Community paramedicine (CP) 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.
In California, many people facing a terminal illness decide to sign up for hospice care. Hospice care focuses on relieving the pain and suffering sometimes associated with the final days and weeks of life, and is provided in a place of a person’s choosing, often in the home.
When someone is admitted to hospice, patients, family members, and caregivers are expected to call the hospice nurse, not 911, if anything unexpected happens. However, it is not uncommon for well-intended caregivers who forgot or were unaware of the hospice protocol to phone 911 in an anxious moment.
Paramedics and Hospice: Nontraditional Partners
The paramedics who work in our 911 systems are focused on saving lives. Hospice care is traditionally not part of their scope of practice, which is to transport patients to a hospital emergency department (ED). In most cases, paramedics and hospital emergency departments end up providing comfort care to these patients when they could have gotten the same care at home from their hospice team — if only the hospice team had been called instead.
The Ventura County EMS/Hospice Partnership Project was designed to blend the 911 paramedic system with the hospice system to provide better care for patients with terminal illnesses. The concept is to train experienced paramedic supervisors to be community paramedics using a curriculum that focuses specifically on hospice care. The county’s three emergency medical services organizations are participating: American Medical Response, Gold Coast Ambulance, and Lifeline Medical Transportation. Their paramedics learn about the dying process, grief support, medications that relieve suffering at the end of life, and more. As a result of this training, when someone in Ventura calls 911 to help a hospice patient, these community paramedics respond and work with the patient, the family, and the hospice team to care for the patient’s immediate needs in the comfort of their own home.
A 911 Call from a Patient with Terminal Cancer
Our team’s first call came from a 56-year-old woman with terminal breast cancer who had fallen at 3 a.m. while going to the bathroom. Although uninjured she called 911, as she was too weak to get back to bed. The community paramedic arrived with the fire department and a paramedic ambulance and helped her back to bed. The fire crew and paramedic ambulance went back in service while the community paramedic stayed to visit with the patient.
He learned that she had a daytime caregiver but was alone at night. Later that morning when the caregiver arrived, they spoke about the patient’s fall and the issues raised by her being left alone. The caregiver shared the concern and had tried to give the patient enough medication to sleep through the night until the caregiver could return the next day. This strategy was well-intentioned but not medically reasonable or appropriate.
They contacted the hospice nurse and learned that a cousin in Northern California was covering the cost of the daytime caregiver. They set up a three-way call with the cousin and explained the situation to him. He said that he was happy to pay for a nighttime caregiver too, and they arranged for someone to begin that night. Five nights later she died while holding the hand of her nighttime caregiver.
Providing Support and Filling a Care Gap
Before this project started, just over 80% of hospice patients who had 911 called on their behalf were transported to the hospital. Since the program’s inception, transports of hospice patients have dropped below 40% and have stayed at that level for more than a year.
When we started this project, we anticipated that most of our work would be administering medications for pain, nausea, and breathing difficulty to help patients be more comfortable. It turns out that less than 2% of the calls have involved the use of additional medications. On most of these calls, our community paramedics are providing hospice education, supporting families, providing grief support, and helping to fill the care gap until the hospice nurse can arrive and take over care.
Our positive experience with this program suggests that these kinds of partnerships should be spread across the country and wired into all of our 911 paramedic and hospice programs.
Mike Taigman is project manager of the Ventura County EMS/Hospice Partnership Project and the improvement guide for FirstWatch, an emergency services data analysis and performance improvement company based in Encinitas, California. Mike has focused for more than 40 years on making improvements in emergency medical services in the US, Canada, Europe, Israel, Palestine, and Australia. He is an associate professor in the Emergency Health Services master’s program at the University of Maryland, Baltimore County, and is a faculty member of the Institute for Healthcare Improvement.