Editor’s note: Community paramedicine has the potential to revolutionize how EMS is perceived, practiced and paid for. In part one of this two-part series, BP looks at three grants that have been awarded by the Centers for Medicare & Medicaid to test the concept. Next month we’ll examine the progress and lessons learned from two of the pioneers in this area: Wake County, N.C., and Eagle County, Colo.
In recent years, some of EMS’s most forward-thinking leaders have worked tirelessly to develop a model of care that moves EMS away from solely responding to emergencies and into the realm of preventive care, public health and home health services. Calling the model community paramedicine, the goal is to position EMS as a partner in the wider health care community’s efforts to deliver better care at lower costs.
Though many within EMS have embraced the community paramedicine concept and several communities have even managed to get community paramedicine programs off the ground, the model has been sorely lacking a key ingredient to its widespread adoption: a way to pay for it. With EMS largely dependent on fees per transport, there is no funding stream or mechanism in place to reimburse community paramedics for taking on roles such as giving flu shots, checking on patients recently discharged from the hospital or visiting the elderly at home to assess falls risk or medication compliance.
That may be about to change. This spring, the Centers for Medicare & Medicaid (CMS) Innovation Center announced more than $13 million in grants to launch community paramedicine programs in communities in three states: Pagosa Springs, Colo.; Prosser, Wash.; and Reno/Sparks, Nev. To be sure, the grants involving EMS are but a small part of the nearly $1 billion given to organizations that submitted plans for innovative programs that would improve care while lowering costs for Medicare and Medicaid patients.
Nonetheless, EMS experts say the grants have the potential to transform the way health care is delivered in this country, and the role EMS plays in delivering that care. While several communities have experimented with community paramedicine programs, mainly getting by with local support—including Wake County, N.C., and Eagle County, Colo.—the CMS grants represent an unprecedented level of federal government support.
“I can’t identify any other major grant program that CMS has done that has EMS written into the grant guidance,” says Gary Wingrove, director of strategic affairs for Mayo Clinic Medical Transport and past-president of the National EMS Management Association. “It’s a huge deal for this industry to finally get some recognition that it’s actually part of the health system, and that it could play a role in improving patient care and cost containment.”
Bold new ideas
The grants include:
- $1.7 million to the Upper San Juan Health Service District in Pagosa Springs, Colo., to enable Pagosa Springs Medical Center and Pagosa Springs EMS to expand a wellness program in a largely poor, rural region, and to expand the use of telemedicine by EMS providers to help with remote diagnostics, particularly stroke. One goal is to save on the costs of transporting people by air if ground is acceptable, says Claire Bradshaw, the Medical Center’s director of development and marketing.
- $1.5 million to the Prosser Public Hospital District, which serves a rural area in Washington state, to launch a program in which physicians can send a community paramedic to visit patients at home, providing in-home medical monitoring, follow-ups, basic labwork and patient education, with the goal of reducing emergency room visits and readmissions. The area has high rates of obesity, diabetes, heart attack and stroke.
- $9.9 million to REMSA (Regional Emergency Medical Services Authority), the nonprofit provider of ground and air ambulance services in Reno, Sparks and Washoe County, Nev. In partnership with Renown Medical Group, the University of Nevada-Reno School of Community Health Sciences, the Washoe County Health District and the State of Nevada Office of Emergency Medical Services, REMSA will develop a Community Health Early Intervention Team to help patients with lower-acuity and chronic conditions access an appropriate level of care. The goal is to reduce unnecessary ambulance responses, hospital admissions and readmissions while improving patient outcomes, says Patrick Smith, REMSA president and CEO.
All of the programs include bold new ideas that, if successful, may pave the way for a new role for EMS in health care, Wingrove says. And the REMSA grant, says Smith, includes a provision that could be revolutionary for the EMS industry.
A central component of the REMSA plan is to be able to direct or take patients to destinations other than the emergency room, such as an urgent care, mental health facility or detox center. That makes sense for patients and for the health care system, Smith says. But because of the way CMS pays for services, taking patients to alternative destinations doesn’t necessarily make sense for EMS, which could face a loss in revenue. “That will financially destabilize our system, and CMS understands that,” Smith says. “We have to stay revenue-neutral to maintain the EMS safety net.”
So as part of the grant, REMSA has received preliminary approval for a waiver from CMS, in which REMSA could get paid to treat patients on scene and not transport them, or to transport patients to alternative destinations. The details have yet to be hashed out, including what procedures would qualify as treating on scene, Smith says. But the way it will probably work is that REMSA would be able to bill CMS its usual transport rate for these other services.
