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Community Paramedic


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Community Paramedic

  1. 1. Dana Sechler, NREMT-P Michael D. Curtis, MD Chief / EMS Director Medical Director Emeritus Baraboo District EMS Ministry Health Care 1
  2. 2. 2 Changes in Mindset  All EMS agencies will not be able to do it  Could possibly decrease call volume—by which we have measured success in the past  Keeping perspective  When you are up to your butt in alligators, it’s difficult to remind yourself that your initial objective was to drain the swamp
  3. 3. 3 Public Health Goals  Prevent injury / disability  Prevent illness  Prevent death  Promote births of healthy babies  Promote a healthy lifestyle  Assure health services where otherwise not provided
  4. 4. 4 Health Care Problems  Decreased access to primary care  Growing number of uninsured/underinsured      Uninsured are less likely to seek out preventive care services and defer care Increased ED visits/emergency care High readmission rates Lack of consistently coordinated, high quality care All of these lead to high costs of care
  5. 5. 5 Rural America  25% of Americans live in Rural America  10% of America’s doctors practice in Rural America
  6. 6. 6 Rural Training Track Program  Program created to attract more Primary Care Providers to the rural communities  Programs like the Rural Resident Program exist because typically physicians do not want to practice in a rural setting due to the special challenges faced such as:     Poor usage of primary care providers Poor use of preventive health measures Patients typically seek treatment for severe cases of acute or chronic health issues Poor means for follow-up care, such as home visits
  7. 7. 7 Rural Residents  Rural residents:  receive fewer regular medical check-ups  are more likely to report fair to poor health status than urban residents  more likely to have experienced a limitation of activity caused by chronic conditions than urban residents  devote more of their income to health care costs  are more likely to engage in risky behaviors
  8. 8. 8 Emergency Departments  Not being utilized the way they were designed  Overloaded with non-essential visits  Recent growth of ED visits has helped increase the cost of health insurance
  9. 9. 9 Medicare  Spends $12 - $15 billion a year on hospital readmissions  1 in 5 (20%) of Medicare patients are readmitted into the hospital within 30 days of discharge  In the case of 50.2% of the patients who were rehospitalized within 30 days after being discharged, there was no follow up with a physician's office between the time of discharge and rehospitalization  1 in 3 (33%) of Medicare patients are readmitted into the hospital within 90 days of discharge
  10. 10. 10 Readmission Diagnoses  30-day readmissions for the most common initial diagnoses in rural hospitals are:      Pneumonia Congestive Heart Failure (CHF) Chronic Obstructive Pulmonary Disease (COPD) Arrhythmia Kidney/Urinary Tract Infection (UTI)
  11. 11. 11 Follow-up Care  Who will provide the follow-up care for these patients?  Doctors?  Chronic shortage  Lack of time for out-of-clinic activities  Nurses?  Chronic shortage  Too many other opportunities for career development  Home Health?  Prepared to service “homebound” and “hospice” patients only
  12. 12. 12 Possible Solution  Community Paramedics  Trained specifically for field medicine and home visitation  Mobility and flexibility are hallmarks of EMS orientation  Scope of practice includes many advanced medical skills complimentary to clinical nursing  Advanced communication methods allow for “telemedicine” type of patient care management with close supervision by primary care providers
  13. 13. 13 Emergency Medical Services EMS ≠ Prehospital EMS = Healthcare EMS Services will need to address the needs of all patients who present with a Healthcare condition or need, throughout the continuum of the Healthcare system i.e.: prevention — rehabilitation
  14. 14. 14 Solution  Non-competitive program that is designed to fill in healthcare gaps  Provide primary healthcare, improve emergency response capabilities, and strengthen community healthcare collaborations in our community  A Community Paramedic is part public health, part disease management, part prevention, part social worker, part patient educator, and part treatment
  15. 15. 15 Advantages  Eliminating health disparities to rural areas  Decreasing overall healthcare costs  Proper referrals to primary care physicians  Decreasing misuse of emergency departments  Proactive EMS care verses reactive EMS care
