Community Paramedics revisited

Ok so there seems to be a disconnect between some visions of community paramedicine and the present reality of these programs in the US is.

Lets take the Medstar program for example.

I don't know much about it except from what I have read, so don't hold me as an expert as to the nuts and bolts of the operation.

First of all as to the statistics, they are irrelevant in this case. All I can gather is they are based on 21 patients which grossly abuse the system, and that providing some sort of special attention to these patients the number of EMS calls they place decreases.

This fails to provide us data about the big picture, or any reason to assume EMS or paramedics played a role in achieving the results, we can just infer that providing ongoing attention to system "abusers" or frequent flyers reduces the amount of times they call.

More of a case for reducing frequent flyers than a case for paramedics gaining a higher level of medical prowess.

And it seems their community health program is really one of nursing, follow up, social work, patient education, and direction to appropriate resources...none of which requires a paramedic or requires any additional advanced knowledge or skill of the paramedic.

I'm all for that type of program, but absolutely nothing at all indicates advanced scope or pay for paramedics.

About every service I've worked for would have a supervisor or a paramedic or the police go talk to a frequent flyer and get them educated on resources and a plan for them to get healthcare that didn't involve 911. We just never called in community health.

This is where alot of confusion comes in to play, because there are folks who genuinely believe this will lead to a midlevel role, increased pay, increased scope, save EMS...nonsense. This is the type of stuff we should do already. We all educate diabetics on their conditions, and how to care for their disease so as to avoid having to activate EMS for a wake up. Directing them to a physician or scheduling an appointment for them is logical. Having someone follow up the next day or week is great.

But none if that really requires a paramedic, it's just medics are familiar with the streets. And it certainly doesn't require advancing the skillset or education of paramedics into degree programs.

It's just smart business and good patient care.

One of the big problems we face is that there is just not alot of places to direct these patients to go, because the ER is about the only place that tolerates difficult patients, and sees the uninsured.

Again, that's a healthcare system problem, not really and EMS problem.
And honestly, it's a fundamental problem to societies: how to care for poor and difficult populations.
We're not locking the lepers outside the gates, but I doubt we will be able to rig up a system where advanced level clinicians roam about the streets seeking whom they might heal.
 
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So, is community paramedicine midlevel practice, a method of home health care, a means to divert "frequent fliers" and system abusers, a method to reduce ER visits, or a way to "treat and street" patients?

Honestly, I'm not sure anyone knows.
 
Wes said:
So, is community paramedicine midlevel practice, a method of home health care, a means to divert "frequent fliers" and system abusers, a method to reduce ER visits, or a way to "treat and street" patients?

Honestly, I'm not sure anyone knows.
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It is a band aid over a bleeding artery.

How to fix the underlying problem extends far beyond EMS.
 
Agreed. A few years back here in Austin, the children's hospital moved out of the city/county hospital/trauma center. I thought the smartest thing would be to turn the children's ER into an urgent care/fast track for non-acute patients. It was turned into more ER beds. Surprise. The ER is still full.

IMHO, we need to have the ERs perform screening exams for non-critical patients and then have someplace to send them. But that would involve the welfare/public health system having hours other than 9-5 Monday - Friday.
 
Well, they used to do the MSE and send them on their way. That method was much more common. But all the hospitals I know just try to keep them now, because if they are insured there's some money to be made, and if they are not, there are some government subsidies, or at least writing off the care helps the tax situation, or keeps donor money coming in.

You know, for way to long we have all been trying to erect barriers to the hospital because the sign above the door says Emergency on it. But patients keep coming, because honestly it's the smartest place to go. They are familiar with the brand. It's easier to sell the brand of a hospital system than it is to market and brand an individual physician, especially for primary care. Good doctors staff the hospitals, There's access to scanners, labs, diagnostics, beds if you need to stay, a cafeteria...it's a one stop health shop.

