In a closely watched pilot program, a cadre of specially trained California paramedics is demonstrating how innovative responses to gaps in access to care are improving patient outcomes and reducing costs. Known as community paramedicine (CP) or mobile integrated health, this approach offers policymakers the ability to increase access to medical care and community resources by training existing personnel to perform expanded roles.
I lead the team that is performing an independent evaluation of the community paramedicine pilot program. Our team, based at the Philip R. Lee Institute for Health Policy Studies and the Healthforce Center at the University of California, San Francisco, recently released data on the first year of pilot project operations, and the results are very promising.
Californians appear to be benefiting from these new models of health care. We found that hospitals, ambulance providers, Medicare, and Medi-Cal all experienced notable financial benefits. Our analysis of the projects’ data and interviews with community paramedics across California revealed many examples of how partnering with patients, rather than simply transporting them to emergency rooms — often repeatedly — is yielding positive results. The findings suggest that the benefits of CP programs will grow as they mature, solidify partnerships, secure stable funding, and find their optimal structure and niche.
Paramedics are uniquely positioned to help address gaps in access to care because they are trusted and accepted by the public. Paramedics are also trained to make health status assessments and to recognize and manage life-threatening conditions outside of the hospital. They are licensed health professionals who operate under medical control as part of a system of care and are available round-the-clock, every day of the year. At least 33 states operate community paramedicine programs.
California’s Health Workforce Pilot Projects Program
California began testing this innovative approach in jurisdictions across the state in 2014, under a visionary program known as the Health Workforce Pilot Projects (HWPP) Program that offers our state the flexibility to test expanded roles for health professionals under controlled circumstances. Begun in 1972 and administered by the California Office of Statewide Health Planning and Development (OSHPD), the program provides pilot sites with a safe harbor from scope of practice laws in order to test and evaluate new, innovative models of care. In all, OSHPD has approved 123 pilot projects, 117 of which were implemented. Seventy-seven HWPPs have resulted in changes in law or regulation that have expanded the scope of practice for a variety of licensed health professionals.
Conducting an HWPP is essential for testing community paramedicine in California, because paramedics’ statutorily permitted scope of practice limits them to delivery of emergency medical care to sick and injured persons at the scene of an emergency, during transport to a general acute care hospital, during interfacility transfer, and while in the emergency department (ED) of a general acute care hospital.
Thirteen California Projects
Through September 2016, the 13 community paramedicine pilot projects in California assisted 1,462 people. The pilot projects are testing the use of paramedics in six expanded roles — each designed by the local emergency medical services agency to meet local needs and approved by the state. An additional project will begin testing a seventh concept later this year. At the state level, the projects are sponsored by the California Emergency Medical Services Authority. The map below shows where the pilot projects are being carried out.
Under this HWPP, paramedics are involved in a variety of expanded roles, including:
Transporting 911 callers with serious mental illness to a behavioral health treatment center
Helping patients avoid readmission following a hospitalization
Helping people who frequently use 911 to obtain behavioral health, medical, housing, and social services that can reduce their need for transport to an ED
Ensuring that people with tuberculosis receive all required treatments
Collaborating with hospices to help them honor patients’ wishes for end-of-life care
Our evaluation is assessing outcomes across three domains: safety, effectiveness, and costs/savings. Among many benefits, we found that five of the tested concepts demonstrated favorable results by:
Expediting care for people with mental illness, which permits law enforcement officers to focus on other duties
Reducing 30-day inpatient readmission rates
Improving patients’ understanding of medication and dietary requirements and fostering patient adherence to prescribed treatments
Reducing ambulance transport for frequent emergency medical services users
Accelerating patient referrals and improving coordination among providers of housing, domestic violence services, drug and alcohol treatment, food assistance, home health care, and mental health services
Reducing the number of missed doses of medication among tuberculosis patients, which lowers their risk of transmitting TB to others or acquiring a drug-resistant strain of the disease
Helping hospices honor patients’ wishes by reducing the incidence of unwanted transport to emergency rooms
One concept being tested in three sites — the transport of 911 callers to urgent care centers — enrolled too few patients to yield conclusive results.
Patients enrolled in pilot projects testing the five concepts for which sufficient data are available to draw conclusions did not experience any adverse events. These projects also reduced health care costs by reducing ambulance transports, ED visits, and inpatient admissions. Savings accrued to health insurers, particularly Medicare and Medicaid, and to hospitals and ambulance providers.
The results make clear that California’s existing emergency medical services network is well suited to adopt the community paramedicine functions. The two-tiered system of local management and state regulation enables cities and counties to tailor programs to meet local needs, while state oversight protects patient safety. Our evaluation is continuing, and updated findings will be released later this year.
Janet Coffman, a health services researcher and associate professor at the UCSF School of Medicine’s Institute for Health Policy Studies, strives to build bridges between academia and policymakers. She has co-authored articles and reports on health workforce shortages, geographic maldistribution, and lack of racial and ethnic diversity among health professionals. Janet has published in a wide range of journals, including Health Affairs, Health Services Research, the Milbank Quarterly, and Pediatrics. Janet received a doctoral degree in health services and policy analysis as well as a master’s degree in public policy from the University of California, Berkeley. She previously worked for the US Senate Committee on Veterans Affairs, the San Francisco Department of Public Health, and the UCSF Center for the Health Professions.