1996 by the NHTSA, there has been a continued effort to integrate EMS systems into the health care system at large and to collaborate to bring illness and injury prevention programs into the community.¹⁷ This plan has included the development of community paramedics, mobile integrated health programs, and advanced practice paramedics. These groups are tasked with reducing EMS calls and ED utilization by specific groups of high utilizers, primarily by coordinating care for patients with chronic conditions on a non-emergent basis.

A key component in the development of community paramedicine and mobile integrated health care (MIH) solutions involves the incorporation of alternative and supplemental providers into the EMS response system, including nonclinical providers. One such example is the MIH behavioral health program at Colorado Springs Fire Department, started in 2012. This example of a community assistance referral and education services program (CARES) was designed to provide special attention to frequent 9-1-1 users with behavioral health issues. Specifically, paramedics made home visits and assisted with directing repeat 9-1-1 users with chronic conditions to community resources. They were successful in decreasing 9-1-1 use by 50% in a subset of the program participants over a
one-year period.¹⁸ This program was developed as a non-emergent program and involved intervention after multiple EMS activations and ED presentations. Colorado Springs later developed a community response team (CRT) to provide emergency care to behavioral health 9-1-1 callers. This included a prehospital medical care provider doing on-scene triage within a specific protocol as well as a social worker providing on-scene guidance and care. Ultimately, the social worker and medical provider collaborated on referrals to outpatient resources versus disposition to a behavioral health facility or the emergency department. Overall, this program allowed 86% of behavioral health callers to achieve disposition and follow up without an ED visit.¹⁸

Clinical providers with advanced training in community health care needs — including primary care, preventive medicine, mental health and even definitive minor acute care — are the foundation of an EMS-based solution to enhance primary care access. Initiatives such as the CRT in Colorado Springs suggest the potential for improving utilization of resources and patient care by allowing EMS providers to offer alternative interventions beyond ED transport.¹⁹ Several EMS and government agencies throughout the nation have successfully experimented with incorporating social workers, case managers, and even clinical pharmacists into their MIH pilot programs.^20,21 It is clear that collaboration with additional allied health providers has great opportunity for the delivery of high-quality care in the pre-hospital environment. This can potentially be expanded into a medical home model, where clinical providers can coordinate with an interdisciplinary team to provide management for chronic conditions, enrollment assistance in social services, and education about appropriate use of health services. However, there remain roadblocks to incorporation of these new paramedicine models at both the financial and legislative level. These include concerns over funding, liability in unconventional practice environments, and concerns that these community activities may be outside the traditional scope of practice for these providers. Future MIH related legislation and regulation should focus on leveraging potential cost savings, delineating liability, protocols, improving patient care, and the appropriate role of alternative providers in the field.

Reducing ED Utilization Through Health System Integration

The prospect of integration and incorporation into the broader health system comprises perhaps the most promising and compelling role for MIH solutions. EMS-driven MIH programs stand uniquely poised to have a broad impact on improving the care of our patients.²²

A national health interview survey conducted by the CDC found that Medicaid beneficiaries utilized the ED at almost a twofold higher rate than their privately insured counterparts, suggesting that overuse of the ED is a symptom of a more fundamental issue concerning lack of access to coverage and a disparity in the availability of comprehensive integrated care.²³ Community paramedicine, in conjunction with additional health providers, can potentially serve to fill this void, and in the process, reduce avoidable ED utilization. Many pilot programs are already seeing success in improving community health needs by training paramedics to work with patients’ primary care providers and provide expanded care coordination services with social services, home health agencies and public health departments. Under this integrated system, patients have access to postdischarge follow up, chronic disease management, home safety assessments, immunizations, and referrals without visiting the ED.²³

• Advocate for bills that provide enhanced liability protections for providers rendering care required under EMTALA.
• Support legislation that increases access to community support, including support using community paramedicine, for patients with mental health conditions and other patients at high risk of avoidable emergency department visits.
• Advocate for appropriate use of telemedicine to allow emergency physicians to assist in the evaluation of patients with acute complaints in cooperation with EMS professionals.