LAFD nurse practitioners

[Carlos Danger]

Sure, they can do a better clinical exam. But how far can they get with only that and no labs or imaging? Let's consider a typical call for abd pain. They can make a better guess at a Dx than a medic, but in the end they will just have to tell the patient that they need to go to the hospital. How is that different than what a medic will do? Most of the 911 "super users" i know will complaints like this or chest pain or SOB.

If you don't think midlevels are better prepared than paramedics to manage primary-care type problems, then I don't know what to tell you.

 

[Ewok Jerky]

Coming late to this discussion.

As remi said, there is a huge amount of out of hospital medicine being practiced by nurses, PAs, and NPs.

As someone who takes call a few times a month, I can syabi would save at least 1-2 ED visits per night if I could actually see the patient at gone rather than just talk to them on the phone...and I work in ortho not primary care.

Being able to prevent readmits is where community medicine save money, not ED visits. Twhis means making astute judgement on dispositions...does the is patient need stat labs/imaging? Or can it wait until tomorrow to be done as outpatient?

This takes understanding of CHRONIC medical problems as well as acute complications, understanding a wide variety of medication interactions, and access to a patients history including recent hospitalizations and PCP visits.

Having authority to prescribe and administer some meds, authority to HOLD meds, POC testing, freedom to practice medicine rather than follow protocols, and acceptance of liabilities requires more education and legal authority than paramedics currently have.

Average hospital stay in America costs $1500-$2000 a day, minimum of 2 days. It does not take a lot of preventative medicine to recover the cost of a community medicine practitioner.

 

[Tigger]

If you don't think midlevels are better prepared than paramedics to manage primary-care type problems, then I don't know what to tell you.

Certainly they are superior at managing the patients.

I am not sure that is necessarily the goal of community paramedic programs, it is not the overall goal of ours at least. Our patients are still managed by their physicians/midlevels and we are just there as follow up. Do you take your meds? Have you had a medication reconciliation? Is your home suitable for your health status?

We play much more of a home health and resources navigation role than that of primary care. For our rural area, there is a shortage of both primary care and home health, but it is much more noticeable with home health. There is one agency for many hundreds of square miles and they are often unable or unwilling to see patients within a reasonable time frame. It's pretty low hanging fruit, but it really does help keep patients out of the hospital. It's not flashy and we aren't suturing or running around with iStats (though those are coming), but we've been able to effectively manage about ten "super users" in our system in the last year. It's not much, but over 2500 calls and two to three ambulances staffed a day, it does make an impact, and we can do it just as effectively as a mid-level can, it's just not complicated to roll up throw rugs or recommend the patient's room have a bathroom on the same floor.

We also do mental health evaluations and transports to a freestanding "psych ED," which with some extra training is more than reasonable for a a paramedic to be doing. Sure it would be nice to bring a case worker right to the scene but the money is not there for that. It is far cheaper to have a paramedic do basic POC testing and a flowchart assessment to see if the patient is appropriate for these sorts of facilities, where they will see a psych provider anyway.

TLDR; community paramedics doing home health is viable and does not require them to mimic the clinical accumen of higher credentialed providers. Perhaps we should be focusing our efforts on this rather than the more flashy "primary care in the patient's living room."

 

[Carlos Danger]

TLDR; community paramedics doing home health is viable and does not require them to mimic the clinical accumen of higher credentialed providers. Perhaps we should be focusing our efforts on this rather than the more flashy "primary care in the patient's living room."

Some patients need to go to the ED to have their needs met. Some patients just need the basic help that community paramedics can provide, such as what you describe. But there is a whole other subset of patients who can probably benefit from something in between the two.

 

[SandpitMedic]

Try to follow this run-on...

If I, a productive tax paying citizen (on multiple spectrums I.e.sales tax, income tax, property tax, local tax, state tax, etc taxes out the WAHZOO!), call 911...and an NP shows up and does a protocol based tx, or some treatment JUST because I called 911 (you call, we haul type of mindset) ... And then I subsequently get a bill from the fire department with 10 digits (not including cents) I am going to lose my ****ing mind! I am not calling for a nurse or doctor or something in between to come to my house- I am calling for an EMT/Medic/ambulance. 90% of what we do is BLS... That's the bottom line. Do not pass the buck onto the 90% for the 10% of sick patients, most of whom would be fine with an EMT or a Paramedic.