  16. 16. 16 Advantages  Decreasing nonessential ambulance transports  Decreases workload and increases quality and efficiency of managing patients in a primary care setting by utilizing EMS personnel through nontraditional methods  EMS personnel currently have a good basis of training, expertise and scope of practice to provide essential primary care services
  17. 17. Role: Physician-Ordered Initial & Follow-up Care 17
  18. 18. 18 Case Study – Mrs. Jones  Mrs. Jones is in her mid-70’s, and lives alone  Has new onset of symptoms to a chronic condition  Physician debating sending pt to floor for observation  The PCP requests a Community Paramedic visit and evaluate the patient once a day for a week  CP writes a report in patient’s chart after each visit
  19. 19. 19 Case Study – Mrs. Payne  66-year-old female recovering from abdominal surgery for small bowel obstruction  Discharged to her residence after 2 days of post surgical observation  Developed complications due to internal leakage of intestinal contents into her abdominal cavity  Patient had one phone call 3 days after discharge with her surgeon and was assured that pain was normal
  20. 20. 20 Case Study – Mrs. Payne  911 called after 5 days at home due to fever and pain  Patient and surgeon were unaware that she was febrile and septic or that the appearance of her suture site was not “normal”  Transferred to UW where she underwent emergency surgery but died 3 days later  Could a Community Paramedic follow-up to augment written discharge orders have saved this person’s life?
  21. 21. 21 Readmissions Reduction Program  The Affordable Care Act of 2010 requires HHS to establish a readmission reduction program. Effective October 1, 2012  Designed to provide incentives for hospitals to implement strategies to reduce the number of costly and unnecessary hospital readmissions.  Readmission = “an admission to a hospital within 30 days of a discharge from the same or another hospital.” 
  22. 22. 22 Readmissions Reduction Program  20% of Medicare patients are readmitted to a hospital within one month of discharge  CMS considers this number excessive and believes that readmissions are an indicator of quality of care, or lack thereof  Provides an incentive for hospitals to decrease readmissions by coordinating transitions of care and increasing the quality of care provided to Medicare beneficiaries
  23. 23. 23 Readmissions Reduction Program  Part of CMS’ goal to transition to value based purchasing  paying for care based on quality and not just quantity  These incentives are escalating penalties that decrease a hospital’s payments from all of its Medicare cases  Purpose is to improve quality and lower costs for Medicare patients  Ensure that hospitals discharge patients when they are fully prepared and safe for continued care at home or at a lower acuity setting
  24. 24. 24 Predicted Costs to Hospitals Total number of discharge patients at local hospital: 2,792 (patients) Percentage of annual admissions at local hospital that are Medicare insured: 42% 1,173 (patients) Percentage that are readmitted within 30 days: 20% Total patients that are non-reimbursable by Medicare: 235 Average amount charged (non-reimbursed) per patient: $15,318 Annual projected non-reimbursable funds: $ 3,599,730 (patients)
  25. 25. 25 Community Paramedic Programs  International:  Programs in Australia, New Zealand, the United Kingdom, and Nova Scotia  Several across the U.S.     Red River project – New Mexico (1990’s) Colorado Minnesota Huge explosion of others attempting some type of program across the U.S.  Already starting to diversify  inner city EMS agencies are adopting CP concepts  applying them to 9-1-1 calls
  26. 26. 26 Community Paramedic Programs  The Community Healthcare and Emergency Cooperative (CHEC) formed in July 2007  addressed critical health care shortages in rural and remote areas— specifically by developing a new community health provider model  From this partnership, the Community Paramedic Program emerged  CHEC members based the Community Paramedic model on the best practices of similar initiatives around the world, including the Alaska Community Health Aide, the Nova Scotia Community Paramedic model and the Australia Rural and Remote Paramedic Program  CHEC has a standardized training curriculum that is consistent internationally, yet can be modified and customized for each community, province and nation
