U.S. News & World Report
Healthiest Communities
America’s ‘Guerrilla’ Medics
Innovative paramedic programs are working to fill the cracks in the nation's health care system.
By Gaby Galvin and Seth Cline June 19, 2018, at 6:00 a.m.
U.S. News & World Report
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Benji Currie, a district chief with the Wake County Advanced Practice Paramedic program, sits in his emergency vehicle in Raleigh, N.C.(Phyllis B. Dooney for USN&WR)
Shirley worked in nursing for a quarter-century, but her professional expertise hasn't kept her healthy.
In October, the 63-year-old native of Raleigh, North Carolina, was hospitalized for a fall and learned she was at risk of congestive heart failure – her blood pressure was "in the roof," she says. She stayed in the hospital about two weeks.
"I was in bad shape," says Shirley, who also has diabetes, vision problems and weighed about 225 pounds at the time. She asked that U.S. News not divulge her last name to protect her privacy. "I couldn't hardly walk, couldn't hardly do nothing, couldn't hardly think."
That stint in the hospital put her on the radar of Wake County's Advanced Practice Paramedic program, which seeks to reduce preventable emergency room visits by sending emergency medical service personnel to provide some health care services in patients' homes.
Within two days of Shirley's hospital discharge in October, designated paramedics came to her house, took her blood pressure and discussed her medications, which are now delivered to her home by a local pharmacy. When her blood pressure feels dangerously high, she calls the paramedics – not 911 – and they usually arrive within 30 minutes to check on her, a process she says has helped her stabilize and manage her health.
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"Sometimes if I felt like I was kind of dizzy, I would call them and I'd talk to them," Shirley says. "Sometimes we talk about my condition and sometimes we just talk about the weather, but it's good. It's good just to have somebody to talk to every now and then."
"I didn't think I was going to be here this year, I really didn't. But I've come a long ways," says Shirley, who is able to drive and keep up with her grandchildren again because her health has markedly improved – due in part to the nearly 50 pounds she's lost.
The Wake County program represents an unusual role for paramedics, who are regularly on the front lines in response to medical emergencies rather than working to prevent them. But initiatives like APP, which has been in operation since 2009, have gained traction across the country in recent years as health care providers seek to keep people from costly – and sometimes unnecessary – visits to the ER.
Such programs are often used to either redirect 911 callers to a more appropriate agency, such as a mental health clinic, or to provide "transitional care" – checkups and in-home services provided after someone has been released from the hospital, in an effort to keep them from being readmitted.
That's the kind of service Shirley, who has health coverage through both Medicaid and Medicare, needed. She hasn't had to call 911 since enrolling in the program last fall.
While dozens of similar programs have sprung up across the country during the past decade, the grass-roots nature in which they have formed means there's no official consensus among EMS officials on what they should be called. Most, however, fall under the common umbrella labels of community paramedicine or mobile integrated health care.
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READ: How Healthy is Wake County? ]
Proponents say the flexibility of these programs is a strength. But a lack of structure also can lead to a program's downfall, so successful initiatives like those in Wake County may hold keys for other communities looking to develop their own.
"We try not to be the experts at every health care problem and crisis, but rather the experts in navigation and coordination and gap-filling of health care within our community," says Michael Bachman, who oversees APP as deputy director of medical affairs for the Wake County EMS system.
Community paramedicine programs can be targeted for people with chronic conditions, such as congestive heart failure, or for those who face hurdles accessing health care – they may not have a car, for instance, or may be unable to get a same-day appointment with their doctor. Other patients may have mental health or substance abuse issues.
Proponents say programs should be designed differently based on the needs in the community.
"Sometimes it feels like guerrilla health care. Whatever it takes," says Ben MacDonald, a nurse case manager with Community Care of Wake and Johnston Counties, a care coordination organization that partners with Wake County on APP. "We work with people where they're at, physically, mentally, medically."
Advanced Practice Paramedics Casey Mason, left, and Chris Gherardi discuss the implementation of a new standardized treatment tool with district chief Benji Currie. (Phyllis B. Dooney for USN&WR)
In Wake County, one effort within the paramedicine program aims to reduce unnecessary emergency room visits by focusing on older adults who fall in assisted living facilities. They may not be seriously injured, but facility policies can require an immediate emergency department visit anyway.
Wake County EMS conducted a 3.5-year pilot program that showed older patients in many cases could receive the care they needed at their assisted living facility. Paramedics now evaluate these residents after a fall and decide whether to treat them on-site or bring them to the emergency department, often in consultation with the patient's primary care doctor.
"911 is the go-to number for people who need help, however acute or chronic or whatever state they're in," says Jeffrey Hammerstein, assistant chief for community outreach for Wake County EMS. "They're calling us anyway, so instead of saying, 'Don't call us,' we're saying, 'Let us get there and figure out what you need, and get you better service than what we've offered before.'"
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Paramedics also can redirect patients to health facilities – such as a 24-hour crisis specialty center for someone having a mental health episode – that may be a more appropriate destination than a hospital or emergency room, where patients could wait hours to be seen.
