Urgent care on wheels

[Summit]

JP: I agree with that, as I mentioned how EMS perceives emergency medicine is far different than "how the ED is forced to deal with" the real patient load.

My last comment was mostly regarding a common theme of cognitive dissonance in EMS when faced with non-acute patients versus when faced with perceived turf battles.

 

[Veneficus]

EMS and the primary care turf war

I think there are 2 issues in play here.

1. I think primary care is an outdated medical modality. The way it is set up and functions does not serve the population very well. As such, the ED has become the entrance to the medical system.

The ED is not set up for, nor optimal for this population. Not to mention it is wickedly expensive.

You can flood a system with primary care, but if it doesn't work for people, it won't matter how much of not working you have.

2. Prevention vs. response.

The amount of people requesting EMS or rather the amount of the same people request EMS is so great that a response only system is only going to be overwhelmed. (which we see everyday in the US)

In order to resolve this system overload, some type of prevention or pre-emptive response is going to be required.

Whether or not EMS is ideal for it doesn't change that EMS is currently best positioned for it.

Other providers, no matter what level, have basically excluded themselves from this mission based on current reimbursement and legal realities.

But that doesn't address the need.

As such, the goal of community paramedicine is to save money ad reduce response in an ineffective system. Undoubtably nurses or others are better educated and would provide a higher level of healthcare.

But they are not going to do it for the price of a paramedic. These "advanced" providers have basically priced themselves out of the market.

You can brag about the superior performance of sports cars all you like, but when all you have is the budget for economy, the performance measure is moot.

 

[Summit]

As such, the goal of community paramedicine is to save money ad reduce response in an ineffective system. Undoubtably nurses or others are better educated and would provide a higher level of healthcare.

But they are not going to do it for the price of a paramedic. These "advanced" providers have basically priced themselves out of the market.

Should it be done for the price of a paramedic? Not if the price justifies more care. We've already discussed that two medics and an E450 ambulance is pricier than a nurse, NP/PA, or even a physician in a Toyota Corolla.

The success of CPs seems grand if you go with, for example, the ECAD program of "Free CP visits. Free. FREE! CALL US WHENEVER! REALLY! NO CHARGE!" But is that viable?

Of course RN, midlevel, and physician as a mobile community health provider would each offer a (variable) increase in level of care at increasing cost. What makes sense?

I think having all of those providers in the program makes sense! My BSN RN/midlevel/physician in a Toyota is reality:

I'll point to a long running viable program with a track record of success (that I bet nobody here has heard of). That is, the VHA Home Based Primary Care (HBPC) program. “HBPC is comprehensive, longitudinal primary care provided by a physician-supervised interdisciplinary team of VA staff in the homes of veterans with complex, chronic, disabling disease for whom routine clinic-based care is not effective. “ It was started in 1970, originally as a palliative and primary care program. In quickly grew into a proactive community health program for qualified veterans with the goals of increasing care while decreasing cost. Increased care (and qualifications) comes by targeting it at known disadvantaged veteran populations, particularly those who are unable to travel to care. Decreased cost comes through preventative care that has demonstrably decreased both hospital admissions, lengths of stay, acuity, and non-institutionalization in the HBPC patient population.

The HBPC program is actually multi-discipline with RN/NP initial assessments, physician referral, RN/NP follow up (depending on disposition), and referral to RD, psychology, and OT as necessary. This program is aimed at preventing exacerbations of chronic conditions through monitoring, education, assessment, medication refills, all of which could lead to 911 calls and in-patient stays, or institutionalization in a ALF/LTC. The program has demonstrated better outcomes for the veterans served by it and a cost savings to the VA institution. The only thing stopping a similar model from being applied to the general public is a lack of will.

 

[Veneficus]

Should it be done for the price of a paramedic? Not if the price justifies more care. We've already discussed that two medics and an E450 ambulance is pricier than a nurse, NP/PA, or even a physician in a Toyota Corolla.

