Advance Care Paramedic discussion in my dept

[46Young]

I belong to an online EMS talkgroup at my job. The subject of starting an Advance Care Paramedic program similar to Wake County NC and Ft. Worth TX was discussed by several officers. The benefits were identified, but the question of cost was also brought up.

Excerpts from a lengthy conversation:

"With the cost savings identified by the Forth Worth and the Wake County programs, I think the system could be beneficial anywhere. I've read about the rural implementation as a home health care Paramedic or a Physicians Assistant who serves a community that has limited access geographically to health care.

In the urban or urban sprawl environment like ours, I could see these Paramedics serving a preventive care role, especially for people who have limited financial access to health care as opposed to geographic access.

I liked the detail in the Fort Worth article that showed them identify their frequent flyers and by doing preventive care with them they reduced 100s of ambulance rides per year.

The APPs could assist with preventive care of serious medical complaints such as diabetics and asthmatics.

They could assist with mental health patients as described in the Wake County website and reduce unnecessary hospital trips when no other complaint is presnt.

They could also assist with pediatric patients who have a fever or other mild condition and need home treatment more than ER treatment.

The Forth Worth article also described the APP going to the homes of discharged ICU patients who have a high frequency of return to the hospital and aiding in their recovery care to reduce subsequent hospital stays.

Within our system, I could see these providers having multiple roles that would fill their day:

1. They would respond to preventive health situations described above
2. They would respond as an extra paramedic for 911 calls when available - MAYBE CARRY EXTRA STUFF SUCH AS RSI
3. They can provide training and Q&A to street providers.

All together, this could be a valuable role for the Fire Department and citizens, as well as a way to make Fairfax County a leading EMS agency."

Response from a high ranking officer who is career EMS as well:


"The problem is the cost savings are either not ours (hospitals) or are actually revenue loss (transport fees). All we would see as an agency are un-reimbursable cost outlays, to set up and maintain the program."

Response to the above:

"Well...

If the program is going to save the hospital money, maybe they would be willing to help fund the program? Espeically in regards to their discharge of ICU patients and reduction of re-entry into the hospital.

Plus, many frequent patients or non-emergency patients do not have health insurance and that is why they use ambulances. We would not gain anything from billing them and could save money and better utilize transport units by not transporting them.

Also, if we are transporting people for the money when they don't need to be transported at all...that is poor patient care and a poor public service...that makes us no better than the for profit EMS companies. We as a fire department are here to utilize our resources and tax money to provide the best service to our community, not transport everybody we see to make revenue.

And, a better utilization of resources could mean the need for less transport units on the street which would create a cost savings. I know I could get some dirty looks for this but having 4 units that run less than 2 calls per 24hrs and transport only 1 person per 24hrs is not the best utilization of resources.

Especially with the full ALS engine concept...and it could be expanded even more with 12 units or a third of our department transporting 3 or less people per day.

There would be a lot to look at...and a lot of potential benefit. But like you said, we already researched and "redesigned" our EMS system once...and it is working...right??"

Officer's response:

"All very good points, and unfortunately all theoretical and difficult to translate into actual programs.

For instance, we would not (in any easily quantifiable way) save any money by not transporting regardless of whether we bill. Our personnel are on duty 24/7, running calls or not. We are over resources to the point that we never put units into service because we are short, nor do we cut staff when call volume is low (even though we know very well when our busy and slow times are).

If you want to get into overall means testing, that is a MUCH broader issue (and I certainly sympathize). I think we at some point calculated we could get by with 25 transport units if we went with a commercial model. Not sure how many rescues or ladders we would need..."

Response:

"Like (name removed) said, this could be talked about for days...so I'll finish with this:

The point to public service (Fire Department) is to provide our services (Fire, Rescue, EMS) in a timely manner and be available 24/7 365...in slow times and busy times.

With Rescue Companies and Truck Companies...these resources may run few calls at times but it is a valuable public service and valuabe use of high tax dollars to have them ready when a major incident occurs.