It really makes sense, and it is what consumers and patients want, to center care around the hospitals in conjunction with community follow up.

We, the medical profession, are the ones clinging to the past by insisting everyone form a relationship with a physician and go to his office and let him guide your care. Things change and it's time for us to change as well.

The first place a patient should go is a satellite facility in the community affiliated with the health system, like an urgent care or primary clinic, open 24 hours a day, and they can begin to triage and coordinate care, as well as direct the community health programs.

Emergencies and acute cases can bypass or be sent out from the community clinics into the main receiving hospital and be handled accordingly.
 
Arovetli said:
They are familiar with the brand. It's easier to sell the brand of a hospital system than it is to market and brand an individual physician, especially for primary care. Good doctors staff the hospitals, There's access to scanners, labs, diagnostics, beds if you need to stay, a cafeteria...it's a one stop health shop.

It really makes sense, and it is what consumers and patients want, to center care around the hospitals in conjunction with community follow up.
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It's somewhat of a digression, but where did that brand come from? Who manages that brand, even to the point of doing customer satisfaction surveys every single day to make sure their underlings are keeping the brand's value up?
The suits are going to fight tooth and nail against anything that diminishes their market share. I suspect this means community health needs to work for them if it's going to have any success. We get the brand and a tiny straw to sip from the vast river of money; they get to follow customers home and bring them back. The only things we'd have to give up are independence and cost-effectiveness. All the health professions already made that trade.
Arovetli said:
It really makes sense, and it is what consumers and patients want, to center care around the hospitals in conjunction with community follow up.
Click to expand...
And now we see the perniciousness of the brand. The healthy customers, the ones our new masters are interested in, don't want to sit at home and wait. They want to go sit in that lovely glass and brushed steel waiting room for a few minutes, then be ushered back into an equally nice room with a more comfortable chair, where their problems will be fixed.
And if they're an equal distance from some strip-mall urgent care that probably doesn't even have an MRI machine and its parent, Big Teaching Hospital, which one are they going to go to?
But what about the sick customers, whom we're probably more interested in anyway? A lot of them don't see themselves as sick. They saw all the ads too, or their loving children did. And if they really are, better go to Big Teaching Hospital so we're sure that they'll have everything in case we need it. Our insurance should cover it.
And the rest? Oh, now we're back to taking care of poor people no one cares about. Except now our job is to keep costs down and keep them out of the hospital, and if we come across a potential good customer, to bring that person right in.
Arovetli said:
the underlying problem extends far beyond EMS.
Click to expand...
 
Wes said:
So, is community paramedicine midlevel practice, a method of home health care, a means to divert "frequent fliers" and system abusers, a method to reduce ER visits, or a way to "treat and street" patients?
Click to expand...

These are good questions. It seems it would be sensible to define the need before trying to design a system or decide who is best equipped to meet that need.

It appears to me that community health paramedicine as a concept is more a way for paramedicine to try to adapt and reinvent itself ithan it is a response to an actual need.

I'm not saying that there is currently no need for additional community health nursing services, or that the need won't grow in the future, or that EMS should have no part in meeting that need. It's just that, even after all this discussion, I still haven't seen any justification for the type of massive new shift in the EMS paradigm that some are promoting.

We already have community health nurses. We already have PA's and NP's.

Do we need the midlevels out in the community more? Yeah, maybe.

Do we need the current home-healthcare infrastructure to expand? Yeah, it sounds like it.

Do we need the current home-healthcare infrastructure working more closely with EMS to identify patients and provide follow-up at home? Yeah, sounds like a great idea to me.

Do we need paramedics to have the education and authority to do more non-acute assessments, treat-and-release, patient education, referrals, giving out short-term scripts pending a clinic or home health appointment? Absolutely - see my last post in this thread for my vision on that.