Yes, that is true, but it is not so easily compared. When you have 2 medics and an ambulance and you add other resources, it is not cheaper.

I wouldn't say the medic model really has the goal of adding care, but primarily to reduce the needfor emergency care, thereby lowering call volumes. That is where the money is saved, not earned.

It basically gives already existing response persons work to do when not responding to prevent calls and thereby allow for less response resources.

I think home healthcare (from all disciplines) is absolutely vital for effective primary care. But as I said, the current primary care system in the US doesn't work, and other countries who use the same model are seeing it stressed or ineffective.

Medical practice must evolve with society in order to maintain value, it doesn't.

The success of CPs seems grand if you go with, for example, the ECAD program of "Free CP visits. Free. FREE! CALL US WHENEVER! REALLY! NO CHARGE!" But is that viable?

Depends...

It will not be self supporting. The money will likely have to come from some form of tax somewhere.

However, not charging a patient for any medical service out of pocket maintains that person's wealth. Which maintains the maximum level of independance without additional support. That prevents asset liquidation for medical care, reatains large assets like homes, which can be passed on to family and friends, so their productive years grow wealth instead of needing to replace it. Wealthy societies require less medicine. It is an interesting economic circle.

In the short and direct term, is having a paramedic or two that on down time drives around installing fall precautions, making sure medications are refilled, and the patient understands and is taking them correctly (the later being a core nursing role currently unfulfilled except for a minority of peopl who "qualify" for this.) cheaper?

An example I like to use, paramedic A knows there is an elderly lady in his response area. (it is always a lady cause the men die years before) This medic has been to the house many times, the lady cannot reliably go to appointments, get to the store, etc. Perhaps she has live in family, perhaps not, doesn't matter.

So once a month she goes into acute CHF exacerbation. This known, baseline, call volume adds the need for more ambulances in the area. (costs $) The ALS ambulance to the ED, ICU admit, and day or two in the ward. (costs a lot of $)

How much would be saved having the paramedic and partner stop by during lower call volumes and maybe bring her $3 of lasix with them. Not that they prescribed, but are simply picking up from the pharmacy like any other friend or family memeber. (thousands of $ a month on 1 person)

Let's say you just plan to liquidate her lifetime middle class assets. (much greater than poor or working poor) put her in an SNF, and she lives 20 more years. Her assets will never cover that cost. In a healthcare environment, she will be sick more often, additional treatment and costs. Over those 20 years, even spending everything she has, somebody (aka tax payers) will be on the hook for 10's of thousands if not 100's of thousands.

Leaving her family to work to reproduce such assets from 0, when they are elderly, this cycle of heavy $ loss repeats.

If her family were wealthier, they would get sick less often, lss severe, maybe have money for healthy food, less destructive outlets (drinking and smoking) and time to exercise. Further reducing healthcare expenditure over time. (it is not individual, once these people are out of the workforce, they become medicare/medicade) when that is an MI at 50 or COPD at 50 instead of osteoporosis at 80 or 90, you add decades of tax funded healthcare costs.

Does free community paramedicine sound more viable?

It certainly does to me.

Of course RN, midlevel, and physician as a mobile community health provider would each offer a (variable) increase in level of care at increasing cost. What makes sense?

Yes it would. to the immediate population, and as I said, ultimately I think to maintain value to society.

But the short term reality is that it is simply too expensive to implement.

I think having all of those providers in the program makes sense! My BSN RN/midlevel/physician in a Toyota is reality:

It happens all over the world.

The thing is though that the VA system is seperate from the overall US system and operates under different rules, with a different population, and a different economic reality. It is not part of the general healthcare market.

The general healthcare market in the US would benefit from many of the VA ways of doing things. But somebody would have to pay. Additionally, there are many very wealthy and powerful competing interests who stand to lose a lot if those changes are implemented. They will not go down without a fight for their life.

