Community paramedicine aims to cut repeat ER visits
By Julian Eure
Sunday, July 14, 2019
First in a series
As an advanced emergency medical technician, Olivia Doherty has helped transport dozens of people to the hospital emergency room who, had they had someone regularly monitoring their diseases and explaining what medications they needed to take and when, might not have needed to go.
People who suffer from diseases like congestive heart failure, respiratory illness, and diabetes but lack help managing them can make a lot of trips to the hospital emergency room. So many in fact, first responders who transport them sometimes refer to them good-naturedly as “frequent flyers” — after those who accumulate a lot of airline miles.
So when Pasquotank-Camden Emergency Medical Services Director Jerry Newell proposed starting a community paramedicine program to try and reduce these avoidable repeat ER visits and asked Doherty to head it, she leaped at the opportunity.
“There was a need for it that I saw on the ambulance,” Doherty explained recently. “It’s such a great program. Every day I find something new we can do to help people.”
As Newell describes it, community paramedicine harkens back to the days before hospitals and clinics when doctors routinely made house calls. It also has a lot in common with home-health services, with the main difference being the visiting provider is a trained EMT equipped to respond if there’s an emergency.
Twice a week, Doherty slides into a used EMS Crown Victoria and drives to the home of patients signed up for the program. During her visits, which usually last about 30 minutes, she monitors their vital signs, talks to them about their disease or medical condition, checks to make sure they understand the medications they’ve been prescribed, and troubleshoots any other problems that may arise.
Doherty started the community paramedicine program in mid-April with two patients. She’s since gained an additional six through referrals from Sentara Albemarle Medical Center and she expected to start seeing two more hospital-referred patients last week.
Newell sees helping Sentara Albemarle reduce its readmission rate as one of community paramedicine’s primary goals. He said the hospital is penalized by Medicare if one of its patients shows up again too soon after being discharged.
“They have a team at the hospital that meets weekly to talk about this,” he said. “One of the things they’ve found is that people come back to the hospital because they don’t understand their new medications. Or people get discharged and a doctor takes them off one medication and puts them on a new one. They feel fine when they’re discharged but then, three days later, they don’t because their sugar is way out of whack. So we go and help them understand when they should take their medications.”
Newell notes that before EMS started community paramedicine someone called 911 because they didn’t know how to use a glucometer, the device diabetics use to test their blood-sugar level. So one of Doherty’s roles is to serve as a health educator, training patients she visits — or someone in their home — to use a glucometer or other health-monitoring devices.
Doherty says her education efforts seem to be working.
“What I tell people is, I’ll take your blood sugar the first time with your glucometer but the next time I come see you I want you to do it,” she said. “What I’ve observed is that they don’t always need the in-home care. They just don’t know how to care for themselves. So now they’re getting this education, this tutorial on how to do these things.”
Doherty doesn’t just monitor a patient’s health during her visits. She also serves as an information source about available health and other community resources.
“Of course I’ll check vital signs when I visit because that’s what I do,” she said. “But they may not need me to explain their medicines. They may need me to help them seek a type of therapy.”
She notes one of her patients was calling 911 just because she felt she needed someone to talk to. Since Doherty helped set up an appointment for her with a mental health professional, the patient hasn’t called 911.
“We just got her in touch with the resources available to provide her the care that she needed,” Doherty said.
Hospital supports program
Annya Soucy, a spokeswoman for Sentara Albemarle, said the hospital has made referrals to the new EMS program as part of its commitment to ensuring patients “receive the right care at the right time and in the right place.”
Noting that the hospital also refers discharged patients to rehab facilities and to home care agencies for in-home nursing visits and to physical therapists for their visits, she suggested the referrals to community paramedicine are part of the hospital’s overall efforts to ensure those patients “receive the care they need in the community.”
“The goal is good outcomes for patients, not the avoidance of penalties, and this EMS partnership has the potential to contribute to that goal of keeping people safely at home,” Soucy said.