If they want to advance medicine and community health and public safety, and roll with the mantra of "we are fire-we are heroes- we will save you- we are the best at everything" then that is fine. Then pay for it, do not pass the cost to consumers.
If they want to advance their pocket books (albeit, unlikely) or advance and perpetuate the absurd costs of healthcare to people, ignorant of medicine, who just dial 3 numbers ---then screw that.

As far as I am concerned this is not the answer to the problems in EMS. From the arguments just here among ourselves, I see this creating more points of conflict than actually benefitting sick people. It creates a rift, and it is a waste of money...

 

[SandpitMedic]

Some patients need to go to the ED to have their needs met. Some patients just need the basic help that community paramedics can provide, such as what you describe. But there is a whole other subset of patients who can probably benefit from something in between the two.

I'm not going to argue- but I disagree with you on this 100%

This isn't the answer. A community paramedic can provide what that subset requires, or can be trained to. A full blown NP/PA is not the answer.

Secondly, I don't know where you live/work(ed) in EMS, but I have never, it seems, encountered the competent "home health nurse" that you seem to have bumped into. Not once can I recall the one with wisdom and insight into what is going on with their patient... Everyone I encounter is a full potato, can't even spout out a decent report or allergies, and it also seems a prerequisite to have a foreign nursing degree and overstay your tourist visa to even qualify for that job.

(Just based on my experiences, not to knock anyone who wants to be a competent home health RN)

Anyways- sorry for the derail.

 

[SandpitMedic]

Certainly they are superior at managing the patients.

I am not sure that is necessarily the goal of community paramedic programs, it is not the overall goal of ours at least. Our patients are still managed by their physicians/midlevels and we are just there as follow up. Do you take your meds? Have you had a medication reconciliation? Is your home suitable for your health status?

We play much more of a home health and resources navigation role than that of primary care. For our rural area, there is a shortage of both primary care and home health, but it is much more noticeable with home health. There is one agency for many hundreds of square miles and they are often unable or unwilling to see patients within a reasonable time frame. It's pretty low hanging fruit, but it really does help keep patients out of the hospital. It's not flashy and we aren't suturing or running around with iStats (though those are coming), but we've been able to effectively manage about ten "super users" in our system in the last year. It's not much, but over 2500 calls and two to three ambulances staffed a day, it does make an impact, and we can do it just as effectively as a mid-level can, it's just not complicated to roll up throw rugs or recommend the patient's room have a bathroom on the same floor.

We also do mental health evaluations and transports to a freestanding "psych ED," which with some extra training is more than reasonable for a a paramedic to be doing. Sure it would be nice to bring a case worker right to the scene but the money is not there for that. It is far cheaper to have a paramedic do basic POC testing and a flowchart assessment to see if the patient is appropriate for these sorts of facilities, where they will see a psych provider anyway.

TLDR; community paramedics doing home health is viable and does not require them to mimic the clinical accumen of higher credentialed providers. Perhaps we should be focusing our efforts on this rather than the more flashy "primary care in the patient's living room."

This! For once we agree.

I'm done posting today.

 

[triemal04]

Certainly they are superior at managing the patients.

I am not sure that is necessarily the goal of community paramedic programs, it is not the overall goal of ours at least. Our patients are still managed by their physicians/midlevels and we are just there as follow up. Do you take your meds? Have you had a medication reconciliation? Is your home suitable for your health status?

We play much more of a home health and resources navigation role than that of primary care. For our rural area, there is a shortage of both primary care and home health, but it is much more noticeable with home health. There is one agency for many hundreds of square miles and they are often unable or unwilling to see patients within a reasonable time frame. It's pretty low hanging fruit, but it really does help keep patients out of the hospital. It's not flashy and we aren't suturing or running around with iStats (though those are coming), but we've been able to effectively manage about ten "super users" in our system in the last year. It's not much, but over 2500 calls and two to three ambulances staffed a day, it does make an impact, and we can do it just as effectively as a mid-level can, it's just not complicated to roll up throw rugs or recommend the patient's room have a bathroom on the same floor.