But again, do we really need "paramedic practitioners" and all the expensive new educational infrastructure, experimentation, legal battles, and bureaucracy that will come with inventing an entire new profession? Do we need EMS to take over home care? Do most paramedics even really know what they are getting into in asking, essentially, to work as a nurse in people's homes?

I hate to be negative about this, but I just don't see the need or the practicality.
 
Meursault said:
It's somewhat of a digression, but where did that brand come from? Who manages that brand, even to the point of doing customer satisfaction surveys every single day to make sure their underlings are keeping the brand's value up?
The suits are going to fight tooth and nail against anything that diminishes their market share. I suspect this means community health needs to work for them if it's going to have any success. We get the brand and a tiny straw to sip from the vast river of money; they get to follow customers home and bring them back. The only things we'd have to give up are independence and cost-effectiveness. All the health professions already made that trade.

And now we see the perniciousness of the brand. The healthy customers, the ones our new masters are interested in, don't want to sit at home and wait. They want to go sit in that lovely glass and brushed steel waiting room for a few minutes, then be ushered back into an equally nice room with a more comfortable chair, where their problems will be fixed.
And if they're an equal distance from some strip-mall urgent care that probably doesn't even have an MRI machine and its parent, Big Teaching Hospital, which one are they going to go to?
But what about the sick customers, whom we're probably more interested in anyway? A lot of them don't see themselves as sick. They saw all the ads too, or their loving children did. And if they really are, better go to Big Teaching Hospital so we're sure that they'll have everything in case we need it. Our insurance should cover it.
And the rest? Oh, now we're back to taking care of poor people no one cares about. Except now our job is to keep costs down and keep them out of the hospital, and if we come across a potential good customer, to bring that person right in.
Click to expand...

I think we are making the same point. Consumer/patient preference for going to the hospital or at least remaining affiliated with one clinic/doctor affiliated with their choice of health system, and favoring a one stop shop approach.

I don't think no one cares about the poor, I just think it's unwise to tip the whole system on its head to care for them and i dont favor that level of government intervention and the centralized planning that accompanies it. We have to figure out a viable way to pay for it, and encourage personal responsibility. No small task.

I favor a come one, come all approach. Come on in the hospital system if you want, but I wish the emergency room and the emergency system wasn't the sole point of entry, and EMS wasn't the primary method of moving patients around. And patients have to pay their bills or at least in some minimal manner have responsibility for themselves and the cost of their care.
 
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With the current educational standards and our limited knowledge of medicine outside of the acute care setting, paramedic initiated refusals are little more than full employment for lawyers.

I'm putting down a down payment on my BMW 635 now.
 
While y'all already know where I stand on Paramedics providing community health...I did stumble across this grant:

http://www.grants.gov/search/search...0ZhJSlMJDw!-1552203449?oppId=235732&mode=VIEW

I know we have discussed ACA and federal funding, and while this type of program isn't specifically for EMS or paramedics, it's not too much of a stretch to think an EMS agency could somehow finagle their way into this or another similar type of grant program.

I don't agree with EMS doing it, but in fairness I thought I should post it as it shows the type of grant money being thrown at community/home health.
 
Wes said:
So, is community paramedicine midlevel practice, a method of home health care, a means to divert "frequent fliers" and system abusers, a method to reduce ER visits, or a way to "treat and street" patients?

Honestly, I'm not sure anyone knows.
Click to expand...

Our pilot is already doing all of these. The didactic training takes approximately 3 months for Medic/RNs and 6-8 months for Medics (more for certain specialty trained units). Along with clinical time before being approved by the MD staff.

First stage of the pilot (18 days) allowed us to prevent 49 out of 50 ER trips in the pilot's 10 mile zone (3 sent to urgent care, 47 treat/release, 1 still had to go to the ER). It's slow going though as there isn't any grant funding available at the moment, so it's all done using private funding. The system as it stands is profitable, however the initial capital outlay was immense (mostly for training development). Our second stage which is starting soon implements our reduction of RTA side of the program.
 
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