Because community paramedicine is still relatively new — Doherty and Newell are aware of a program in Pitt County but none in the immediate area — there’s no data yet on how successful it’s been at reducing preventable ER visits.
Pasquotank-Camden EMS does have its own limited data, however, about the program's effectiveness so far.
“I have one person I see who used to call 911 twice a week,” Doherty said when interviewed in late May. “I’ve been seeing her now a month and a half and she’s called 911 only twice. The other hasn’t called at all.”
Newell said Pasquotank-Camden EMS records show only about half-a-dozen people the agency transports to the hospital qualify for the “frequent flyer” moniker. However, they call 911 a lot, so they can have an outsized impact on EMS' time and resources.
No impact on budget
Currently there’s no fee for participating in Pasquotank’s community paramedicine program. There’s also no additional impact on EMS’ budget. That’s because Newell used a vacant EMT position to fund Doherty’s new role. Newell did, however, add a new SUV to the current year’s EMS budget for Doherty to use.
It remains to be seen how much of an impact the community paramedicine program will have on reducing EMS’ costs. Initially, the program could actually spur a small revenue decrease for EMS, because it could lead to fewer Medicare billings.
Newell notes that Pasquotank-Camden EMS currently responds to about 1,000 calls a month. Right now, EMS bills $400 for most calls that result in someone being transported to a medical facility, particularly if the patient lives in Elizabeth City. If EMS is no longer transporting patients Doherty visits to the hospital, it’s obviously losing those billings.
Newell expects that impact, at least initially, to be small.
“If we take four patients off the street, are you really going to see that in a graph or a trend?” he asks. “Maybe, maybe not. It depends on how many patients you have enrolled (in community paramedicine) and how big the program were to get.”
One thing that could help, Newell says, is a new reimbursement model from Medicare that would allow Pasqutoank-Camden EMS to bill what is known as a “mobile integrated health” rate for Doherty’s community paramedicine visits. That rate is currently about $150, he said.
Pasquotank-Camden EMS in fact is applying for the new reimbursement model. If its application is approved, it could start a pilot program starting in January that would reimburse EMS’ community paramedicine visits at the MIH rate.
Newell likes Pasquotank-Camden EMS’ chances of being selected for the model. Given no other area county operates a community paramedcine program, the agency won’t have much competition in the region, he said.
“Nationally, I don’t know what we’re up against, but east of 95 ... and in our surrounding counties, this is the first program of its type,” he said. “So given that we’re over here by ourselves, getting ready to take off on this program, I’d say our chances are pretty good.”
Regardless of how effective community paramedicine is at reducing EMS’ costs, Newell believes the bigger issue is lowering health care costs overall.
“We feel that when you start reducing hospital readmissions, later on that is going to impact the health care system as a whole,” he said. “It’s the overall savings in health care nationwide, and even worldwide, that’s important, and we’ve got to start making an impact somewhere.”
Growing the program
Newell and Doherty are currently looking to grow the Community Paramedicine program. Besides seeking referrals from Sentara Albemarle, they’ve also asked the Pasquotank Sheriff’s Office and Elizabeth City Police Department to make referrals.
“If they see someone while they’re out in the field who could benefit from this program, we’ve asked them to make a referral,” Newell said.
One area already taking up more of Doherty’s time are drug overdoses. As part of the newly formed Post Overdose Recovery Team, Doherty has started reaching out to overdose victims within 24 hours of a reported use of Narcan — the drug that reverses the effects of an overdose from opioids or heroin — and following up with them again in 72 hours.
Newell is also talking about expanding the program into other areas. One potential growth area, he said, are “welfare checks” on residents whose children or other relatives live out of the area. EMS would charge a nominal fee to provide those checks, he said.
Newell sees so much growth potential for the program that he envisions community paramedicine being its own division within EMS in two years.
“It’s so new, there’s so many things we can do with it. And there are so many needs that can be met,” Doherty adds. “That’s our goal: to meet these needs in the home by providing patient-specific health care.”
To find out more about the Pasquotank-Camden Community Paramedicine program, call 335-1524.