 

[abckidsmom]

The trouble with what you're saying, Vene, is that it's boring. People don't get into EMS because they want to go around helping people have a good plan for taking their meds. Nor to scan the houses for throw rugs or smoke alarms.

They want to *save lives*, dangit! And what you are suggesting is just lame! /sarcasm.

In all the medics I have ever known, I can think of less than a dozen who would happily let that be their job forever.

 

[Veneficus]

The trouble with what you're saying, Vene, is that it's boring. People don't get into EMS because they want to go around helping people have a good plan for taking their meds. Nor to scan the houses for throw rugs or smoke alarms.

They want to *save lives*, dangit! And what you are suggesting is just lame! /sarcasm.

In all the medics I have ever known, I can think of less than a dozen who would happily let that be their job forever.

That has been my experience also.

But here is something to think about:

Have you ever heard a frefighter suggest not giving out free smoke detectors or doing fire inspections so they can have more exciting calls and save more lives?

Have you ever heard a LEO suggest not patrolling, writing tickets for speeding, dui, etc. Have you ever heard of LEO wanting to scrap DARE programs so they can make more drug arrests?

Military medics, do you spend more time in life and death combat saves or handing out 800mg motrin and antibiotics?

Who do these paramedics think they are that they are only around to save lives? What feeble skills do they think they have to do it?

 

[Wheel]

The trouble with what you're saying, Vene, is that it's boring. People don't get into EMS because they want to go around helping people have a good plan for taking their meds. Nor to scan the houses for throw rugs or smoke alarms.

They want to *save lives*, dangit! And what you are suggesting is just lame! /sarcasm.

In all the medics I have ever known, I can think of less than a dozen who would happily let that be their job forever.

This is the reason I think so many medics burn out. They expect the life saving, but the vast majority of what we do is far from it. I think if paramedicine wants to survive (or thrive) then they need to embrace this population. We are already responding to these calls, and will continue to for the foreseeable future. Community health RNs are wonderful, but the fact is that people still call 911 for primary care complaints, so I think it's our duty to tailor our education and response to better serve our patient population. I doubt anyone would argue with that.

 

[Summit]

In the short and direct term, is having a paramedic or two that on down time drives around installing fall precautions, making sure medications are refilled, and the patient understands and is taking them correctly (the later being a core nursing role currently unfulfilled except for a minority of peopl who "qualify" for this.) cheaper?

Whenever they aren't busy is like pissin on a fire. Even if we don't talk about which is better, which is easier? Improving availability for home based primary care and home health nursing? Or expanding paramedics to non-EMS roles?

How much would be saved having the paramedic and partner stop by during lower call volumes and maybe bring her $3 of lasix with them. Not that they prescribed, but are simply picking up from the pharmacy like any other friend or family memeber. (thousands of $ a month on 1 person)

Again it comes to the insanely broken nature of primary care... why the hell is the system so broken that we need to put a parabandaid on it and want to call it an acceptable solution?

I guess the real question is, how about that downtime? Are those paramedics out of service when they are half through her med box and a 911 tones out for their area? We know the truth about response times, but when grandma Phyllis strokes out and it take the medics 5 minutes longer to respond because they had to extricate themselves from their "downtime duties" in aunt Florences medicine bin, someone is going to complain, or sue, etc because perception is reality.

Does free community paramedicine sound more viable?

Sure. So doees free community nursing. Except the CHRNs got into the field to fulfill that exact role, not have it be "slow duty."

The thing is though that the VA system is seperate from the overall US system and operates under different rules, with a different population, and a different economic reality. It is not part of the general healthcare market.

The general healthcare market in the US would benefit from many of the VA ways of doing things. But somebody would have to pay.

If we are talking about altering the national or regional health system models with bandaids like CP, and we are talking about paying for free CPs (like the grant funded ECAD CP program) then why not do it with CHRNs or a VA HBPC physician managed model?

