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Emergency Medical Services Mobile Integrated Healthcare-Community Paramedicine Programs
By Reena Underiner, MD; Emily Smith, MD; and Irfan Husain, MD, MPH, on behalf of the SAEM Emergency Medical Services Interest Group
Over the last few decades, there has been a rapid rise in emergency medical services (EMS) agencies seeking better ways to serve their communities and address gaps in the local health care system. Although EMS traditionally has served the role of responding to 911 calls and providing treatment and transport to the emergency department, the role of EMS has broadened in scope to include a greater focus on tailored, need-based prehospital initiatives practiced within the community. Much of this has been accomplished through the development of mobile integrated healthcare-community paramedicine (MIH-CP) initiatives/programs.
Though there is no singular definition of MIH-CP, it can generally be thought of as a model to provide out-of-hospital care to patients using mobile resources, with the overarching goal of enhancing access to health care and reducing strain on existing emergency care systems. Community paramedicine programs fall under the umbrella of the MIH approach in which specialized EMS professionals are equipped with an enhanced scope of practice that usually includes management of common chronic diseases and other primary care skill sets. However, MIH is not limited to just the use of community paramedics; it can involve various healthcare professionals such as advanced practice providers, mental health professionals, social workers, and nurses, to name a few. MIH-CP was first developed to meet the needs of rural communities, where access to healthcare is often limited due to provider shortages, geographic barriers, and/or other limitations. In these settings, community paramedicine has been used to address gaps in healthcare needs. EMS providers have taken on expanded roles, including chronic disease surveillance, administration of routine immunizations, and community health education.
Expanding Beyond Rural Communities
Although having originated in the rural setting, MIH-CP programs have been widely adopted to all community types and are continually evolving to meet the specific needs of various rural, suburban, and urban communities. These programs have expanded to include a broad range of services, like readmission reduction, alternatives for high EMS and ED utilizers, chronic disease management, redirection of patients to alternative care sites (e.g. behavioral health centers, primary care offices, urgent care centers), referral to social services, and 911 nurse triage. Let’s take a closer look at a few MIHCP program models: 911 Nurse Triage. In this model, a nurse triage line is built into the 911 dispatch system. After the standardized call-taking protocol is followed, low acuity calls may be directed to a nurse line. The nurse will then be able to further triage the patient to decide whether if the patient would be better suited to a different care setting (e.g. urgent care, primary care office, dentist, etc.). They can alternatively determine if the patient is safe for private transport (if the patient is amenable). At any point, the nurse is able to initiate ambulance transport if deemed necessary.
Chronic Disease Management.
Programs targeting chronic disease management focus on what is relevant to the needs of the community. Programs have addressed diabetes, heart failure, COPD, hypertension, asthma, etc. Activities include education on disease process (e.g. symptoms, warning signs, lifestyle modifications), addressing social determinants of health, medication reconciliation, glucose checks, weigh-ins for heart failure patients, and vital sign checks. Alternative Destinations. In this model, qualified providers, through protocol or direct medical oversight, have the ability to transport patients to destinations other than the ED. In one such program, qualified EMS providers can transport patients with primary psychiatric or substance abuse complaints to a behavioral health facility, as long as a strict set of inclusion criteria are met. Readmission Reduction. A statistical brief by the Healthcare Cost and Utilization Project (HCUP) showed that in 2018, there were 3.8 million adult hospital readmissions within 30 days, with a 14% readmission rate and an average readmission cost of $15,200. Often, patients have difficulty following up with their primary care physician, lack a primary care physician, or have no means of transportation to follow-up appointments after hospital discharge. Research has shown that early follow-up after hospital discharge can help decrease readmission. Typically, readmission reduction programs call for contact with the patient within 72 hours of discharge. Many programs focus on CP follow-up with heart failure patients, with initiatives that can include medication reconciliation (e.g. changes to diuretics), access to medications, weigh scale compliance, diet education, etc.
Role of Telemedicine
In recent years, telemedicine has emerged as an additional means of providing care to patients outside of the hospital and potentially avoiding unnecessary emergency department utilization. One program uses teleconferencing to connect low-acuity patients with an emergency medicine physician who then helps to determine disposition (e.g. primary care clinic, home care, ED) and type of transport (e.g. taxi, ambulance, etc.). A study analyzing four years of data from the program found a savings of $4.712 million using this telehealth triage model. Telemedicine has also been utilized during the COVID-19 pandemic to limit exposures to first responders. One program used telehealth to connect lowacuity patients to an advanced practice provider, who evaluated the patient virtually, connected patients to local testing and quarantine resources, arranged follow-up appointments, and prescribed medication refills. In the appropriate settings, telehealth can be useful in triaging patients and redirecting less urgent matters to primary care clinics, limiting ED resource utilization.
Role of the EMS Medical Director and Medical Oversight
The key to a successful MIH-CP program is creating an initiative that fulfills the needs of the local community. The EMS medical director (EMS physician that oversees protocol/policy development, QA/QI, and education for a specific EMS agency) should be closely involved in the conception, development, and implementation stages of any MIH-CP program. This starts with performing a needs assessment and identifying program goals of care, coordinating with stakeholders and experts, verifying that local and state regulations have been met, ensuring professionals within the MIH-CP team have been appropriately trained, and ultimately having a QA/ QI system in place that allows for monitoring, analyzing, and trending data.
Emergency Triage, Treat, and Transport (ET3) Model for Reimbursement
Traditionally, EMS agencies are compensated based on patient transportation and not patient care. As such, one of the greatest deterrents for agencies in implementing a MIH-CP program has been lack of a sustainable funding mechanism and inability to bill for services. Thus far, many agencies have had to rely on creative measures to sustain their MIH-CP programs, including but not limited to: internal funding, grant funding, and contracts with healthcare partners. However, in 2019 the U.S. Department of Health and Human Services announced a new payment model, ET3, for Medicare reimbursement for 1.) transport to an alternative destination (e.g. primary care office, urgent care, etc.); 2.) treatment in place by a qualified practitioner, on scene or via telemedicine); and 3.) transport to the emergency department. The ET3 model hopes to decrease costs while enhancing quality of care by providing patients with the appropriate level of services, improving efficiency within the EMS system by allowing agencies to focus on high acuity complaints, and encouraging appropriate utilization of resources. Currently 160 EMS agencies are participating in this voluntary, fiveyear, payment model which did not launch until January 1, 2021 due to the COVID-19 pandemic. If the data from this five-year test period proves cost effective, hopefully we will begin to see a shift towards this payment model as the standard for commercial payers as well, thus incentivizing the development of more MIH-CP programs.
ABOUT THE AUTHORS
Dr. Husain is an assistant professor of emergency medicine at Emory University School of Medicine, Atlanta, Georgia. He also serves as the associate medical director for Sandy Springs Fire Department and MetroAtlanta Ambulance Service. Dr. Smith is a third-year emergency medicine resident at Emory University School of Medicine, Atlanta, Georgia. She was formerly a paramedic and is planning to pursue an EMS fellowship. Dr. Underiner is a third-year emergency medicine resident at Emory University School of Medicine, Atlanta, Georgia. She is planning to pursue an EMS fellowship.
About the EMS IG
The Emergency Medical Services Interest Group promotes the education of medical students, residents, fellows, and attending physicians in the area of emergency medical services (EMS) through research, innovation, and collaboration. Membership in SAEM's academies and interest groups is free. To participate in one more groups: 1.) log into SAEM.org; 2.) click “My Participation” in the upper navigation bar; and 3) click “Update (+/-) Academies or Interest Groups.”
