By Olivia Belanger
The Keene Sentinel
GREENFIELD, N.H. — Jun. 10—Ralph Donfro called 911.
The 73-year-old Greenfield resident said his heart felt like it was “beating out of control.” But once he arrived at Monadnock Community Hospital’s emergency department, he was told he had no urgent medical needs.
Donfro’s wife had been hospitalized for about a month, and without her, he was struggling to manage daily tasks.
His rapid heart rate, it was determined, was likely due to anxiety.
Rather than sending him home without help, they referred him to a different department in the hospital — its Mobile Integrated Healthcare (MIH) program.
The next day, a paramedic arrived at Donfro’s door again — not in an ambulance, but in a white cargo van.
Joshua Patrick, lead community paramedic clinician for the MIH program, joined Donfro in his living room, carrying with him a black toolbox.
The box is one of several in the van that are divided by medical equipment: one for primary care, another for wounds, one more for blood draws.
Patrick checked Donfro’s vitals, reconfigured Donfro’s medication sorter to correct the doses of more than 20 different pills, urged him to make an appointment with a psychologist to help with his anxiety and put in a referral for transportation and meal supports — all within 30 minutes.
“What else can I do for ya before we take off, my friend?” Patrick asked before heading out the door.
“Just convince me I’m doing OK,” Donfro replied.
“Well,” Patrick said, “I think you’re doing good.”
Monadnock Community Hospital’s MIH program, launched in April 2020, is one of thousands that have popped up across the country in the past decade, particularly in rural areas. Also known as community paramedicine, this health care model allows paramedics to use their skillset to help patients access various types of care outside of emergency settings.
Several studies show these programs have improved health outcomes, reduced use of emergency services and lowered overall health costs.
And for paramedics, Patrick said the model’s draw is to see — more completely — the impact they’re making.
“If you’re [working] on an ambulance, you may bring somebody in and spend 15, 30 minutes, and you never know what happens [when] you leave the emergency room,” he said. “But this program, there [can be] multiple visits, and I get to see the improvement of health, and even the improvement of social factors.”
Community paramedicine growing in nation, state
MIH programs started in the United States about 15 years ago, and now, it’s estimated thousands exist nationwide, according to Martha Peribonio, executive director of the National Association of Mobile Integrated Healthcare Providers (NAMIHP).
“They’re popping up literally every day,” she said.
Though more research is needed, data so far show these programs are promising.
A pilot program in Fort Worth, Texas, saw a 61 percent reduction in ambulance rides between 2013 and 2015, according to an academic study of 64 patients.
Since October 2013, nearly 5,500 emergency department visits were prevented among the program’s 905 participants, who also needed 48 percent fewer ambulance trips. This saved about $16.3 million in health care expenditures over nine years, according to the program’s operator, MedStar.
Monadnock Community Hospital runs the busiest MIH program in New Hampshire and the only one in the Monadnock Region, according to information from the N.H. Department of Health and Human Services. The Peterborough hospital’s program tallied 632 visits in 2022, representing 49 percent of the total visits from the state’s 12 programs.
Eight of those programs, including Monadnock Community Hospital’s, are for primary-care or general services, while others are specifically geared toward mental health or substance-use prevention.
New Hampshire’s emergency services bureau received a five-year waiver from the state health department in 2014 to authorize MIH programs in the state. The waiver was granted a second time in 2019, and is set to expire in September 2024.
“This simply waives the home health care licensing requirements of licensed EMS providers operating in MIH activities,” a spokesman for the N.H. Department of Safety said in an email.
Justin Romanello, bureau chief for the N.H. Division of Fire Standards, Training and EMS, said he expects the waiver to be renewed once again.
Each community paramedicine program varies, depending on local needs and resources.
The programs that are centered on primary care often support people with chronic illnesses, patients recovering from surgeries or hospital stays or those who frequently visit the emergency room for non-emergencies. Through these programs, paramedics can also give vaccinations, wound care and blood tests.