“For the first time in my career, CMS has said, ‘We will pay you to do this other stuff,’” Smith says. “After God knows how much lobbying, it’s finally about to occur. It’s a game changer.”
Unexpected winners
With so much riding on the outcome, Wingrove admits to being somewhat surprised at which organizations were chosen by CMS to receive the grants. As chair of the International Roundtable on Community Paramedicine, Wingrove is a long-time champion of community paramedicine and has worked with leaders from around the globe promoting the concept. Meanwhile, his nonprofit organization, the North Central EMS Institute, is a national leader in developing a curriculum to train community paramedics.
North Central EMS Institute applied for an Innovation grant but did not receive one. The funding would have launched community paramedicine programs involving 16 organizations in nine states, he says. Several of those programs were counting on federal money to enable them to move ahead and are now in limbo.
Despite his disappointment, Wingrove says he will support the programs that received grants in whatever way possible, as much is riding on their success. For instance, it’s likely that private insurers will be closely watching how the new community paramedicine programs perform. If they can show success in containing costs without sacrificing quality, insurers may move toward funding EMS activities beyond transporting patients. “We can’t afford to have a failure,” he says. “We are at that point in the evolution of community paramedicine where a well-publicized failure may turn everything upside down.”
No one was more surprised at being chosen than some of the winners. According to CMS, more than 3,000 organizations had applied for the grants, and 107 were given out. “We knew it was extremely competitive,” says Pagosa Springs’ Bradshaw. “We have no doubt that we are going to be scrutinized. That said, we’ve had great support from CMS in implementing this grant.”
Among Pagosa Springs’ plans: expanding an early detection/wellness program in which members of the community pay $45 per month for preventive services such as blood pressure and cholesterol screenings, monthly health education classes, exercise classes and dietary support meetings. As a relatively poor area, many couldn’t afford the monthly fee, Bradshaw says. So one of the goals is to offer the wellness program, which now has 400 participants, free of charge to some 1,500 low-income residents, helping them lose weight, eat better, manage chronic conditions and get preventive screenings.
Another aspect of the project is expanding the use of telemedicine by EMS, connecting providers with primary care doctors, doctors at their local hospital or specialists at Swedish Medical Center in Denver, a Level 1 trauma center. EMS providers will also make house calls, handling follow-up for patients recently released from the hospital, or checking on patients with chronic diseases and perhaps using telemedicine to contact docs as needed.
In the process of hammering out the details and implementing the plan, CMS has provided assistance, including technical support and guidance from doctors and a program evaluator.
“It’s not like they’ve thrown this money out there and said, ‘Ok, you said you could do it, now do it. You’d better perform,’” Bradshaw says. “They’ve been helping us with tech support. They’ve put us in touch with medical professionals and other consultants to make sure we are asking the right questions and setting up our program in a way that will make it more likely to succeed.”
The process includes weekly meetings with a program officer to fine-tune their operations plan, including timelines, which then has to be approved. “They are helping us navigate the best strategies and pathways and have asked us to identify barriers,” Bradshaw says. “CMS is our partner in this.”
Community paramedicine taking hold
While the grants are certainly big news, community paramedicine is advancing on other fronts as well. The Agency For Healthcare Research and Policy recently awarded the North Central EMS Institute a grant to host a national consensus conference on community paramedicine in conjunction with its partners, the Joint Committee on Rural Emergency Care, the National Association of State EMS Officials and the National Organization of State Offices of Rural Health.
Held in Atlanta at the beginning of October, the conference brought together stakeholders for presentations and to discuss how community paramedicine should be regulated and other policy issues, which will eventually be published in a policy paper, Wingrove says.
In March, the North Central EMS Institute also published the latest version of a community paramedicine curriculum, which is provided free of charge to accredited community colleges or universities that work in conjunction with EMS organizations to train paramedics to become community paramedics. There are currently more than 100 paramedics nationwide taking the course, Wingrove says.
One of the keys to the curriculum is that it doesn’t change the paramedic scope of practice—it’s just used in different ways, Wingrove says. For example, medics learn to give vaccines rather than dealing with acute issues. The curriculum includes 150 hours of didactic instruction about primary care and public health and 150 hours of clinical time.
Another advance: On July 1, Minnesota became the first state to institute a law authorizing Medical Assistance (the state’s Medicaid program) to reimburse community paramedics for services such as chronic disease monitoring, medication compliance and immunizations. These services are covered for individuals who frequently use emergency rooms, or for whom the provision of community paramedic service would prevent admission to, or allow discharge from, a nursing facility or prevent readmission.
Observers say that taken together, the grants signal that community paramedicine is indeed an idea whose time has come. “I don’t think it’s a fad anymore,” Wingrove says. “Community paramedicine is here to stay.”