EMS is a little different. ALS/BLS care is still delivered in a timely fashion by our Engines/Trucks/Resuces throughout the county. If you need immediate ALS care via medicaiton admin/defib/airway control/ etc, it will be provided quickly. It is the transport component that could be evaluated for utilization of resources.

Less transport units and more resources such as Advanced Paramedics - or numerous other ideas - could be a better utilization of our budget with either a cost savings or breaking even but providing a better more efficient service.

These are the types of things that could create a nation leading Fire/EMS service vs. a large service with a large budget that provides the same care as everyone else.

As my 1st post stated...oh to dream..."


Any thoughts? An answer to the question of how it is financially beneficial for a muncipal department to initiate an Advance Care Paramedic program, and also lose call volume along with billable transports?

 

[bigbaldguy]

Wow lots of reading. Sounds a bit like the EMS systems in some European countries and possibly Austrailia. Main hurdles in this type of system here in the US are training and liability.

Training is costly and Americans have a very hard time taking the long view in this sort of thing. Our attitude has always been why spend a bunch of money now to save even more money SQUIRREL.

Liability in the US is different. We are very sue happy here. The only way I could see a system like this working in the long run would be to limit liability amounts in some way. That means massive legal reform and again I think that's a loosing argument in the current political climate.

I like the idea though.

 

[Handsome Robb]

I'm interested in this as well. I heard a little rumor that the agency I work for would like to eventually start something similar to this as well.

From a cost saving side I'm not sure exactly how it would cut costs for EMS directly, it seems like, as you said in the post above, that the hospitals would benefit more from it. EMS is still using a company vehicle, supplies and personnel to assess and treat these patients without getting any return from it.

I do see the possibility of having transport units available for transport which does generate cash flow *sometimes* as opposed to having that unit tied up making a house call.

 

[Veneficus]

I'm interested in this as well. I heard a little rumor that the agency I work for would like to eventually start something similar to this as well.

From a cost saving side I'm not sure exactly how it would cut costs for EMS directly, it seems like, as you said in the post above, that the hospitals would benefit more from it. EMS is still using a company vehicle, supplies and personnel to assess and treat these patients without getting any return from it.

I do see the possibility of having transport units available for transport which does generate cash flow *sometimes* as opposed to having that unit tied up making a house call.

except that a KIA with a few preventative meds and devices and 1 paramedic is much cheaper that a $100K transport vehicle with at least 2 providers on it plus some really expensive equipment.

The KIA reduces the amount of transport vehicles needed and buys newer cooler engines, ladders, and rescues with the money saved.

 

[JPINFV]

So... has anyone tried to bring in the hospitals and public health agencies to see if they would be willing to help support the program? At EMS Expo, one audience member commented that his (and I don't remember the service... I should have taken better notes) was able to get the hospitals to help defray the costs of implementing CPAP because of the cost savings to the hospitals by decreasing ICU stays.

Also, looking at the long game, once a value is proven, can that be used to leverage a change in Medicare/cade policies to reimburse non-transport services?

Also, if we are transporting people for the money when they don't need to be transported at all...that is poor patient care and a poor public service...that makes us no better than the for profit EMS companies. We as a fire department are here to utilize our resources and tax money to provide the best service to our community, not transport everybody we see to make revenue.

[Oh Snap.jpg]

 

[MSDeltaFlt]

With the availability of telemedicine and the constant advancement of video conferencing technology, an Advanced Paramedic Provider could be beneficial. Especially if you got the ability to bill for the "treat and street".

However, more emphasis should be placed on education and training over skills and drugs.

 

[Handsome Robb]

except that a KIA with a few preventative meds and devices and 1 paramedic is much cheaper that a $100K transport vehicle with at least 2 providers on it plus some really expensive equipment.

The KIA reduces the amount of transport vehicles needed and buys newer cooler engines, ladders, and rescues with the money saved.

You bring up an excellent point.

