Paramedics can play a bigger role in helping chronically ill patients in doctor- and nurse-deprived rural areas and even in cities, supporters of a national trend say.
The concept, called “community paramedicine,” has penetrated spots of Nebraska and Iowa so far, but experts say it has the potential to take off here, as it has in Minnesota and other places.
Paramedics, who have primarily been used for emergency services, can check on patients and reduce hospital readmissions, for which hospitals can be penalized under the Affordable Care Act. Community paramedicine also could reduce the number of “frequent fliers'' — repeated users of ambulance and emergency room services — and lower health care costs, proponents say.
In short, community paramedicine theoretically can make better use of paramedics, cut health care costs and provide basic medical services to underserved populations. In practice, the concept has been met with lukewarm responses from some home health care and nurses groups, which expect that community paramedics will compete with them and duplicate services. The movement also needs to persuade government and insurance firms to pay for the additional services.
No such program exists in Omaha, although Medics at Home, which includes the private Omaha Ambulance Service, is trying to start a community paramedicine test with a hospital or health agency.
“It's definitely something that's gaining momentum around the U.S.,” said Tom Townsend, chief operating officer of Medics at Home, which was founded three years ago to pursue community paramedicine opportunities.
The trend is gaining ground in some states and in at least a few Nebraska communities.
In Minnesota, Medicaid can be used to pay for community paramedicine services. North Dakota's Legislature this year allocated $276,600 to examine how community paramedicine might be deployed.
In Scottsbluff, Neb., Valley Ambulance Services and Regional West Medical Center have teamed up on a test project using both paramedics and home health nurses to occasionally visit the homes of patients just released from the hospital after suffering from pneumonia or congestive heart failure. The pilot program is funded by the ambulance service and hospital, and will report results after 100 patients have been seen in the community paramedicine program.
Bev Overman of Scottsbluff was hospitalized as she fought pneumonia in April. After her discharge from the hospital, she received four visits from paramedics, including Randy Meininger, who owns the ambulance service and is mayor of Scottsbluff.
Overman, executive administrator of the Oregon Trail Community Foundation, said she was shaken by her illness. She exercises a lot, gardens and isn't accustomed to being knocked flat by illness.
“It was scary,” she said, but she took comfort in Meininger's visits and found his suggestions helpful.
Overman, 67, overcame pneumonia. She called community paramedicine “an innovative concept of aftercare” and credited it with playing a role in keeping her from being readmitted to the hospital.
Community paramedicine should be tailored to the needs of the community, experts say. In San Francisco, it has been used to treat the homeless. In Fort Worth, Texas, it is utilized to cut the number of repeated visits to emergency rooms by certain patients, said Gary Wingrove, chairman of the International Roundtable on Community Paramedicine.
Wingrove said there were about 15 community paramedicine programs in the United States last year and more than 100 this year. “And so I think it's here to stay,” he said.
As shown by the Scottsbluff example, community paramedicine doesn't have to rely solely on paramedics. Communities might use emergency medical technicians, who have less training than paramedics, or other providers.
William Raynovich, director of emergency medical services education at Creighton University, said an early incarnation of the concept began in Alaskan villages 30 years ago, when community health aides started checking people's blood pressure, providing diabetes care and performing other services.
“You have to find solutions,” Raynovich said. He and Dr. Richard Walker of the University of Nebraska Medical Center have helped review a national curriculum for community paramedicine that provides more training for paramedics.
Paramedics in Nebraska are allowed to perform various airway maneuvers to assist a patient with breathing, gain intravenous access and dispense some medications, among other services. Emergency medical technicians are more limited in what they are allowed to do.
Last year the Nebraska Legislature changed the definition of emergency medical services to say that they provide “medical care” and not just “immediate medical care.” This nods to the emerging belief that such providers shouldn't be used solely for emergencies.
Dean Cole, the state's EMS/trauma program administrator, said state law would probably have to further clarify what community paramedicine is and what it can do before insurers would pay for the service.
The Nebraska Nurses Association and the Nebraska Association of Home & Community Health Agencies issued neutral statements last week regarding community paramedicine. The home health group said it would work with community paramedicine leaders to discuss how to deliver services within each group's scope of practice. The nurses group said it “is reviewing the role of community paramedics.”
Townsend, the Medics at Home executive, said he has no desire to compete with nurses or home health providers. Paramedics would provide short-term service, not long-term care, he said.
He added that ambulance services know people who use them multiple times a month for transportation to hospital emergency rooms, when often basic monitoring and care at the patient's home would suffice. Community paramedics could look in on those patients a couple of times a week, checking their blood pressure and other vital signs and assessing how they're doing, he said.
This would save thousands of dollars per “frequent flier” patient, Townsend said.
The Affordable Care Act penalizes hospitals that have excessive readmissions for certain diagnoses, and paramedic visits to patients' homes might reduce rapid returns to hospitals.
“So the timing is really right here for paramedics to step up and be part of the health care team,” Wingrove said.
Some other small-scale efforts in community paramedicine are evident in Nebraska and Iowa. In Oshkosh, Neb., a paramedic goes to the town's senior citizens center once a week to check people's blood pressure, blood sugar, heart rate and other health risk indicators. In Sumner, Iowa, paramedics perform occasional health screenings in the library and do in-home safety inspections for senior citizens.
Shirley Knodel, a vice president at Regional West Medical Center in Scottsbluff, said the population in her region is shrinking and getting older. “It's difficult to recruit physicians and nurses to rural areas,” said Knodel, a registered nurse. It's better for everyone if various medical providers collaborate, she said.
Dorothy Meier spent time in the Scottsbluff hospital a month ago because of fluid retention from congestive heart failure. Since she was released and returned to the assisted living center connected to the hospital, she has been visited a number of times by Mary Coon, a home health nurse and a participant in the city's community paramedicine project. Meier, 87, said she liked the visits from Coon, who monitored Meier's weight and checked her vital signs.
Meier said she feels good again and is eager to do things at the assisted living center.
“Anyway,” Meier said, “it's off to the next activity, whatever that is.”