We also do mental health evaluations and transports to a freestanding "psych ED," which with some extra training is more than reasonable for a a paramedic to be doing. Sure it would be nice to bring a case worker right to the scene but the money is not there for that. It is far cheaper to have a paramedic do basic POC testing and a flowchart assessment to see if the patient is appropriate for these sorts of facilities, where they will see a psych provider anyway.

TLDR; community paramedics doing home health is viable and does not require them to mimic the clinical accumen of higher credentialed providers. Perhaps we should be focusing our efforts on this rather than the more flashy "primary care in the patient's living room."

It really just depends on what a department wants and is willing to do, and what the community wants/needs/is willing to pay for. A simple system like what you describe would be very effective (and has been repeatedly, even before the current buzz about this) and wouldn't require a major investment by a department, just buy in and acceptance from the rank and file.

Or, you could go even further than that, and have people (qualified people) essentially performing house calls, like doctor's did way, way back in the day. Just depends on what is wanted and what can feasibly be provided.

It's also worth remembering why this is really happening and getting big; due to changes made by obummercare hospitals will no longer be paid for treating people who are readmitted to the hospital for the same problem within a set time frame; given that the type of person who would benefit from this type of program (either what Tigger is doing or something more in depth) will likely be going to the ER for the same issues...easy to see why it's needed. (and easy to see why some hospital systems are willing to help with the costs)

With a system like this is place, everybody, in theory, wins; EMS agencies don't have to keep transporting frequent fliers (and likely not be paid for doing so or be paid very little), ER's get to deal with fewer people who don't need to be there, and hospitals don't get stuck with an unpaid bill. Win win win.

 

[Summit]

call 911...and an NP shows up and does a protocol based tx, or some treatment JUST because I called 911 (you call, we haul type of mindset) ... And then I subsequently get a bill from the fire department with 10 digits (not including cents) I am going to lose my ****ing mind!

So you just made up a ludicrous model in your head then declared it ludicrous?

That is not how such a service would work. Come on... are you interested in an honest debate?

 

[Summit]

A community paramedic can provide what that subset requires, or can be trained to.

By the time you educate and train a paramedic to do this:

Being able to prevent readmits is where community medicine save money, not ED visits. This means making astute judgement on dispositions...does the is patient need stat labs/imaging? Or can it wait until tomorrow to be done as outpatient?

This takes understanding of CHRONIC medical problems as well as acute complications, understanding a wide variety of medication interactions, and access to a patients history including recent hospitalizations and PCP visits.

Having authority to prescribe and administer some meds, authority to HOLD meds, POC testing, freedom to practice medicine rather than follow protocols, and acceptance of liabilities

They'll have invested the time and money it took to be a PA.

I'd could go on, but I'll just wait for your next post about how all RNs of specialty X are incompetent potatoes...

 

[johnrsemt]

True community paramedicine would work well with dispatch center and when dispatch sees that the pt was taken to the hospital yesterday, and was Dx'd with pneumonia and was released at 0500 and was calling 911 at 0700 same day: they would send the paramedicine type truck to talk to the patient to let them know that "no, they won't be better 2 hours after being released from the hospital" and "no going back to the same or a different hospital will not get them better faster".

And send them to the patient that has a laceration that needs 6 sutures and an antibiotic script: Better yet, give them the antibiotics so that after they suture the laceration they can give the patient a bottle of antibiotics.

Even better for the 2nd type of patient let the regular 911 crews (or IFT that is doing the run) be able to call for the community paramedicine truck to come take over the patient so that we don't have to transport them

 

[Carlos Danger]

A community paramedic can provide what that subset requires, or can be trained to.

Again, if you can't envision the difference in capability between a paramedic and a mid-level, then I don't know what to tell you.

I think there's probably a reason why family practice offices and urgent cares and hospitals hire PA's and NP's instead of paramedics.

 

[SandpitMedic]

Yeah, because they can write scripts... And do a detailed physical exam.

Lol.