 

[Summit]

Who do these paramedics think they are that they are only around to save lives? What feeble skills do they think they have to do it?

They think they ought to be doing "fun and exciting things" for their $16/hr. That's why street medics last 5 years on average; they get tired of drunks and BLS runs.

 

[Wheel]

They think they ought to be doing "fun and exciting things" for their $16/hr. That's why street medics last 5 years on average; they get tired of drunks and BLS runs.

Agreed. I wish we could do a better job preparing people for what the job entails, rather than what we want people to think we do.

 

[Veneficus]

Whenever they aren't busy is like pissin on a fire. Even if we don't talk about which is better, which is easier? Improving availability for home based primary care and home health nursing? Or expanding paramedics to non-EMS roles?
Again it comes to the insanely broken nature of primary care... why the hell is the system so broken that we need to put a parabandaid on it and want to call it an acceptable solution?

I definately don't call it an acceptable solution, but it is better than nothing.

The other thing we have to keep in mind is community paramedicine whether in Texas, Carolina, or Montana is funded locally. Local economies do not have the resources to fix US heathcare. They have the ability to add a local band-aid.

For the forseeable future it is band-aid or no-aid.

I guess the real question is, how about that downtime? Are those paramedics out of service when they are half through her med box and a 911 tones out for their area? We know the truth about response times, but when grandma Phyllis strokes out and it take the medics 5 minutes longer to respond because they had to extricate themselves from their "downtime duties" in aunt Florences medicine bin, someone is going to complain, or sue, etc because perception is reality.

The reality is people demand unrealistic response times when they call. If all of your units are busy, then you will have to add more units in order to meet these unrealitic measures ad demands. There will be less downtime for all.

Eventually your call volume demands will make response times impossible on your budget. (this is seen in every major city every day)

So you can increase the units on the road by 5 or 10% Maybe even 25% in order to meet response times and provide preventative care.

Alternatively, you could constantly have to be adding to your resources to meet increased demand.

Sure. So doees free community nursing.

Yes but communities cannot afford nurses at their salary demands. In areas where EMS is provided by govt agencies, EMS also enjoys increased legal protection against legal action.

From the private EMS standpoint, the operating loss seems to be justified by the maintaining either less resources and/or maintaining profit margins from people who actually pay. The town drunk not on medicare/cade who calls once a day still needs to be responded to per your contract. Those yearly response time summaries don't differentiate who calls or how often.

If we are talking about altering the national or regional health system models with bandaids like CP, and we are talking about paying for free CPs (like the grant funded ECAD CP program) then why not do it with CHRNs or a VA HBPC physician managed model?

But we are not talking about national or regional change. We are talking about what is locally affordable.

If you do talk regional/national, you are still talking about paying much higher priced providers at a time when cost savings is a higher priority than effectiveness.

Revamping primary care and all the things I talked about in asset retention require no out of pocket expenses, at the national level that can only come from 2 sources. A complete government controlled health system or a government subsidized private health system. The later is what the US has now, how is that working out?

There is simply not the political will to overhaul the current US health system. It will take bodies in the streets before there is.

 

[Summit]

I can't disagree with what you are saying, but I can disagree that we should be resigned to doing what is easy if it is not best.

 

[Veneficus]

I can't disagree with what you are saying, but I can disagree that we should be resigned to doing what is easy if it is not best.

Then we are in agreement.

I have just given up that the US and its leadership will do what is best.

 

[mycrofft]

Sort of reminds me of the cattle barons who fought losing open range, and the replacement of cattle drives by the railroads building further west. Keep the old and inefficient model because it's what you can excel at and shun the more civilized one because some new pup will come in and do it better.

There will still be places for rescue and daring-do, just not on our city streets.

 

[Bieber]

As a current CP student, I found the responses to this thread interesting to read. A lot of good ideas, critiques, and observations.