With the availability of telemedicine and the constant advancement of video conferencing technology, an Advanced Paramedic Provider could be beneficial. Especially if you got the ability to bill for the "treat and street".

However, more emphasis should be placed on education and training over skills and drugs.

I think the ability to bill for ACP services would be key as well. I wonder how many waves it would make if these providers were educated to the point to be able to prescribe meds. It seems like pharmacists might be up in arms about us intruding on their dispensing turf although if you are consulting with a physician through telemedicine it would be his script.

 

[Veneficus]

i don't think the value is in having medics prescribe meds.

I think the value is having them go and pick them up for home bound elderly people and helping said elderly people be compliant.

All the fancy diagnostics to decide what meds to disperse and which are more important to avoid poly pharm, or decide better treatments like surgery is with the doctor at the hospital.

It is also easier to drive pts to routine appointments when they don't meet ambulance transport criteria or wheel chair van, and charge the patient a small cash fee than it is to wait untill they are in extremis and need that transport ambulance to the hospital.

 

[Veneficus]

And for the record, the last person I treated where a paramedic dispensed motrin (in an sub optimal dose for 7 days) for shoulder pain secondary to a fall had a dislocated shoulder, a fractured clavical, and a blood in the wrist capsule which was likely an early callus from a wrist fracture.

Primary care fail.

 

[systemet]

It is also easier to drive pts to routine appointments when they don't meet ambulance transport criteria or wheel chair van, and charge the patient a small cash fee than it is to wait untill they are in extremis and need that transport ambulance to the hospital.

On a side note, a lot of the evil comminazi countries like Sweden give out free taxi vouchers to seniors both for medical appointments and general getting out and being alive.

I imagine this wouldn't help the US deficit. But then, I doubt anyone would be happy with a 20% sales tax either.

 

[systemet]

And for the record, the last person I treated where a paramedic dispensed motrin (in an sub optimal dose for 7 days) for shoulder pain secondary to a fall had a dislocated shoulder, a fractured clavical, and a blood in the wrist capsule which was likely an early callus from a wrist fracture.

I'm becoming more curious about this. I haven't seen a lot of shoulder dislocations, which is to say, I think I've seen about as many as most paramedics with my level of experience have. The ones I've seen have been very clear, with a lot of pain, obvious deformity, and a very definite loss of range of motion.

What were the factors that lead to this being missed, do you think?

 

[Veneficus]

On a side note, a lot of the evil comminazi countries like Sweden give out free taxi vouchers to seniors both for medical appointments and general getting out and being alive.

I'll bet it would be cheaper than what happens now by a respectable margin.

Either the hospital demands the BLS IFT contract transports out at a loss or lose the contract, or the doc comes up with a BS medical need because he needs to open up bed space and medicare pays $300 for a BLS ambulance.

I imagine this wouldn't help the US deficit. But then, I doubt anyone would be happy with a 20% sales tax either.

The US is generally unhappy with paying for anything.

 

[Veneficus]

I'm becoming more curious about this. I haven't seen a lot of shoulder dislocations, which is to say, I think I've seen about as many as most paramedics with my level of experience have. The ones I've seen have been very clear, with a lot of pain, obvious deformity, and a very definite loss of range of motion.

Yep, and this one was the same.

What were the factors that lead to this being missed, do you think?

I am torn between complacence and ego

 

[EMSLaw]

And for the record, the last person I treated where a paramedic dispensed motrin (in an sub optimal dose for 7 days) for shoulder pain secondary to a fall had a dislocated shoulder, a fractured clavical, and a blood in the wrist capsule which was likely an early callus from a wrist fracture.

Primary care fail.

Indeed. Out of curiosity, was the paramedic authorized to reduce the dislocation? Though I guess that might have been complicated by the other fractures in this particular case.

I'm assuming this was your garden-variety anterior frank dislocation of the shoulder? I understand (though I'm no expert on it) that posterior dislocations are often undiagnosed for prolonged periods.

I can understand missing a fracture, if it happens to be quite minor. But as someone already pointed out, dislocations are usually screamingly obvious.