 

[SandpitMedic]

Different strokes for different folks, I guess.

 

[Summit]

Different strokes for different folks, I guess.

What does that even mean in this context?

 

[Ewok Jerky]

And order AM labs, schedule appropriate follow up, make complex medical decisions, collect cultures, administer a wider range of meds, and yes suture and perform a more thorough H&P.

I think that there is a role for community paramedics in the setting of frequent flyers, hit them before they hit you. It would make EMS and EDs more efficient.

But from a cost of overall healthcare in the context of readmission to hospitals, having the ability of on scene EMS being able to triage to a PA/NP fly car, I think there is an absolute advantage to using them over medics.

 

[Akulahawk]

In a way, I think we're actually talking about 2 different kinds of community medicine. One kind is where a "trained someone" is sent out (via whatever mechanism pleases you) to evaluate specific types of patients and bring their specialty knowledge to the case. That visit may result in treatment or transport. The other kind is one where a "trained someone" is sent out to follow up after a visit to the ER, to fill the gap between ER discharge and a first visit by Home Health Nursing.

The first model may cut down on some ER costs because certain patients aren't seen by the ER. Those patients would be seen, evaluated, get referrals, possibly have a direct admit to a specific service... never seeing the ER from the get-go.

The second model may cut down on costs through limiting readmits. The visit would be frequent fliers or recently discharged patients that have diagnoses that are known to result in frequent return trips.

What I think would work would be both types of models running alongside each other. A patient calls 911, gets seen by a 911 medic who determines that this patient is more "clinic" level or specific dispatch crieria is met and an NP or PA unit is called to evaluate the patient. Dispo from that would be back to the street, referral generated to Primary Care, transport to the ER by 911, or consult and direct admit to a specific floor/unit by 911. The NP/PA unit shouldn't have to transport unless absolutely necessary as while it's ALS capable, it's job is basically screening. After a patient with certain diagnoses (or specific referral) is discharged from any of these services, a community unit (say a "community paramedic) then goes out to briefly meet with the patient to ensure that things are going OK. If something's amiss, then they might request an NP/PA unit for further follow up...

The one thing that may cause issues is that the NP/PA unit should have secure access to each of the area hospital EHR systems. That way the NP/PA can access appropriate records for any recent visits. In order to keep things separate, I'd think that the access would be mostly read-only so that records can't cross from one system to another through the intermediary NP/PA system.

"Mr. Jones, you've recently been seen at Mercy, Kaiser, and UC hospitals for the same complaint 6 times in the past week... and your labs/imaging/other diagnostics all look OK. What can we do for you?" That conversation could take place early or after discharge... however that may cause certain patients to start getting really angry...

 

[FiremanMike]

A few thoughts

1. I don't pretend to know why some of you have such an adversarial relationship with the IAFF, but some of you have some serious anger issues on that matter. Additionally, I've not seen anything from the IAFF against community paramedicine and they certainly aren't opposed to our members who are working in this capacity now.

2. I don't know what type of community paramedicine programs you guys are thinking of or seeing, but community paramedicine is not designed to be the primary access point, instead it's designed to be a followup. Maybe LAFD is doing something different, but here, you won't get the community paramedic if you call 911, you'll get a medic and likely a trip to the hospital. The providers and/or ED will then pass along potential cases for follow up to the community paramedic who will then go out and follow-up with the patient "hey Mr. Jones, I see we've been here 20 times this year, lets make sure we can't find a better way to help you..."

 

[GloriousGabe]

Where are they getting the money to pay PAs and NPs a full-time salary while seeing fewer patients?

 

[Carlos Danger]

Where are they getting the money to pay PAs and NPs a full-time salary while seeing fewer patients?

Do NP's in LA even make much more than the LAFD FF/PM's? I don't know for sure, but I kind of doubt it.

This is a pilot program being paid for by a grant from the mayors office. If it works out, I imagine the FD will solicit area hospitals to help fund it, as they would be the main beneficiaries......unreimbursed ED visits are very expensive.

Google is a great thing: http://ens.lacity.org/lafd/lafdreport/lafdlafdreport186498079_08252015.pdf