  27. 27. 27 Value to the Local Hospital  Patients can be discharged earlier with proper continuation of care and no decrease in Medicare compensation  Better patient retention due to higher patient satisfaction as hands-on care follows through home recovery period  Positive publicity of participating in this unique program  Overall community health improvement as care plans include prescheduled home follow-ups
  28. 28. 28 Goals  Decrease hospital readmission rates  Decrease non-essential ED visits  Improve patient outcomes  Improve continuum of care  Decrease overall healthcare costs
  29. 29. 29 So, what have we been doing? Past:  Baraboo is the 3rd Nationally approved CP Program   Consortium with the North Central EMS Institute  Approved as a pilot program through WI State EMS Office  Appointed Captain Lori Spencer to administer the CP program  Began working with Dr. Marv Birnbaum and Jan Beyer  UW Emergency Education Center  Goal is to collect data over 3 years to prove the validity of CP
  30. 30. 30 So, what have we been doing? “It is important to note that such studies have not ever been done for evaluation of the impacts of EMS, especially regarding ALS —and we do not want the CP programs to go down the same path. Current CP efforts around the U.S. are not collecting data to determine the value of the program. This process must be better and must show its worth.” ~ Dr. Marvin Birnbaum
  31. 31. 31 So, what have we been doing? Partnerships:  Created a Steering Committee with the following entities:  UW Madison Medical School & Emergency Education Center  Sauk County Public Health  State EMS Office  Office of Rural Health  St. Clare Hospital  Home Health  Ho Chunk Nation  Ambulance Commission members  Others
  32. 32. 32 So, what have we been doing? Curriculum:  Colorado Community Paramedic course   Dr. Birnbaum sits on the oversight committee Lori took the course  Didn’t take the clinical portion, as she is an RN  Marv, Lori, and Jan took curriculum and ‘Wisconsinized’ it  The revised curriculum is specific to primary care  Intent is to be taught by UW Medical School   around 200 hours with didactic and clinical portions Other staff are ready to take the course though UW  waiting for…
  33. 33. 33 So, what have we been doing?  The intent was to fund the CP Program through grants  For the first 3 to 5 years  After that, we believed that Medicare and insurance companies will reimburse for these services  Based upon perceived cost savings  Reality:  Applied for numerous grants  Scored over 93 points in all the grants  Denied for numerous reasons
  34. 34. 34 So, what have we been doing?  Grants—    UW School of Medicine & Public Health grant Health Resources & Services Administration (HRSA) Innovation Grant from Center for Medicare & Medicaid Services    Also applied as a consortium with North Central EMS Institute ($27 million) No CP programs were granted any funds with the CMS grant Robert Wood Johnson Foundation  Reasons for denial  Physician comment, “EMT’s shouldn’t be doing this in the field.”  “Great idea(s), but too cutting edge—come back in 3 to 5 years.”
  35. 35. 35 So, what have we been doing? Present:  Minnesota passed law to recognize CP as a practicing level of EMS  Services can bill, and get reimbursed  Program administrator took new job as a Hospice nurse  Still applying for grants  Changed focus  CHF Wound care  Include partnership with Madison FD 
  36. 36. 36 We’ve come a long way, but still have a ways to go…
  37. 37. 37 What’s next? Future:  New Name: Mobile Integrated Health Care  Telemedicine  Locally, we will continue working with Partners to:  Finish State curriculum  Send additional staff to CP training  Implement actual field program  Collect data  Work on Legislative initiatives  Work on permanent funding  Hospitals?
  38. 38. 38 What’s next? Future:  National / State perspective will look at Scope of profession  Similar to RN licensure  A Paramedic will be credentialed (endorsed) based upon training  ACLS, PALS, TEMS, Critical Care, Community Paramedic, etc.  State will regulate the service that provides the level—not necessarily the individual  EMS Office will host a Stakeholder meeting at the State the level, to begin discussions with partner groups  Appears that there may be support at the National level   Grassroots effort from the bottom up National acceptance from the top down
  39. 39. 39 Questions? Contact info:  Dana Sechler, NREMTP Office: 608-356-3455  Michael D. Curtis, MD Cell: 715-498-2240