As part of my program, we have to develop an assessment of our own communities and determine the gaps in the local health care system and how a community paramedic program would fill those niches. Working in a large, urban community, I immediately realized that a CP takeover of home health was not a feasible option... There are already tons of home health aid services available, and we'd be competing against every one of them with a much smaller CV to support our cause.

What I DID notice, however, was that in spite of the high number of home health services, we in EMS still encounter what seems to be a high number of patients whose needs are not currently being met. One of the things I will be attempting to determine is whether those home health services are too costly for the uninsured/under-insured or whether the services provided by those agencies are not sufficient to meet the needs of the patients. I suspect the former is more likely but we'll see.

I also oftentimes encounter patients who don't necessarily need EMS transport to an ER, but who would benefit from a followup by some sort of medical provider; or those who refuse transport despite being in a critical condition. I think that these kinds of patients might benefit from aftercare that could be provided by a CP. I also believe that there is a fair sized subset of patients who require immediate or urgent care, but care which could also be provided in a more cost-effective manner than EMS transport to an ER.

Ultimately, the EMS system is broken; it's wildly cost-ineffective, lacking in evidence in a good number of respects, and really our patients deserve more than what they're getting. We won't undo the last forty years of teaching people to call 911 for any and everything under the sun, nor will we be able to improve health care resources outside of our sphere of control, but what we CAN do is increase the bang for the buck in our own industry. Less transport, more treatment, followups, referrals; those are all areas where I personally believe CP programs can lead the way and pave a path toward the widespread adoption of these modalities. Community paramedicine, in my humble opinion, has more to do with improving EMS and ushering in the transformation from emergency medical services to mobile health services than it does with trying to take over the job of anyone else. I don't have any numbers to support it, but it seems to me that the majority of our jobs are more urgent care/primary care based, but paradoxically we have almost no treatment modalities or education in handling them. Community paramedicine, then, isn't about replacing existent primary care providers or home health care providers as much as it is about meeting the needs of our own patients.

Home health nurses are fine, and I don't want to take over their job or the job of any other health care provider, but at the same time I want more options for my patients than to just take them to the ER because we don't have any other care pathways available to us. If a patient is a repeat 911 user because they have a home health problem but no way to afford home health, then the solution is not for us to keep transporting them to the ER over and over again. Whether that's working with a particular home health agency to provide that care for the patient pro bono or us providing that care for them ourselves, as long as we're improving their health and quality of life and doing it in a more cost-effective manner than by transporting them to the ER over and over, I'd call that a win. And that is what I see as the heart of community paramedicine and the future of paramedicine in general: creating cost-effective, evidence-based avenues to care that aren't limited to transport to the ER.

Finally, with regards to those who weren't fans of community paramedicine, I'd encourage us all to remember that EMS is a highly variable industry. In some places paramedics are firefighters first obligated to spend six months in a certificate academy so they can rotate through the meat truck, receive orders from RN's and have a very limited scope and cookbook protocols that they may NOT deviate from under any circumstances; in other places they are associate degree minimums with a scope limited only by their medical director and are expected to be independent, critical thinking clinicians that don't even routinely accept orders from on scene physicians. Because of that, the ideal model is going to be different from location to location depending on the capabilities of the local paramedics as well as of the local health care system. Is a CP program the right thing for every community? Absolutely not. Is it the right thing for some communities? I think so. That's why it's COMMUNITY paramedicine; the needs of the community define the role, scope, and mission of the program.

Like Vene said, paramedics are probably going to be the least economically burdensome model for a program such as this. Not necessarily the right ones in every instance, but neither will nurses or other providers be the right ones in every instance either. It doesn't have to be a nurse, or a paramedic or a mid-level, it just has to work and be cost-effective. But trying to paint EMS with a broad brush (less educated than nurses, less capable than other providers to do the job, etc) is a fallacy given how widely variable the educational level of paramedics is, both between regions and between individual providers.