Community Paramedicine Models for Reducing Use of Emergency Resources

Traditional models of emergency medical services (EMS) generally involve rapid response to the scene, life-saving or stabilizing measures, and then transportation to an emergency department (ED) or other facility that can provide higher-level care. However, this model is not always a good fit for every situation when a person may dial 911. Not only is ED care expensive, but the ED may be providing a level of care that is not aligned with the patient's needs. In rural communities with limited EMS and ED capacity, community paramedicine can be employed to achieve both goals: conserve resources for emergent issues and provide more cost-effective, beneficial care to patients.

Payers are particularly interested in community paramedicine models that can reduce EMS use. The Centers for Medicare and Medicaid Services (CMS) has developed Emergency Triage, Treat, and Transport (ET3), a five-year, voluntary payment model that provides some flexibility to EMS providers in how they assess, manage, and resolve emergency calls. Awards for this model were announced in early 2020.

Arizona has also developed a model called the Treat and Refer Recognition Program, which provides urban and rural EMS agencies with greater flexibility to determine the appropriate destination for a 911 caller, including primary care or behavioral healthcare services. Once in the program, first responders are given enhanced responsibilities to assess the patient's condition and determine how best to proceed. First responders are still able to receive reimbursement even if the patient is not transported to the ED. EMS providers are advised to obtain community paramedicine training to strengthen their application to the program.

Frequent EMS Callers

A study by the Rural Policy Research Institute and Stratis Health reports that 5% of patients account for 25% of emergency department visits in the U.S. These patients, called “super-utilizers,” often have complex health issues that may be compounded by significant social, mental health, or physical resource needs that make it difficult to manage their conditions. As a result, they bounce between home, the emergency department, and the hospital, which is distressing, ineffective, and costly.

Often, super-utilizers resort to calling 911 because they need support for a range of medical and non-medical needs but do not have the ability or resources to seek out alternative solutions. This issue may be particularly challenging in rural areas, where there are fewer primary care providers and where services are more likely to be closed evenings and weekends. However, traditional EMS providers are not well-suited to provide care navigation and resource referrals, which can better suit this population and help stabilize their health.

Community paramedicine programs often target super-utilizers because of the disproportionate share of EMS and/or hospital resources that are used to respond to their 911 calls. Programs generally begin by defining super-utilizers in their community, based on data from their EMS call logs and knowledge of their patient population.

Once eligible patients have been recruited, community paramedics use regular home visits to help the patient stabilize their health, including medication education, symptom management, lifestyle coaching, and linkage to primary care. The community paramedic will also conduct an assessment to determine the patient's social resource needs. Referral to social services can help the patient address some of the underlying issues that have led to their frequent use of the EMS system. More information about community and social services referrals is available in Referrals for Social Services.

One model that has been adopted by fire departments in a variety of settings is the Community Assistance Referral and Education Services (CARES) program, which targets super-utilizers by engaging with cross-agency partners who can better serve the patient's needs. Clients are assigned a “navigator” who helps manage their care. The goal of this program is to reduce 911 calls coming into the fire department's EMS unit. An evaluation of this model found a significant reduction in 911 calls, ED visits, and hospitalizations.

Hospice Care

For many patients with terminal illness, hospice agencies offer palliative care. The goal is to relieve suffering rather than cure disease, and generally emergency life-saving measures are not taken to prevent or postpone death. However, caregivers may reflexively call 911 rather than their hospice nurse if the patient appears to be in distress. This can trigger an EMS visit and transportation to the ED, even if that is not aligned with the patient's stated wishes. It may also result in a disenrollment from hospice, which could make it more difficult for the patient to receive those services at a later time.

Community paramedics can work with home hospice agencies to better serve these patients and their families. Once patients are dually enrolled in hospice and the community paramedicine program, EMS will be made aware of the patient's wishes and can ensure they are carried out when responding to a 911 call. EMS can also notify the hospice agency and utilize the patient's comfort pack (which includes medications to relieve pain) as needed until the hospice nurse arrives.

Alternative Destination

Particularly in rural communities with limited alternatives, 911 may be called for people who need assistance other than emergency medical treatment. For example, a person experiencing a psychiatric crisis may need mental health services, or a person with a substance use disorder may need a safe place to detox. However, an ED is often not the best place to receive this help because these facilities are not appropriate and staff do not have the proper training. More immediate physical issues (like a heart attack) receive precedence for care. Other times, a family may call 911 for healthcare because they do not have a primary care alternative and may be better served by an urgent care clinic than the ED.

