Community paramedicine: What, why and how?
It is in our healthcare system gaps in coverage where the community paramedic lives and can show their worth
The term community paramedicine (CP) has worked its way into the vernacular of the prehospital medical field in recent years. It has been described as “mobile integrated healthcare” and “EMS prevention.” Several other buzzwords have also been used to explain why already limited resources should be diverted away from traditional emergency response.
I’m willing to bet that if you traveled to any state and asked what a community paramedic does, you will encounter a wildly diverse range of answers from a person who does house calls out in rural communities, to someone who handles narcotic overdose follow-up, to a researcher who examines why gravity seems to affect the elderly in ways different from the rest of the population.
It is difficult to build an archetype for the community paramedic as easily as we can for a police officer, firefighter or EMS provider. But that may be the point.
A CP program is designed to alleviate the burden to existing medical and social services, as well as emergency services, that is placed on them by misappropriated requests for resources. While all CP programs share this mandate, they differ in the execution of the services provided based on local need.
Understanding U.S. healthcare
Why should an agency operate a CP program? To answer this question, we should first look at how the U.S. healthcare system is designed to work, then examine how breakdowns in the system design lead to improper use of ancillary services. The Commonwealth Fund describes healthcare in the U.S. as follows:
… a mix of public and private, for-profit and nonprofit insurers and health care providers. The federal government provides funding for the national Medicare program for adults age 65 and older and some people with disabilities as well as for various programs for veterans and low-income people, including Medicaid and the Children’s Health Insurance Program. States manage and pay for aspects of local coverage and the safety net. Private insurance, the dominant form of coverage, is provided primarily by employers. Public and private insurers set their own benefit packages and cost-sharing structures, within federal and state regulations.”
The model can be broken down among types of providers:
- Primary care, where family physicians provide well checks, physicals, and manage more mundane issues, such as high cholesterol and high blood pressure.
- Secondary providers include specialists such as cardiologists, ENTs, obstetricians, oncologists, etc.
- Tertiary care is the most intensive in terms of cost and resources. This includes trauma centers, open heart surgery, intensive care, and interventional radiology.
If this sounds overly complex, it is. The U.S. model is the most regulated and expensive in the world. This complexity leads to difficulty in communication among providers, from providers to insurers, and from both entities to the patient. Additionally, each insurer can dictate what types of services are covered, and these costs drive the choices made by providers. Further, cost can determine decisions on what health issue a person will address.
Disparities in access to healthcare exist across the system and involve many factors – location, race, gender and income. According to Dickman, Himmelstein, and Woolhandler:
Poor Americans have worse access to care than do wealthy Americans, partly because many remain uninsured despite coverage expansions since 2010 due to the ACA. For individuals with private insurance, rising premiums and cost sharing have undermined wage gains and driven many households into debt and even bankruptcy. Meanwhile, the share of health-care resources devoted to care of the wealthy has risen.”
Disparities will become evident as access to care is disrupted. When a patient is diagnosed with a medical condition but must choose between purchasing a medication and paying for housing or food, preventable health problems can occur. This type of issue is most acute for those who are employed and have limited income, but do not qualify for government assistance. These preventable issues should be handled at lower levels of care – primary or secondary. If left untreated, they become much more acute, and result in treatment in tertiary facilities. A large population of seniors in the U.S. are on fixed incomes and fall into this category.
From EMS to CP
Due to the inability of some Americans to obtain effective healthcare, patients will turn to one resource that is always available for access – EMS, supported by hospital-based emergency medicine. This division of the U.S. healthcare model was designed to rapidly respond to trauma.
Prior to the 1960s, there was not an effective method to gain access to hospital services other than private automobile. EMS then branched out to include treatment for life-threatening cardiac events, such as heart attacks and cardiac arrest. This changed with the Emergency Medical Treatment and Labor Act (EMTALA), which requires that no person will be turned away from emergency stabilization and treatment in the U.S. In short, if you arrive at an ED, you will receive treatment. The intent of the law is to guarantee that no patient will be turned away from life-saving measures because of cost. The law was created due to that very phenomenon when hospitals could refuse care to low-income patients due to perceived inability to pay. This has created a condition where the most reliable access to healthcare in the U.S. is through emergency services.
Any system will have inefficiencies, flaws and drawbacks. By designing a process to address an entire population, there are always situations that cannot be imagined and therefore not addressed. It is in these gaps in coverage where the community paramedic lives and can show their worth. The community paramedic is adept at negotiating the healthcare system, partnering with local agencies, and ensuring effective communication within all aspects of care in their jurisdiction. Diverting patients to available resources and appropriate level of healthcare saves time and money for the entire system.
CP program data
An effective CP program must be data-driven. A common reason programs fail is that their creation and intent differ from the needs of the community. Running a falls prevention program in a region devoid of elderly living at home or duplicating an opioid cessation program in a region where multiple programs already exist is a waste of time and resources. The best question a program manager can ask is “why are we doing this?”
To answer this question, your own EMS run data will provide the answer. By utilizing best practices for EMS run data collection, a manager can look to root causes of disparities in care in your jurisdiction:
- Locate geographic locations to where frequent EMS calls occur.
- Research who is calling.
- Screen out reasons for frequent calls, such as group homes or assisted living providers as they already have embedded medical staff to address issues.
- Finally, look for spikes in call volume at a particular location or for a person.
Once these data points are identified, the community paramedic can begin interviewing the patient and researching what potential social determinants of health may need to be addressed.
- Is there adequate food and water, shelter and access to primary care?
- What is their income level?
- What do the medications previously prescribed have to do with their presentation?
Instances of polypharmacy (simultaneous use of multiple drugs to treat a single ailment or condition) in the elderly can have a massive impact in cognition and falls risk. Tracking lift-assist calls provides insight into subtle changes in patient physiology that can predict injury severity from falls.
Once a cause is identified, having partnerships with area health agencies or social services can steer a patient to the most appropriate resource. By facilitating coordination among agencies, efficiency can be increased, and costs decreased.
A community paramedic should not exist to perform every aspect of healthcare. They should exist to simply help the healthcare system work for our patients.
Find your medic
At this point, you might wonder how to find a community paramedic to guide this process.
Working interpersonal connections between regional health partners is important for keeping your network together. A good community paramedic is inquisitive about patient outcomes, has a well-developed emotional IQ and empathy. They can place themselves in another person’s shoes and have a stubborn streak to ensure that their client is not left behind by the inefficiencies of the healthcare system.
This type of work can be frustrating, tedious, nerve-racking, even dull. Many hours are spent looking over data sets and attempting to contact potential clients. But for all the mundane hours spent, the community paramedic is uniquely positioned to recognize when a patient is in desperate need of help. Once you know what to look for, you may realize that you can be the first person in position to save a life.
The missing piece
CP at its heart is an investigative process. Instead of digging for bones, looking for criminals or determining cause and origin of fires, the community paramedic looks into root causes of health-related emergencies. Inability to access appropriate care leads to activation of the EMS system as it is the only assistance some people can rely on. Pulling quality data can allow for patients to be located where they have been lost in between systems. The worth of community paramedicine is measured not only in reduction of financial burden to health systems, but more importantly, in lives that otherwise could not be located to save.