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Tuesday, June 17, 2014

More EMTs Doing House Calls, Not Just ER Transport

An unidentified woman is wheeled into a hospital by members of the Bedford-Stuyvesant Volunteer Ambulance Corps (BSVAC) on June 21, 2013 in the Brooklyn borough New York City. (Spencer Platt/Getty Images)

An unidentified woman is wheeled into a hospital by members of the Bedford-Stuyvesant Volunteer Ambulance Corps (BSVAC) on June 21, 2013 in the Brooklyn borough of New York City. (Spencer Platt/Getty Images)

It’s being called the house call of the future: ambulance crews who rush when you call 9-1-1, but instead of taking you to the emergency room, they treat you at home.

Community paramedicine, as it’s called, is a growing trend across the country. It’s aim is to bring down hospital costs, but there are concerns about who’s going to end up paying for the service.

David Kimbrell, the fire chief in Hall County, Georgia, and Scot Phelps, a former paramedic and a professor of disaster science, speak with Here and Now’s Robin Young.

Interview Highlights

David Kimbrell on the advantages of community paramedicine

“They’re able to do blood withdrawals and do some analytical tests on the scene. They have a centrifuge. They can spin down blood to do various blood tests on the scene. None of those things are done by paramedics on the scene. So if you think about healthcare, we’re basically going back to the old house calls by the doctor.”

David Kimbrell on funding the new service

“We were seeing more and more people calling 911 and our medics were treating them on the scene, and then we were not getting reimbursed for that because a paramedic has to transport in order to be reimbursed by insurance and Medicare and Medicaid. So we were able to utilize a nurse practitioner. So the nurse practitioner and the paramedic teams up as the mobile care team. Then, if they go out and treat a patient, it is reimbursable through the nurse practitioner’s license.”

Scot Phelps on a previous attempt at community paramedicine

“We tried this in 1995 in Red River, New Mexico and what we found after spending hundreds of thousands of dollars was that it didn’t actually save any money or improve any care. So they abandoned it and now eight years later its the topic du jour.”

Scot Phelps on paramedics’ responses to the service

“I don’t think paramedics are really anxious about being replaced because all the data shows that all the ambulance calls across the country, and in fact, across the world, are increasing increasing at about 5 percent a year. The problem is that very few communities have sufficient numbers of paramedics. There is extraordinarily high turnover. That was one of the key conclusions of the 1995 Red River project was that with the high turnover the training costs add up kind of quickly.”

Guests

  • David Kimbrell, fire chief and director of emergency management in Hall County, Georgia.
  • Scot Phelps, former paramedic and professor of disaster science at the Emergency Management Academy. He tweets @emergencymgmt.

Transcript

ROBIN YOUNG, HOST:

It's HERE AND NOW. It's being called the house call of the future - crews that rush to respond when you call 9-1-1, but instead of taking you to the emergency room, they treat you right there. Community paramedicine, as it's being called, is a growing trend across the country. The goal is to bring down hospital costs. Some of questions - we'll get the big picture in a minute. But first let's hear what's happening in and around Gainesville, Georgia. David Kimbrell is fire chief and director of emergency management in Hall County, Georgia. And David, we understand you have a committee mobile team that's been operating for a few months now. Why? What were the problems you saw? And how is it going?

DAVID KIMBRELL: It's going very well. Thanks for asking. We started this because we began to see an increase in nonemergency 9-1-1 calls for service. This was people accessing healthcare through 9-1-1, which we discovered is the most expensive way to access that care.

YOUNG: And what were some of the problems people had? What are the reasons they were calling?

KIMBRELL: Pains in their knees that was not - that was a chronic pain. Or high blood pressure, that they were not taking care of themselves and not following doctor's orders. Also we are seeing more and more calling 9-1-1 and our medics were treating them on the scene and then we were not being reimbursed for that, because a paramedic has to transport in order to be reimbursed by insurance and Medicare/Medicaid. So we were able to utilize a nurse practitioner. So the nurse practitioner and paramedic teams as act as the mobile care team. Then if they go out and treat a patient then it is reimbursable through the nurse practitioner's license.

YOUNG: OK. So let's hear about this new plan. You've got a nurse practitioner and a paramedic who go out. We're reading in some places that have done this it's not an ambulance. It's maybe an SUV that is stocked with things that maybe an ambulance doesn't even have - more kind of treatment things. What does it look and feel like - the team?

KIMBRELL: They're able to do blood draws and do some analytical tests on the scene. They have a centrifuge. They can spin down blood to do various blood tests on the scene. None of those things are done by paramedics on the scene.

YOUNG: No.

KIMBRELL: So, if you think about health care, we're basically going back to the old house calls by the doctor - an extension of the doctor's office through the nurse practitioner.

YOUNG: A couple of things - who decides who should go out when the 9-1-1 call comes in?

KIMBRELL: We use a system that uses algorithms. So we've determined the non-emergency high propensity for no-transport types of calls. And that's what the mobile care team is dispatched on through the 9-1-1 system.

YOUNG: We understand another benefit of these teams is that they can do regular care. They can regularly visit let's say the elderly, check on the house, make sure they have their medication, make sure there are no rugs they can slip on. Is this something you're using these things for as well?