Estimates of the total number of non-urgent ambulance transports vary but range from 11%-61% of trips to the ED. Community paramedicine programs can decrease demand on ED resources by triaging patients in the field to ensure there are no life-threatening medical issues, obtaining their consent for an alternative destination, and then bringing the patient to a sobering center, mental or behavioral health clinic, or urgent care.

Because emergency medical technicians and paramedics do not have the same training or facilities available to assess a patient's status compared to an ED, additional training (such as a community paramedic certification) and medical director supervision may be important components of an alternative destination program to ensure patients are accurately triaged.

One challenge with this model is reimbursement, as many EMS providers only receive payment when the patient is transported to the ED. In addition to the national CMS Emergency Triage, Treat, and Transport (ET3) payment model, which will reimburse EMS for services other than transportation, some rural programs have been able to work with private payers, Medicaid agencies, or state health departments to develop pilot programs or payment models that facilitate alternative destination services.

Examples of Rural Community Paramedicine Programs Reducing Use of Emergency Resources

The Regional Emergency Medical Services Authority (REMSA) in Washoe County, Nevada, has developed an Alternative Destination Transport program to bring low-acuity 911 patients to urgent care centers, detoxification centers, and mental health hospitals. First responders conduct a detailed evaluation in the field to determine what type of care is needed and then transport that patient to the ED or to other partner agencies who can best serve the patient's needs.
Bedford County Fire & Rescue in south central Virginia has implemented a pilot program to reduce the frequency of 911 calls. Community paramedics and a social worker conducted regular home visits with high utilizers and connected them with social services, including food pantries. Over the course of the project, call volume from the participants decreased by 60%. Based on this success, the county has created a dedicated Department of Social Services position to continue serving high utilizers moving forward.
McDowell County EMS in North Carolina implemented a pilot Community Care Paramedic Program, funded by the Kate B. Reynolds Charitable Trust. The program includes alternate destination transportation to a behavioral health clinic for patients experiencing a mental health emergency. It was also designed to avert ED visits by high utilizers through home visits to identify problems (like broken medical equipment or medication issues) and address them with the patient's primary care provider. An evaluation calculated that 125 EMS transports and ED visits were avoided during the pilot program.

Considerations for Implementation

While reducing use of EDs and ambulance transports can lower overall costs to the healthcare system, some rural hospitals or EMS systems struggle with volume and rely on ED visits for needed revenue. Therefore, it is important to meet with all stakeholders and identify potential unintended consequences of a new program. Exploring alternative payment models like the Treat and Refer Recognition Program may be one option to ensure all participating organizations benefit from the community paramedicine program.

Program Clearinghouse Examples

Resources to Learn More

ED Utilization – Right Care. Right Place. Right Time.
Document
Identifies the challenges with emergency department (ED) utilization in rural Missouri communities. Compares national and state trends in ED usage. Demonstrates strategies to improve utilization such as using community paramedics to provide managed care for patients with chronic conditions and to address the needs of patients identified as super-utilizers of the ED.
Author(s): Williams, A.
Organization(s): Missouri Hospital Association
Date: 12/2017

Emergency Triage, Treat, and Transport Project (ET3)
Presentation Slides
Provides an overview of the Emergency Triage, Treat, and Transport Model (ET3) presented at a National Association of State Emergency Medical Services Officials Annual Meeting. Includes ET3 background information, model goals and design, and payment models.
Author(s): Brown-Ashford, N. & McGinnis, K.
Organization(s): National Association of State Emergency Medical Services Officials, Centers for Medicare and Medicaid Services
Date: 5/2019

Hospice Partnership
Document
Describes the Hospice Partnership, a program developed by MedStar Mobile Healthcare to serve patients enrolled in hospice care. Discusses enrollment and program procedures and the results of the first demonstration project.
Organization(s): MedStar Mobile Healthcare

South Carolina Community Paramedic Protocols: Hospice/Palliative Management
Document
Provides step-by-step guidelines for community paramedics when assisting patients in hospice or palliative care in South Carolina.
Organization(s): South Carolina Community Paramedic Advisory Committee
Date: 3/2018