A day in the life of a typical paramedic is nothing like that of a primary care provider. Though both are central to the healthcare system, a paramedic performs in a high-stress environment that focuses exclusively on providing emergency medical services, while a primary care physician is more focused on a patient’s long term needs.
That wall between primary care and emergency health care may soon be eroded, however. California’s Emergency Medical Services Authority (EMSA) and Office of Statewide Health Planning and Development (OSHPD) are working together to implement community paramedicine pilot programs, which would expand paramedic and EMS responsibilities in order to fill healthcare gaps.
According to Lou Meyer of EMSA, up to 12 locations in California will be selected to take part in these programs starting as early as next summer.
Pilot programs have already begun in several states throughout the country, including Minnesota, North Carolina, Texas, and Colorado.
“We’ll come into the office, we’ll receive orders from medical practices,” said Christopher Montera, assistant CEO of the Western Eagle County Ambulance District in Colorado, describing a community paramedic’s typical day. “We’ll receive orders from public health, whoever needs us that day, we give those orders, we’ll schedule visits with patients we’ll go see the patients, and we’ll report back findings back to the providers who ordered us to go.”
Montera listed blood tests, neonate visits, and medication reconciliations as examples of the types of services community paramedics are called out to perform in Eagle County.
“We have a rural population, so we have to be the Swiss army knife,” he said. “We have to make sure we can provide all the things that are needed in our community.”
Eagle County implemented one of the first rural community paramedicine programs in the country, and according to Montera, data collected so far suggests that in the program’s first year, it saved $1,250 per visit in healthcare costs for each of its 29 patients over 97 visits.
In urban areas, the impact of community paramedicine programs may be different, according to Jim DeTienne, President of the National Association of State EMS Officials. Rather than providing primary care to potentially underserved populations, the focus may be on the healthcare gaps specific to urban areas, such as hospital re-admissions and chronic conditions that increase hospital healthcare costs.
According to Mike Taigman, an expert with 30 years of experience in the emergency medical services industry, community paramedics can achieve these ends by creating a system of support alongside other healthcare providers that is responsive to the gaps in a given community’s healthcare system.
“As you think about community paramedics as partners for the rest of the healthcare system-—so partners for hospitals, partners for physicians, partners for county healthcare departments—and if you think about patient groups that have a chronic disease that can be better managed through a support system or good healthcare—asthma, diabetes, congestive heart failure—[these] are the kind of things that respond really well to self care and systems of support,” he said. “Community paramedics help provide those kinds of systems and provide the education and support for folks.”
Those savings in healthcare costs and coverage of healthcare gaps are some of the program’s main appeals in California, especially given efforts to implement the Affordable Care Act. However, the issue of financial sustainability brings up a number of other questions about the costs of implementing community paramedicine, for example, providing additional education to help paramedics take on new responsibilities.
“Certainly California has no new money sitting around to do new things,” DeTienne said. “I’m really encouraged that California’s going to take this on.”
DeTienne added that the large number of pilot programs that will happen in California will help explore the various ways a community paramedicine program can be run.
According to Meyer, the pilots are moving forward first through the waiver of certain regulations for the 12 local pilot programs. If those go well and the state decides to implement community paramedicine programs on a larger scale, there must be more substantial regulatory changes from the Legislature. In other words, the law will have to change to allow paramedics to take on more duties typically performed by nurses and physicians.
“It obviously deals with the paramedic scope of practice because that’s the limitations that we’re dealing with today: either a total change in the scope of practice, or a scope of practice for the community paramedic as a separate accreditation,” Meyer said.
The issue of scope of practice is where, initially at least, community paramedic programs in other states encountered opposition from nursing organizations. However, advocates insist that the approach focuses on simply partnering more effectively with other healthcare providers.
“I was always asked when I first started talking about it what do the nurses think, the more that we educate them, the more that we let them know what the program is really about, that breaks down a lot of doors, but it’s still going to be a challenge,” DeTienne said. “I wouldn’t call it opposition. There’s still a lot of people standing back and waiting to see what is this and what it’s going to be someday,” he added, emphasizing that the best way to gain support for the programs is to implement more pilot programs and gather more data on the potential benefits.
“This in no way takes the place of a registered nurse or a doctor,” Meyer added.
While the program presents a substantial change to the traditional role of a paramedic, advocates believe community paramedicine is the development of a natural partnership between the various entities of the healthcare system.
“Paramedics are unique in that they’re geographically dispersed, they’re really comfortable working in just about any environment you put them in, they’re comfortable practicing medicine on the side of some raspberry fields and they’re comfortable practicing medicine inside a $10 million mansion,” Taigman said. “That kind of community relationship and geographic coverage along with the clinical training and competence that they have makes paramedics another resource to the rest of the healthcare system to help achieve some of the outcomes that they’re hoping to achieve.”