|Director’s Message: Howard Backer, MD, MPH, FACEP
Community Paramedicine in California: Results from the First Year of Operation
Community paramedicine (CP) is being tested in California through a pilot project. There are 13 projects around the state testing six different concepts. One new project evaluating transport to an alternate destination sobering center started last month in San Francisco. The projects are authorized under as a Health Workforce Pilot Project under the Office of Statewide Health Planning and Development (OSHPD). Philip R. Lee Institute for Health Policy Studies and the Healthforce Center, at the University of California, San Francisco, serves as the independent evaluator for the CP pilot project in California. This past January, the evaluators released a report on the first year of operation. The summary below is taken from the executive summary section of the evaluation report and summarizes the evaluator’s findings for 12-16 months of operation.
I want to both thank and congratulate the EMS agencies, paramedics, and the many others who are committed to these programs and put the time and effort into developing and operating these projects. This is a beginning, not an end. Our hope is that we can continue to demonstrate the benefits of these projects while creating a path to allow other EMS providers to develop innovative collaborations that can improve healthcare in their communities.
Community paramedicine, also known as mobile integrated health, is an innovative model of care that is being implemented throughout the United States. This model utilizes the unique abilities of paramedics and EMS systems to meet local health care needs through partnerships between EMS agencies and other health care providers. Objectives of CP also support the triple aim of improving patient experience, improving community health status, and decreasing the cost of care. Community paramedics receive additional training beyond that required for paramedic licensure and provide care outside of their traditional role, which in California is restricted to responding to 911 calls, transporting patients to an acute care hospital emergency department (ED), and performing inter-facility transfers.
In 1972, California established the Health Workforce Pilot Project (HWPP) program, a farsighted program administered by the California Office of Statewide Health Planning and Development (OSHPD) that waives scope of practice laws to test and evaluate new and innovative models of care. On November 14, 2014, OSHPD approved HWPP #173, a project sponsored by EMSA that encompasses 13 projects that are testing six community paramedicine concepts.
Findings regarding the safety, effectiveness, and cost and savings associated with each CP concept were evaluated. Through September 2016, the 13 CP pilot projects enrolled a total of 1,462 people.
Post-Discharge Short-term Follow Up (Los Angeles, Butte, Alameda, San Bernardino, Solano)
Provide short-term, home-based follow-up care to people recently discharged from a hospital due to a chronic condition to decrease hospital readmissions within 30 days. All sites enrolled patients hospitalized with congestive heart failure; in addition, two sites enrolled patients hospitalized with acute myocardial infarction, two with chronic obstructive pulmonary disease, and one with pneumonia. Hospital readmissions within 30 days of discharge decreased for all sites and diagnoses except for heart failure patients enrolled in one project that provided less intensive services than other post-discharge projects. Community paramedics identified 129 patients (14%) who misunderstood how to take their medications or had duplicate medications and were at risk for adverse effects. Community paramedics explained to patients how to take their medications and identified incidences where they were given duplicate prescriptions. They also assisted patients in obtaining refills, if needed. Four of the five post-discharge projects achieved cost savings for payers, primarily Medicare and Medi-Cal, due to reductions in inpatient readmissions within 30 days of discharge. Participating hospitals realized additional savings by lowering their risk of being penalized by Medicare for having excess readmissions. The fifth project reduced 30-day readmissions but the reduction was too small to offset the cost of operating the project.
Frequent EMS Users (San Diego, Alameda)
Provide case management services to frequent 911 callers and frequent visitors to EDs to reduce their use of the EMS system by connecting them with primary care, behavioral health, housing, and social services. These projects achieved reductions in numbers of 911 calls, ambulance transports, and ED visits among enrolled patients. Community paramedics assisted patients in obtaining housing and other non-emergency services that met the physical, psychological, and social needs that led to their frequent EMS use. Both of the projects achieved cost savings for payers but only one realized sufficient savings to offset the cost of operating the program. These projects also decreased the amount of uncompensated care furnished by ambulance providers and hospitals because 35% of enrolled patients were uninsured.
Directly Observed Therapy for Tuberculosis (TB) (Ventura)
Collaborate with local public health department to provide directly observed therapy to people with TB (i.e., dispense medications and observe patients taking them to assure effective treatment) to prevent the spread of TB. Community paramedics dispensed appropriate doses of TB medications and monitored side effects and symptoms that could necessitate a change in treatment regimen. Persons with TB who received directly observed therapy (DOT) from CPs were more likely to receive all doses of TB medication prescribed by the TB clinic physician than patients who received DOT from the TB clinic’s community health workers. Receiving all doses prescribed by the TB clinic physician increases the likelihood that a patient will be cured and will not spread TB to others or develop a drug-resistant strain of TB that would be more difficult to treat and to control in the community. No additional cost to the health care system because community paramedics who provide DOT at the pilot site did so while already on duty to respond to traditional 911 calls.
