Health care systems are struggling to provide integrated and accessible care that meets the needs of patients rather than providing a fragmented and poorly coordinated patient experience. For many people, the emergency care system accessed through 911 and the emergency department has historically been and remains the most reliable and rapid means of access. The problem is that it is also the most expensive health solution and unable to efficiently and effectively meet patient needs. The use of 911 and emergency departments as the access point to the health care system has resulted in stress on our emergency medical services systems and overcrowded emergency departments.
One promising solution for breaking the cycle of dependence on the emergency care system without increasing barriers faced by patients is to rethink the roles of existing frontline emergency response personnel. For the past two years, California has been pilot testing models of expanded roles for paramedics that extend the reach of health care and social service services. This new role is called “community paramedicine.”
Paramedics are widely distributed in most communities and available to rapidly go to the patient 24 hours a day, 7 days a week, 365 days a year. They are highly trained and trusted to make quick decisions for lifesaving interventions using invasive procedures and a large formulary of medications. They also evaluate and triage patients to decide the best facility to provide the emergency care needed, such as a trauma or stroke center. They go into every part of the community and work with the entire spectrum of the population. But current laws restrict their practice to responding to an emergency and transporting patients to an emergency department.
The pilot program in community paramedicine being run by the California Emergency Medical Services Authority collaborates with local emergency medical services (EMS) agencies, public (fire departments) and private paramedic providers, and health care organizations to identify needs and to bridge gaps in local health systems. The projects integrate and support existing resources without displacing any other health care personnel. The projects include:
Post-hospital discharge: Community paramedics visit patients within 48 hours of hospital discharge for certain chronic conditions to ensure that patients understand discharge instructions, have sufficient medications and are taking them as prescribed, have scheduled follow-up with primary care and specialists, and evaluate the need for additional support services. Patient care is transferred to home health care when patients are eligible. This project has resulted in lower rates of hospital readmission and more successful transition from inpatient to outpatient care.
Frequent 911 users: Community paramedics identify frequent 911 callers and emergency department users and provide case management to link these patients to primary care, mental health services, substance abuse treatment, food, housing assistance, transportation assistance, and other services that can address patients’ needs more effectively than the EMS system. These projects greatly reduced the number of times that enrolled patients called 911 and were transported to an emergency department.
Tuberculosis therapy: Community paramedics collaborate with public health staff to administer directly observed tuberculosis therapy to patients who cannot come into the public health clinic during regular hours or are particularly hard to reach. Paramedics can reach patients that are not accessible to community health workers or public health nurses.
Hospice care: Community paramedics respond to 911 calls from hospice patients or their families and evaluate the need for transport to the emergency department. The paramedic will determine whether the problem can be managed at home, communicate with the hospice nurse, and provide pain medication if needed. These programs have helped support patients’ end-of-life decisions to remain in their homes and decreased visits to the emergency department by providing a care bridge until the hospice nurse could make a determination about next steps for the patients.
Psychiatric crisis care: Community paramedics transport a person experiencing a behavioral health problem directly to a crisis care center. Typically, all people with behavioral health issues that result in a 911 call are transported to the emergency department for medical screening before being transferred to a mental health crisis center. This routinely results in a delay of many hours to receive the needed mental health evaluation. In this project, community paramedics perform the medical screening in the field and, if no medical intervention is needed, take the patient directly to a psychiatric crisis center for evaluation. This has resulted in many of these patients avoiding unnecessary emergency department visits and more rapid definitive care for their behavioral health problem. This also frees up law enforcement personnel who must otherwise accompany the patient to the emergency department.
Sobering center: Community paramedics transport inebriated people directly to a sobering center. Usually, intoxicated patients for whom 911 is called are taken to an emergency department or to jail until they are sober. Patients taken to a sobering center are monitored by nurses much more closely than in a busy emergency department and certainly more closely than in jail. Moreover, patients are offered a range of social services and referral to detoxification programs. Community paramedics in the pilot program screen intoxicated patients and transport them directly to a sobering center if they meet the admission criteria.
Independent evaluation of the pilot projects indicates that community paramedicine programs are improving the efficiency and effectiveness of the health care system. These pilot projects have demonstrated that specially trained paramedics can provide services beyond their traditional and current statutory scope of practice in California. The projects are enhancing patients’ well-being by improving the coordination of medical, behavioral health, and social services, and are decreasing health care costs by reducing ambulance transports, emergency department visits, and hospital readmissions. The results of the project evaluation are available at Healthforce Center at UCSF.
The California projects are not demonstrating all the potential roles of community paramedics. There are community paramedicine programs in most other states and in other countries that provide additional services. The programs have especially great promise for rural or inner-city areas that are underserved by health providers. For example, in some programs outside California, paramedics serve as outreach for primary care providers and support preventive services such as immunizations or home visits where there is no home health nursing program.
In addition to improving health care delivery, there are other benefits to community paramedicine programs. The additional training and new role provides an opportunity for career advancement for EMS personnel and a transition or alternative from the emergency response role that results in high degrees of stress and burnout. For community paramedic programs to continue to operate, California law will need to be amended to authorize these programs. Making full use of California’s paramedic workforce is one solution to addressing unmet community care needs through augmentation and coordination with existing services.
Howard Backer, MD, MPH, FACEP, is director of the California Emergency Medical Services Authority (EMSA), which establishes and enforces standards for Emergency Medical Services (EMS) personnel, coordinates with local EMS systems, oversees development of statewide care systems, and prepares for and responds to disasters. Backer previously served at the California Department of Public Health, where he was chief of the immunization branch and was interim director and interim state health officer. From 2008 to 2011, Backer was associate secretary for emergency preparedness at the California Health and Human Services Agency. Before government service, Backer practiced emergency medicine full-time for 25 years in rural, urban, and suburban settings. He received his medical degree from the University of California, San Francisco, and a master’s degree in public health from the University of California, Berkeley.