Designer of Paramedicine Pilot Says Safety Is Job One

Avram Goldstein, Senior Engagement Officer

September 14, 2017
Avram Goldstein
Avram Goldstein

Community paramedicine is a locally designed health care model in which paramedics and emergency medical services (EMS) systems collaborate with other health care and social service agencies to provide patients with the right care at the right time. California community paramedics receive extra training, and work under local medical control in six different models in 12 existing pilot programs statewide.

Dr. Kevin Mackey, a paramedic turned emergency physician, designed and implemented the model in Stanislaus County. The project employs community paramedics who assess patients with mental health conditions and, when possible, connect them to treatment resources faster than if they were transported to a hospital emergency department (ED). Patients enrolled in Medi-Cal or who are uninsured and who pass medical and mental health assessments can be taken directly to a mental health facility without having to stop first at an ED, saving time and resources. This interview has been lightly edited and condensed for clarity.

Dr. Kevin Mackey
Dr. Kevin Mackey, medical director of Mountain-Valley EMS Agency in Modesto (photo: Avram Goldstein)

Q: The Stanislaus community paramedicine project was your brainchild, and it's now two years old. How is it going?

A: By any measure, I would call the model successful. We have accomplished what I set out to do — show that a trained, skilled paramedic can safely and effectively screen and evaluate a patient suffering a mental health crisis and safely redirect that patient to a psychiatric facility instead of to the ED. In Stanislaus, we have the largest enrollment of any community paramedicine pilot program. Our pilot has now surpassed 910 patient contacts, of which 190 patients were successfully screened, cleared, and taken to a behavioral health facility. Our local health care system would otherwise have spent an average of $5,500 on each of those patients.

The biggest improvements involve increased speed to definitive care. In emergency medical services, we talk about time-sensitive conditions like strokes, heart attacks, and trauma, and about the importance of getting the right person to the right place at the right time. In this program, they get face to face with an appropriate behavioral health specialist at the right facility. We had a recent case where a suicidal person was taken to the nearest available ED, and it took 13 hours before he was evaluated. In my program, it would have taken 20 minutes. And speed matters, because the faster you can get someone their mental health care, the faster they will get better. Speed to definitive care is probably the single biggest advantage regarding outcomes.

Q: What has been the most striking result of the Stanislaus behavioral health pilot?

A: The biggest surprise is the broad support we've had from all levels of government, starting with the chief executive officer and chief operating officer of Stanislaus County, the mayor of Modesto, the CEOs of the local hospitals, the director of behavioral health and the public health officer for the county, and just recently, support from our law enforcement partners. In 2016, roughly 1,200 individuals were transported by Modesto police to the ED for psychiatric care. The sheriff and police chiefs of both Modesto and Turlock are all in on better addressing this population's needs. The Modesto chief and I met with the top three officers of the department to discuss how we can integrate with law enforcement even more than we already do, and this helps them by returning the officers back to duty faster.

In Modesto there is a new partnership between the police and fire departments to case-manage high-volume users — the individuals who call so often that the responders know them by name. Most of the time, these individuals need access to resources like housing, clothing, medicines, health care, primary care — just basic human needs. This program is designed to get them the resources they need, which improves the patient's quality of life and decreases demand on the 911 service. San Diego has a program that focuses on the cadre of 30 to 50 people who hit the 911 system a total of 5,000 to 10,000 times a year. These individuals call every other day. If communities can help those individuals get the resources they need, it will free up law and emergency medical services providers to care for greater needs in the community.

This example shows how community paramedicine models can be tailored to solve unique local problems. No two are identical. So while we're already running a community paramedicine behavioral health diversion model, the frequent user model is happening organically. If an individual frequently makes demands on the system and the program knows him, community paramedics can collaborate and meet with him to engage and be proactive instead of reactive. Police and fire can address the community's legal and basic service needs while at the same time, we can address public health and behavioral health needs.

These paramedics are among the best in our community. They were hand selected for their exceptional skills and patient care prowess, and the police chief wants to use them in the future for quick response to tactical situations. Community paramedics can be available to police where they need someone immediately and embed with law enforcement. It's been great.

Q: What have been the biggest challenges to implementing the community paramedicine system?

A: In Stanislaus County, behavioral health bed space is inadequate. We could at least double the number of patients if there were more capacity. With more beds, the number taken directly to a behavioral health facility could easily exceed 400.

Statewide, the key task we need to address is persuading state officials to allow local EMS agencies under the direction of the state Emergency Medical Services Authority to train and integrate community paramedics into the system. Right now, there is no ability to do that outside of this special pilot demonstration project under the auspices of the Office of State Health Planning and Development (OSHPD), and that's unfortunate. We stand to make a big dent, but we can't do it until the regulations change. The lawmakers should open the gates to get this done.

Q: Is it difficult to train and manage the community paramedicine staff?

A: Community paramedicine is not a plug-and-play system, because every community has unique local needs, resources, and issues. We use a 96-hour course developed and recorded by UCLA. It's a broad-brush approach. UCLA built the foundation, and on that I built our program. That's the way it works in all community paramedicine projects — everything is tailored to solve local problems. In Stanislaus, we lost several community paramedics to promotions and job changes, and that caused a lull in pilot enrollment this year. But we just graduated a class of six, and they are on the road doing their thing. We're back to full strength.

Q: What makes community paramedics different from their colleagues?

A: Not every paramedic is cut out to do this kind of work. It's vastly different from what your average paramedic signs up to do when they enroll in paramedic school. It's like telling a thoracic surgeon to do dermatology for a while. All paramedics use their skill sets for patient care, but community paramedicine adds a twist of public health, social work, and primary care medicine to the mix.

Q: Is there public support for this approach?

A: The general public isn't really familiar with this kind of project. It flies under their radar. However, the patients themselves speak highly of it. They say they'd rather go directly to the behavioral health hospital.

Q: How has the health care industry reacted to the pilot projects?

A: The hospital administrators say they like it, although so far they have not stepped up with the hardest part of the whole program, which is the financial side. It's expensive to train paramedics and run this program on a day-to-day basis. My program has been helped greatly by donations from American Medical Response, a local paramedic provider, to the tune of nearly $750,000. I talk often with the hospitals about financial sustainability. The community paramedicine model that is most exciting to administrators would be postdischarge follow-up, which stands to save hospitals big money — seven digits — by avoiding preventable readmissions.

The California chapter of the American College of Emergency Physicians hasn't been outright opposed, but they have been extremely vocal about questioning whether it's safe. In projects throughout the state and the country, that question has been asked and answered. Community paramedicine is not only safe, it's essential as health care evolves and as changes come to our local health care economy. Treating people in the traditional way in doctors' offices and hospitals is really a thing of the past. We are now able to take care of people with technology in their living rooms or on the side of a highway — in pretty much any situation.

We should stop trying to cram our patients into this very traditional mold of transporting everyone to an ED. Community paramedicine is one way of moving in a new direction with out-of-the-box thinking using approaches that are safe and save money. It answers the triple aim, which is what the Institute for Healthcare Improvement has promoted and shouted from the mountaintops for the last decade. Community paramedicine answers all three elements of the triple aim: It improves the patient experience of care, improves the health of populations, and reduces the per capita cost of health care. A policymaker who understands the triple aim will know what I'm talking about.

Read about California's other community paramedicine pilot programs.