KIMBRELL: It is. We have tried to address some of our top users of EMS that we felt like it did not need to go to the ER. Our top user was a lady who had some blood pressure problems, but she was very scared. So she would take her blood pressure several times a day and call 9-1-1 and want an ambulance to come out. That resulted in a lot of cost.

YOUNG: By the way, can you give us that price tag to bring an ambulance out?

KIMBRELL: The charge for ambulance $775 plus patient-loaded mileage.

YOUNG: Wow.

KIMBRELL: $12 a mile.

YOUNG: That's a lot of money for woman who sounds like she's scared and maybe a little lonely.

KIMBRELL: It is. And so the mobile character is able to go out and visit with her. There's much less cost with the unit that they drive, which is basically an SUV. She's just ecstatic with the service and the attention that she's getting. In fact last week she actually called them before they were able to call. She said I just wanted to check in and tell you I was doing okay.

YOUNG: Well, hold on David Kimbrell, because I think we have Scott Phelps on the line. Scott Phelps is a former paramedic, an emergency movement consultant, professor of disaster science at the Emergency Management Academy. So Scott, we've just been hearing from David Kimbrell there in Hall County, Georgia. They are loving this community care mobile team that they have. Your thoughts.

SCOTT PHELPS: You know, we tried this in 1995 in Red River, New Mexico. And we found after spending hundreds of thousands of dollars with that - it didn't actually save any money or actually improve care. And so they abandoned it. And now eight years later it's the topic de jour.

YOUNG: But isn't that because - I could be wrong here - but isn't that because in Red River, they had people pay for these visits.

PHELPS: They were actually going to charge people a pretty minimal fee - something like $20 to be seen by a community paramedic. And what they found was that they just wasn't the demand for it. People love their community paramedics but they just didn't associate the paramedics with providing primary care. And we already have people in - most communities in the United States that provide primary care, and those people are nurses.

YOUNG: Well, but nurses don't have a way to respond to a 9-1-1 call. I'm wondering - you are a former paramedic, could it be that maybe paramedics are nervous about this? That this might replace what's become kind of a booming and much appreciated business - the ambulance that responds to a 9-1-1 call.

PHELPS: You know, I don't think paramedics are really anxious about being replaced because all the data shows that the number of ambulance calls across the country and actually across the world are increasing at about 5 percent a year. The problem is that very few communities have sufficient numbers of paramedics. There is extraordinarily high turnover. And that was one of the key conclusions of the 1995 Red River project was that with the high turnover, the training costs just sort of add very quickly. In career fire service models where you're going to have staff staying for 20 or even 30 years, that wouldn't be nearly as much concern. But, you know, probably about a third of this country has services provided by private paramedics. And I think there's a lot to be said for the nonclinical safety services - the ability to sort of just improve the community's health and eliminating those ambulance calls to begin with.

YOUNG: You mean a program that send people out to help the elderly to put night lights up?

PHELPS: There's a lot of fire departments in America that will check your smoke detector battery every time they come to your house on an ambulance call. Arlington County Fire Department actually - they carry nightlights in the officers' turn out gear. And those kind of systems both don't involve any sort of clinical training, don't involve permission from anybody. You can put them in place right away. And then we would be stepping on any other clinician's toes.

YOUNG: Stepping on toes, that's key. Thank you Scott. Scott Phelps is a former paramedic, who now teaches at the Emergency Management Academy, and thinks community paramedicine doesn't always work. We also heard from David Kimbrell, Fire Chief and Director of Emergency Management in Hall County Georgia. He says it's working in his community just fine. But those stepped-on toes, might that be the problem? We'd love to know is your town trying this? What's the outcome there? We'd love to know at hereandnow.org. Transcript provided by NPR, Copyright NPR.


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  • john r

    Sr. Scott Phelps hit on it without even realizing- High turn over and training cost was the downfall to this program and why it didn’t work where he was, and he also mentioned how in the fire sector they have people that stay on for 20-30 years. Why is that? It’s because private ambulance pays poor. These paramedics are getting paid sometimes $12/hour, with poor medical coverage and no retirement (or small 401k- like 3% matching).

    At many of these fire departments they make much much more than the private ambulance paramedic, have pensions, and better medical coverage. Maybe we shouldn’t prioritize big business and executive making money of the community health coverage.

    I have been a paramedic for private ambulance, fire department, and helicopter for more than 16 years and this cycle has not changed.

  • Dan C

    Thanks for the coverage on this growing and important topic.

    Not sure if the guests selected represented a good sampling of community paramedic programs. I Believe the National Association of Emergency Medical Technicians (www.naemt.org) could point you in the right direction.

    Many community paramedic programs work independently without a middle level provider (NP/PA) and have medical oversight though a physician and function above the level of a regularly licensed paramedic.

    Educational/certifications/licensing standards, state regulatory issues need to be developed along with improving reimbursement channels (all of which is currently being addressed at the state and federal levels.

    Hopefully it will lead to the development of an advanced practice paramedic (community paramedic), who would funtion as a middle level provider (provider level above a RN or a currently practicing paramedic) in areas were paramedics practice significantly and predominantly (prehospital, critical care transport and community paramedicine areas of practice).

    Thanks again for providing coverage to this important topic in health care.

    Dan C., Paramedic, FP-C

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