In response to 911 calls, collaborate with hospice agency nurses, patients, and family members to treat patients in their homes, according to their wishes, instead of routinely transporting the patient to an ED. Community paramedics mainly provided hospice patients and their families with psychosocial support and administered medications from the hospice patients’ “comfort care” packs when necessary, in consultation with a hospice nurse. The hospice project enhanced the EMS and hospice agencies’ ability to honor patients’ wishes to receive care at home by reducing rates of ambulance transports to an ED from 80% to 36%. The project also achieved savings for Medicare and other payers by reducing unnecessary ambulance transports, ED visits, and hospitalizations.
Alternate Destination – Behavioral Health (Stanislaus)
In response to 911 calls, offer people who have behavioral health needs but no emergent medical needs transport to a mental health crisis center instead of an ED. Paramedics performed medical screening of patients to determine whether they could be safely transported directly to a mental health crisis center. Ninety-five percent of patients were evaluated at the behavioral health crisis center without the delay of a preliminary ED visit. Only five percent of patients required subsequent transfer to the ED, and there were no adverse outcomes. After refining the field medical evaluation protocols, the rate of transfer to an ED fell to zero for the following six months of the evaluation period. The project yielded savings for payers, primarily Medi-Cal, because screening behavioral health patients in the field for medical needs and transporting them directly to the mental health crisis center obviated the need for an ED visit with subsequent transfer from an ED to a behavioral health facility. For uninsured persons, the amount of uncompensated care provided by ambulance providers and hospitals also decreased. Enhanced community safety because it reduced the amount of time that law enforcement devotes to behavioral health calls.
Alternate Destination – Urgent Care (Los Angeles, Orange, San Diego)
In response to 911 calls, offer people with low-acuity medical conditions transport to an urgent care center instead of an ED. More data are needed to make firm conclusions about the alternate destination – medical care projects due to the limited number of patients enrolled and the number of patients rerouted or transferred to an ED. Among the limited number of patients who were enrolled, paramedics were able to identify patients for whom transport to an urgent care center was an appropriate option. No patients experienced an adverse outcome, although two patients were transferred to an ED following admission to an urgent care center and nine patients were rerouted to an ED because the urgent care center declined to accept the patient. To operate safely and efficiently, these projects need to closely match field screening protocols with the capabilities of urgent care centers and the illnesses and injuries they are willing to treat. The projects yielded modest savings because insurers pay less for treatment provided in urgent care centers than in EDs for the same illnesses and injuries.
The CP pilot projects have demonstrated that specially trained paramedics can provide services beyond their traditional and current statutory scope of practice in California. These projects are improving patients’ well-being, improving the integration and efficiency of health services in the community, and decreasing health care costs by reducing ambulance transports, ED visits, and hospital readmissions. In addition, the pilot projects provide new options to persons who call 911 that enable them to obtain the care they need more efficiently and in the settings they prefer. The majority of savings achieved by these pilot projects accrue to Medicare and hospitals serving Medicare patients because Medicare beneficiaries accounted for the largest share of persons enrolled in the pilot projects (43%). Savings also accrue to the Medi-Cal program and providers that serve Medi-Cal beneficiaries because Medi-Cal beneficiaries constitute 28% of enrollees. None of the projects realized savings for EMS transport providers, because they operate on a fee-for-service basis and are reimbursed only for transport. These agencies had to provide in-kind contributions of resources and labor to operate the pilot projects.
Findings from the evaluation indicate that Californians benefit from these innovative models of health care that leverage an existing workforce that operate under medical control, either directly or by protocols developed by physicians experienced in EMS and emergency care. These projects were designed to integrate with existing health care resources and utilize the unique skills of paramedics and their availability 24 hours per day, 7 days per week. No adverse outcome is attributable to any of these pilot projects. No other health professionals were displaced; in fact, these pilot projects demonstrated that CP programs can collaborate with physicians, nurses, behavioral health professionals, and social workers to fill gaps in the health and social services safety net.
The evaluation report yielded consistent findings for five of the six CP concepts tested: post-discharge, frequent 911 users, DOT for TB, hospice, and alternate destination – behavioral health. The projects improved patients’ well-being and, in most cases, yielded savings for payers and other parts of the health care system. The sixth concept, alternate destination – medical care, shows potential but further research involving a larger volume of patients is needed to draw definitive conclusions. If CP is enabled on a broader scale, California’s current EMS system design is well-suited to utilize the results of these pilot programs to optimize the design and implementation of proposed programs and assure patient safety. The two-tiered system of local control with state oversight and regulation enables cities and counties to tailor CP programs to meet local needs while both local and state oversight and regulation ensure patient safety.