Some hospitalizations are unavoidable. But to keep patients from returning to the emergency room, paramedics will provide basic, preventative primary care services for those at risk of developing chronic obstructive pulmonary disease or congestive heart failure – patients like Shirley.
Unlike most community paramedicine programs, Wake County also offers another type of transitional care: follow-up support for drug users who overdose, leading to a 911 call. The day after someone overdoses – whether paramedics take them to the emergency department or not – a paramedic and peer support counselor locate them to offer information on recovery programs or access to a clean needle exchange.
"Their crisis is far from over at that point," Bachman says. The 24-hour gap between an overdose and intervention may be the right amount of time for a drug user to reflect on the situation and become open to change, he says.
Wake County launched the drug abuse initiative in April to combat the opioid crisis in the area. Between 2015 and 2016, the number of unintentional deaths in the county from commonly prescribed opioids spiked from 20 to 38, while deaths from synthetic opioids such as fentanyl rose from 20 to 48.
It's too soon for concrete results, officials say, but despite some challenges gaining patients' trust, they already have connected several people with services.
"The thing with addicts is a lot of people don't know how to ask for help, or they don't know where to get the resources," says Gabby M., a 20-year-old in recovery who has been an inpatient at the rehabilitation facility Healing Transitions in Raleigh since February.
She says she would have benefited from a paramedic and peer counselor contacting her after her last overdose – the result of mixing heroin and Xanax – and although she probably would not have been ready to accept help the next day, she says she "definitely" would have used the resources eventually.
"Everybody has their breaking point where they really need to get help, and I wasn't at that point, but a lot of people are," says Gabby, who declined to give her last name. "So I definitely think it would help tremendously for people that are more broken than I was, or more sick of it at that point in time."
Wake County's overdose follow-up initiative is perhaps the most unique segment of its community paramedicine program. But the wide scope of services APP offers reflects the nearly 10 years it has been in existence, and officials caution other regions looking to implement similar programs against trying to do too much too quickly.
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Communities without a solid plan or long-term funding may find themselves shuttering their programs. For example, a community care program in Mesa, Arizona, was suspended in March due to a $12.5 million federal grant running out, despite the program serving about 13,000 patients during three years.
"If you bite off too much, you won't succeed," says Kevin McGinnis, who specializes in community paramedicine and rural emergency care for the National Association of State EMS Officials. "If you do one thing, do it right and keep adding services, that's the way to build it. Start in the community proving you're doing something right and prove you're saving money."
Once EMS departments have demonstrated their value to the community – and to those who may be fronting the bill – they can look to expand to more complex issues, as Wake County and others have done, he says.
"Keep it simple, keep it small to start. That just means pick a problem, but don't pick 10," McGinnis says. "Do it really well, document it and show how it's impacted health care or patient experience or both."
As with any new care-delivery model, funding remains a major challenge for community paramedicine programs, which may not yield immediate savings but are long-term investments in a community's overall health and well-being, McGinnis says.
EMS services are often reimbursed only when a patient is transported, so there's no standardized payment plan for the treat-and-release model employed by community paramedicine programs.
That may change as these programs show they can improve patient outcomes and save money. This year, Anthem BlueCross BlueShield became the first major commercial insurer – beyond a few small pilots – to roll out coverage for EMS "treatment without transport," expecting to implement the practice in 14 states throughout 2018.
"The way you empower EMS systems to fill gaps in health care needs in their communities – and get patients to the right place the first time – is reimbursement reform," says Dr. Jeff Williams, deputy medical director for Wake County EMS. "By shifting funding for EMS to evaluation and treatment, or assessment and care, as opposed to simply being tied to transport, then you empower a lot of systems to do that and better meet the needs of their community."
Benji Currie, a district chief in Wake County's Advanced Practice Paramedic program, stands over a training mannequin at EMS headquarters in Raleigh, N.C. This room is used to simulate home visits for new recruits. (Phyllis B. Dooney for USN&WR)
While North Carolina isn't one of the 14 states where Anthem is paying for services given without transport to a health care facility, community paramedicine isn't going anywhere in Wake County.
North Carolina's 2017-2019 budget allocates $350,000 for the continuation of community paramedicine pilot programs in Wake, McDowell and New Hanover counties. The budget law also directs the state's Department of Health and Human Services to design a plan to use Medicaid funds to reimburse paramedics who take patients to behavioral health facilities instead of emergency departments.
"What works and is reimbursed locally may not be the same in another state," Bachman says. "So having to work through the politics of that and working through organizations that have a voice – whether in your local community, the state level or nationally – will be important as well."
Gaby Galvin, Staff Writer
Gaby Galvin is a staff writer at U.S. News & World Report. You can follow her on Twitter and em... READ MORE »
Seth Cline, Staff Writer
Seth Cline is a producer at U.S. News & World Report. You can follow him on Twitter or reach hi... READ MORE »
Tags: North Carolina, health care, health insurance, Medicaid, hospitals, public health
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