Community paramedicine is a locally designed, community-based, collaborative model of care that leverages the skills of paramedics and emergency medical services (EMS) systems to take advantage of collaborations between EMS and other health care and social service providers. Community paramedics receive specialized training in addition to general paramedicine training and work within a designated program under local medical control as part of a community-based team of health and social services providers.
Community paramedicine is making significant strides across the United States. Instead of automatically transporting every patient to a hospital, a new breed of paramedics is taking on new roles to respond to local needs and help patients get the care they need outside of hospitals. In many cases, this involves referring patients to nonemergency health and social services in cooperation with relevant professionals involved in the client's care. The goals of each community paramedicine program differ based on local needs.
In California, the city of Alameda is one of 13 jurisdictions that joined this exciting movement under a pilot program authorized this year by the state Emergency Medical Services Authority. The California Health Care Foundation provided support for the paramedics' in-depth training program.
The Alameda Fire Department launched its community paramedicine project in June with two key goals: easing unnecessary hospital readmissions and reducing 911 calls for nonemergencies — especially those that come often from the same patients.
For community paramedics (CPs) in Alameda, the scope of practice has changed modestly, with new protocols developed, approved, and monitored by our department's medical director. So in the city of Alameda, how does the role of a community paramedic compare to a traditional 911 paramedic? The key difference is that we have taken on an expanded role in the lives of our patients. Clients seen by CPs are the same or similar to those seen through the 911 system. But instead of spending 20 minutes on-scene with the patient plus another 20 minutes in transit to a hospital, we take responsibility for partnering with the client. We spend a lot of time thinking about game plans with them.
Even when we make progress with clients, setbacks are common. We've learned to be patient and adapt to the client's situation. Usually it's a waiting game, and only when the client is ready can we effectively use our tools. We are gratified to help clients gain control over difficult personal situations.
Client with a Familiar Face
When we first met Brad (patient names have been changed) in his home, he was lying on a soiled mattress wearing shorts and no shirt. His bed had no sheets, and his studio apartment was a mess. He was clearly embarrassed by his living situation. We enrolled him in the CP program as a "familiar face" and a "post-hospital discharge" client secondary to his diabetes. He had been to the hospital emergency department 12 times for alcohol-related problems in the first six months of 2015, with six visits resulting in admissions. We measured his vital signs and began medication reconciliation. Brad had more than 100 bottles of prescription medications in his apartment, and he had no idea how or when to take any of them. Some were many years old.
We asked Brad what he wanted, and then we aimed to establish a set of realistic goals. What he wanted most was to get rid of his soiled mattress and clean up his apartment. We noticed that he had a new set of sheets still in the original packaging. We asked why he had not put them on. He replied that he was in pain and depressed and could not summon the energy to do it. We looked at each other, gave a little shrug, and without speaking, started making Brad's bed for him. In looking around his living space, we noted that with a tiny bit of work, his place could be straightened up. We put a few things away, ran a vacuum cleaner through the living room, and brought all his dirty dishes to the kitchen sink. With each chore completed, Brad's spine straightened, and he displayed a sense of pride. And he began to help.
On the next visit, we found his apartment was still clean. He was wearing clean clothes and sitting at his desk using a computer. He told us that we had lit a fire under him just by listening and immediately helping. We told him that most mattress stores will take away an old mattress and dispose of it with the purchase of a new one. The following week he had a new mattress and bed set.
During the third week of our program, Brad decided he felt good enough to celebrate with a few drinks, which turned out not to be a good idea. He wound up in the ED with nausea and intractable vomiting, and we went there to visit him. We agreed to meet him later that afternoon when he returned to his house. We had a long discussion about alcoholism and gastritis. We mostly listened. At his request, we poured his last three bottles of beer down the drain. We talked about rehabilitation programs. He thought an inpatient stay would be most effective for him. We began making calls right away.
Brad has graduated from our program and not been back to the hospital in three months. He has remained sober. We drop by for an informal visit as often as our patient load permits. He is making plans to visit his new grandchild in Nevada. We could not be more pleased for him.
Finding New Energy
We met Helen in her apartment after she was discharged from the hospital with a diagnosis of respiratory failure secondary to congestive heart failure. She was virtually confined to bed due to obesity and depression. Her discharging physician said she would need to make significant life changes to stay alive. She told us she did not have the energy to make those changes and would accept the consequences. Without saying it directly, she clearly communicated to us that she was ready to die.
We began with a thorough medical and a bio-psycho-social assessment of her situation. We found a physician and a physical therapist close to her home in Alameda (her previous physician was 10 miles away). We arranged to have nutritious food delivered to her home through Project Open Hand.
We listened to her goals and made a few suggestions. She had been an accomplished watercolor artist, and she said she wanted to begin painting again. Our most important accomplishment was that Helen now felt that someone cared enough about her to visit and help her. She has graduated from our program and has not been back to the ED. She walks to her doctor and physical therapy appointments and has begun swimming twice a week.
Helen recently won a wonderful award for her watercolor works. We visit her often, and she continues to improve and says she is happy.
Newly minted community paramedics show their graduation certificates at an August ceremony in Alameda City Hall. From left to right: Paramedics Steve Lucero, David Wills, and Armando Baldizan, EMS/Community Paramedicine Coordinator Gail Porto, and Paramedics Mike Dewindt and Patrick Corder
Not only are community paramedics helping people who are slipping through gaps in the system, but we also are connecting local resources to one another. Networking is 80% of the job, and the other 20% is listening to the client. We are the boots on the ground, holding people accountable and helping with medical questions, referrals to needed resources, and sometimes just being present.
In only a few months of doing our part to increase health care system efficiency in Alameda, we've learned that one of the most effective tools we have to help our patients is simply showing we care.
Watch this video to learn more about community paramedicine.