 

[Shishkabob]

The goal is to get the local hospitals to hop on board as well. Sure, you're technically taking away a funding resource from both your transports and the hospital billing, but a vast majority of these patients cost more than you get reimbursed for. If you can get the main local hospitals on board, it will make it that much easier. Like the article states, there are 4 competing hospital systems that, while they don't like eachother, are working with the EMS system to make this work.

If the grant that was applied for gets accepted, things are really going to take off.




I know MedStar routinely has visitors from other EMS systems all the time to view the APP program and just MedStar in general, both nationally and internationally (Hong Kong visited last year). On top of that, MedStar also sends its supervisors to other agencies in the US to see how they do things.

Check with your higher ups to get in contact with MedStar and see if you can't do that sort of exchange. Send a couple of your training/clinical people to observe the system for a bit and see how it's done, discuss things, and see if it can't be implemented in your agency.





It's been proven effective in several agencies, it can be done, you just have to have the people who write the checks jump on board. MedStar, Wake County, Eagle County... some of the leaders in this realm, and I'm quite sure every one will be more than happy to help get things set up elsewhere. The more that jump on board, the more pressure we can put on Medicare to actually put their money where their mouth is.

 

[tacitblue]

i don't think the value is in having medics prescribe meds.

I think the value is having them go and pick them up for home bound elderly people and helping said elderly people be compliant.

All the fancy diagnostics to decide what meds to disperse and which are more important to avoid poly pharm, or decide better treatments like surgery is with the doctor at the hospital.

It is also easier to drive pts to routine appointments when they don't meet ambulance transport criteria or wheel chair van, and charge the patient a small cash fee than it is to wait untill they are in extremis and need that transport ambulance to the hospital.

You don't need an advanced care paramedic let alone a regular paramedic to drive to a pharmacy or drive a wheelchair van....

 

[Veneficus]

You don't need an advanced care paramedic let alone a regular paramedic to drive to a pharmacy or drive a wheelchair van....

True, but you do need somebody to do it.

But when not doing that, the advanced care paramedic can be doing other things.

The trick to home care is doing what is needed most. It may be a ride. It may be assisting with taking meds. It may be following up after a hospital discharge.

I was assuming though in this department, they have the ability to equip the "fly car" with ALS gear and keep it available for first response as well.

 

[tacitblue]

True, but you do need somebody to do it.

But when not doing that, the advanced care paramedic can be doing other things.

The trick to home care is doing what is needed most. It may be a ride. It may be assisting with taking meds. It may be following up after a hospital discharge.

I was assuming though in this department, they have the ability to equip the "fly car" with ALS gear and keep it available for first response as well.

I think the question is then, if the tasks that a community/advanced paramedic would be doing could be done a lot cheaper through a new public health service, is EMS the right organization for the job?

Equipping fly cars are expensive. Drugs that expire, monitors with 12 leads, etc cost money. An experienced paramedic costs money.

 

[Veneficus]

Indeed. Out of curiosity, was the paramedic authorized to reduce the dislocation? Though I guess that might have been complicated by the other fractures in this particular case.

I'm assuming this was your garden-variety anterior frank dislocation of the shoulder? I understand (though I'm no expert on it) that posterior dislocations are often undiagnosed for prolonged periods.

I can understand missing a fracture, if it happens to be quite minor. But as someone already pointed out, dislocations are usually screamingly obvious.

sent PM for confidentiality reasons.

 

[Veneficus]

I think the question is then, if the tasks that a community/advanced paramedic would be doing could be done a lot cheaper through a new public health service, is EMS the right organization for the job?

Absolutely public health is a better answer. But I don't think it is realistic to see a new service.

I also think that there is clinical benefit to acute cases when the provider is familiar with chronic presentations and care.

So I think that EMS is a good solution, both for the patient and providers.

The goal of reducing expense to a response agency as well as positive community outreach are both good reasons for the FD to do it, and I support those efforts.