Particularly in rural areas, community paramedics help fill health care gaps caused by the ongoing primary care provider shortage, lack of public transportation and adverse weather conditions because they are able to treat patients at home. A 2017 survey of 129 programs found that 55 percent were in “rural” or “super rural” areas.
How the local MIH program operates
Monadnock Community Hospital started its MIH program in response to the COVID-19 pandemic, according to Patrick. Amid the uncertainty of that time, he said primary care providers were worried about how to continue seeing patients, and in turn, keep them healthy.
“Our program is designed to fill the gaps in health care,” Patrick said. “We don’t replace going to the ER, we don’t replace home health care ... The main objective of our program is really to increase access to primary care.”
Patrick is one of two providers running the program. Both he and his colleague Tom Dardas are board-certified community paramedics — a college-level certification that includes clinical hours in primary care, wound care and case management — and also work for EMS departments.
Only one paramedic is on duty at a time, Patrick noted, with the program running Tuesday through Friday from about 9 a.m. to 5 p.m. He and Dardas typically jump from patient to patient their entire shift, with quick pitstops at the hospital to restock supplies.
In addition to providing primary care services, Patrick and Dardas collect laboratory specimens for testing, facilitate telehealth visits for those without Internet or the necessary technology and even perform home safety inspections. Their van also has a box full of brochures on area social support programs that they can give patients when needed.
The only requirement to utilize Monadnock Community Hospital’s program is to be a primary care patient there. All ages are able to be seen, Patrick said, noting he’s worked with patients ranging from infants to seniors.
Patients can be directed to the program in several ways, including through referrals from their primary care provider, as well as emergency, speciality and home care services.
Patrick said the program’s success differs by patient, but ultimately, is measured by their finding the right care.
“We want to avoid the avoidable,” he said. “If you need to go to the ER, then yes, we want you to be there. But if it’s appropriate to navigate you to another access point in the health care system that’s cheaper and can take care of you better, then that’s what we want to do.”
Patrick said the hospital doesn’t have exact data on how many emergency department trips the program has prevented because this is difficult to nail down, but uses case studies to determine the program’s impact.
One example, he said, is a patient who had four emergency department visits within three weeks, and then another three in just as many days. After she was enrolled in the MIH program, he said her emergency department visits decreased to only two in four months.
Community paramedics like Patrick are also able to spend more time with patients. Rather than a typical 15-minute appointment, Patrick said he can spend 45 minutes to an hour to check on the patient and their surroundings. All of his findings are then uploaded to the patient’s file for their primary care provider to review.
Patrick also praised the MIH program’s ability to connect patients with resources outside the hospital’s walls, such as free smoke detectors from the American Red Cross or The Doorway in Keene, a referral hub for substance use recovery.
“We’re kind of like the bridge,” he said.
MIH often free for patients, but costly for providers
Nationally, MIH programs are often free for patients to use, but this has proven burdensome for providers.
MIH programs are unable to bill most insurances directly because there isn’t an established billing code for EMS services that don’t require a patient transport, according to Romanello of the state’s emergency services bureau.
The only billable services within these programs are those that do have codes, like blood work or lab testing. Aside from these exceptions, the providers need to foot the entire expense.
Those providing the services pay for this in several ways, such as through grant funding or by writing it off as a community benefit.
Monadnock Community Hospital invested $156,000 in the MIH program last year, according to hospital spokeswoman Alycia McDuff.
“While this number is technically a loss, we consider it an investment toward our mission of improving the health and well-being of our community,” she said in an email.
However, due to the cost-benefit, private insurance companies have increased their interest in these programs, according to Romanello. He noted there is also a national push for Medicaid and Medicare to offer coverage.
Until then, the financial toll of these programs remains their biggest pitfall, providers say.
But to the paramedics, the benefit is clear.
“What has drawn me into [this program] has been the ability to make a big impact and to see that impact ... ,” Patrick said, “and really help people live healthier, more independent lives.”
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