‘Community paramedicine’ aims to keep patients out of the ER.
Nancy Nolan is wearing a neon-pinkish-sort-of-creamsicle-colored fleece, which nicely compliments her magenta nail polish and slate gray neck brace.
“Well, I have muscular dystrophy. I’m living on a respirator, it is actually a life support system. Other than that, I’m pretty healthy. I can’t walk, I can’t breathe, but other than that, I’m healthy,” she says with a laugh.
Nolan, who is 68 and in a wheelchair, lives in Dedham, just outside of Boston, Massachusetts. When she does need medical care, she coordinates it through Commonwealth Care Alliance, a local nonprofit that uses federal and state money to treat low-income people with complex medical conditions.
“I didn’t feel good one day…so I texted [my doctor], and I said, ‘I’m not feeling good at all,'” says Nolan. “He goes, well let me send a paramedic out. And I was like, what? You’re going to send a paramedic to the house?”
Increasingly, paramedics are forgoing the adrenaline of an ambulance to make house calls. It’s part of the medical system’s wider push to improve care and reduce costs by keeping people out of emergency rooms.
For the past year, Commonwealth has been contracting with EasCare, a private ambulance company, to do after-hours patient care. While Commonwealth has a team of nurses who do home visits during the day, they don’t staff the overnight. And so, for a lot of people like Nolan, medical care in the evening meant a trip to the emergency room, even when it wasn’t an emergency.
“Wherever possible, our patients said to us, ‘if we can, we’d like to be home.’ This program really enabled us to do that,” says Dr. Toyin Ajayi, chief of medical services for Commonwealth.
She adds that paramedics remain one of the most “underutilized specialities” in the field of medicine.
“They are highly skilled, they are mobile, they are used to taking care of people in the community,” she says. “They are used to home settings, on the street, they are flexible in their nature.”
Ambulance companies also see value in changing their practices, as reforms are pushing health care providers to treat patients anywhere but emergency rooms.
“Our whole model is based on the idea of picking up someone at home, taking care of them on the way to the hospital, leaving them in the emergency room to be cared for,” says Greg Davis, program manager for EasCare. “This model is a different ideal.”
Selected paramedics get more than 300 hours of additional training, learning everything from wound care to managing chronic conditions, like diabetes.
Nancy Nolan recieved a visit from a paramedic, instead of having to make the trip to the hospital. (Todd Bookman/WHYY)
No lights, no sirens
Joe Sequeira, clean shaven and in cargo pants, is one of EasCare’s first community paramedics. On a Wednesday overnight shift, his first call is in Revere, Massachusetts. Rush hour traffic on I-93 inches along, and he inches along with it in his SUV–no lights and sirens to clear the path.
“It is a very different approach. It is a different mindset,” he says. “On an ambulance, your mindset is to stabilize the patient, and get the patient to the hospital quickly. Where, with the community paramedic…it is all about treating the patient at home, at bedside.”
After a bit of trouble finding the address, he pulls up to a vinyl-sided house in a rough part of town, an otherwise rundown apartment around back, spruced up with Elvis paraphernalia on the walls. The patient is in his mid-60s, with a history of serious heart and lung disease. He’s on oxygen, but complains of shortness of breath.
“Have you been eating and drinking okay? What about going to the bathroom?” asks Sequeira, who has been with EasCare for 13 years.
From the back of his truck, he grabs portable equipment and a laptop, which gives him access to the patient’s electronic medical records. Once he’s reviewed medications and taken vitals, he does a blood workup. Sequeira then gets on the phone with both the oncall doctor and a night nurse, and together the team figures out a plan.
“Instead of him getting worked up and going to the ER tonight, and calling 911, talked to the doc, he’s going to get doubled up on his diuretic, and stay home for the night, and get followed up with tomorrow,” he says. “And maybe even get another visit from one of us tomorrow night just to check up on him.”
Sequeira spends two hours with the patient, at times sounding more like a social worker than an emergency medic. That mixing of roles raises some concern with professional home health aides.
“We question whether [paramedics]–even with additional training–would be able to provide ongoing home-based care of the type these complex high hospital-risk patients need,” Pat Kelleher, executive director of Home Care Alliance of Massachusetts, an advocacy group for home health care workers, told the Boston Globe last year.
There are other barriers to more paramedics doing home visits, including a myriad of state regulations, and a clunky insurance system not set-up to cover this kind of care.
Some hospitals, though, argue the math of health reform means it’s worth figuring community paramedicine out.
For example, Methodist Hospital in South Philadelphia is launching a small trial program to check in on patients recently discharged. Dr. Andrew Miller is spearheading the effort, and says the potential cost savings are big.
“Let me put it in perspective for you,” says Miller. “If a pilot like this to run for a few months costs us $25,000 and an automobile, you need to prevent two readmissions to recoup that cost, so I hope that answers the question.”
Geisinger Health System, based in central Pennsylvania, has been using its team of community paramedics since March, 2014, preventing an estimated 200 hospital admissions.
No surprise, the patients appreciate the service.
“Our scores are a ‘5 out of 5’ star rating for all of our questions, and that is not our average score. That is the only score we have ever received from a patient survey,” says Dr. David Schoenwetter.
He says community paramedicine is one part of the industry’s focus on providing the ‘right care in the right place at the right time,’ a phrase that’s become the mantra for healthcare executives around the country.
Nancy Nowlan, whose visit from a paramedic saved her a trip to the ER, uses slightly less polished language to describe her experience.
“It was really fabulous. Really fabulous. I hate going to the hospital, literally hate it.”