community paramedicine the evidence...community paramedicine: the evidence william raynovich,...

C P COMMUNITY PARAMEDICINE: THE EVIDENCE

William Raynovich, NREMTP, EdD, MPH, BSAssociate ProfessorCreighton University

Reforming States Group Pre-ConferenceNovember 13, 2014

GOALGOAL

Describe the body of knowledge regarding Communit Paramedicine and Mobile Integrated Community Paramedicine and Mobile Integrated Health Care

© 2014 The Paramedic Foundation. All Rights Reserved.

ACKNOWLEDGEMENTSACKNOWLEDGEMENTS

Gary Wingrove, Co-PresenterGovernment Relations & Strategic AffairsGold Cross, Mayo Clinic Medical Transport

D i G P tt PhDDavis G. Patterson, PhDDeputy Director, WWAMI Rural Health Research CenterInvestigator, Center for Health Workforce StudiesResearch Assistant Professor, Department of Family Medicine University of Washington


Medicine, University of Washington

OVERVIEWOVERVIEW

Historical contextC d Ch llConcepts and ChallengesDefinitionsTh E idThe Evidence

Peer-Reviewed LiteratureGeneral Public Media ArticlesFuture Research Initiatives


HISTORICAL CONTEXTHISTORICAL CONTEXT

Community Paramedicine has been in existence continuously since the dawn existence continuously since the dawn of civilization

Hospitals are relatively new concepts in medicineW d ilit di i h b l di i flWars and military medicine have been leading influences

Modern Concept of Community Paramedicine

Alaska Community Health Practitioner (CHAP) - 1980’sNew Mexico Taos County Red River Project – 1995-2000Native American Reservations Today


International Analogs

Throughout the world, populations in frontier, rural and urban areas are under-

d b th i t h lth t

The Primary Challenge served by their current health care systems.

Frontier areas may have a lack of a physician, a nurse, a pharmacist, or a d i bi i f h ll

Challenge

dentist, or any combination of these, as well as having no physician’s assistant, physical therapist, social worker, trained public health professional, or many other health care professionals that resource-rich metropolitan areas have.

“Resource-rich” metropolitan areas often have “distribution” issues; where there are concentrated economically depressed inner city populations that are under-served by the health care professions.


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SECONDARY CHALLENGES

Expanding population needsA i b b bAging baby-boomers

Medical economicsProjected Medicare Revenues & Expenses ShortfallProjected Medicare Revenues & Expenses Shortfall

Medicare Insolvency Projections, Congressional Research Service, Patricia A. Davis, Specialist in Healthcare Financing, July 3, 2013g, y ,https://fas.org/sgp/crs/misc/RS20946.pdf


SECONDARY CHALLENGES CONTINUED

Hospital ReadmissionsTh id bl i ll d f lThese are avoidable, economically and safely

Use of Hospital Emergency DepartmentsIn Lieu of Family CareIn Lieu of Family CareIn Lieu of any other available care


COMMUNITY PARAMEDIC &MOBILE INTEGRATED HEALTH CARE

Community Paramedicine is an awkward titleThe practitioner may be a paramedic; however, not necessarily

Mobile Integrated Health Care is an awkward termMobile Integrated Health Care is an awkward termThe practice may not be mobile


ROLES AND DEFINITIONSROLES AND DEFINITIONS

The Community Paramedic (CP) is a practitioner ho “fills” gaps in the health care s stem The who fills gaps in the health care system. The

CP practice is well-regulated, is accountable, has medical supervision, and is systematically integrated into the community health system based on demonstrated need and whose practice is restricted to only filling identified gaps in is restricted to only filling identified gaps in services.


SOCIAL PROFESSIONAL AND POLITICAL CHALLENGESSOCIAL, PROFESSIONAL AND POLITICAL CHALLENGES

Social challenges involve acceptance by the iti th i i t f communities – the recipients of care

Professional challenges involve acceptance by existing paramedics (EMS professionals) practicing in paramedics (EMS professionals) practicing in emergency response agencies and transporting agenciesPolitical challenges involve acceptance by the medical and nursing communities


THE EVIDENCETHE EVIDENCE

The body of knowledge is impressiveM ffi i id i h d l Most affirming evidence is at the model systems case-based level, where governmental grants funded demonstration projects establishing p j gfeasibility, acceptability, safety, and efficacy.


THE EVIDENCE CONTINUEDTHE EVIDENCE CONTINUED

Most negative evidence is historical and stale and has been eclipsed b an o er helming number of has been eclipsed by an overwhelming number of successful programs that have gained established status with regulatory grounding, fiscal sustainability, and integrated professional acceptance.


THE EVIDENCE CONTINUEDTHE EVIDENCE CONTINUED

Professional objections have been raisedLevel of educationLevel of education

EMS has been highly trained to administer interventions that require high levels of skill; however these interventions are administered in life-however, these interventions are administered in lifethreatening settings and when rapid transport to a hospital ED is integrated into the practice

Suitability of the emergency responder professionalsy g y p pAffective Skills, Aptitude, Motivation

Compromise (Lowering) of the standard of careThis is fundamentally true; unless one considers no


This is fundamentally true; unless one considers no care as being superior to this “lesser care level”

PERVERSE INCENTIVES

Transport biasOur current EMS system favors “transporting patients, y p g p ,even if another response is wanted, needed, safer and less expensive.”7 – 34% of Medicare patients could (and should) have been treated other than the destination hospital EDtreated other than the destination hospital ED26% of EMS responses result in no transport (and no payment)Most frequent users are often homeless, have no primary care provider and often have a chronic life threatening or care provider, and, often have a chronic, life-threatening or debilitating illness, including mental health illnesses

Realigning reimbursement policy and financial incentives to support patient-centered out-of-hospital

JAMA 309(7) 667 668 M j l & C 2013


care. JAMA, 309(7); 667-668. Munjal & Carr, 2013

PERVERSE INCENTIVES CONTINUEDPERVERSE INCENTIVES CONTINUED

Affordable Care Act encourages realignment of incenti es (to ard bundled pa ments and shared incentives (toward bundled payments and shared savings) but does not address EMS reimbursement and practice issuesMany EMS transports and downstream economic inefficiencies are avoidable


PERVERSE INCENTIVES CONTINUED

Non-acute, chronic, and under-served patients often do not recei e the right care in the right often do not receive the right care in the right place at the right time

All of which consequently results in higher overall system costs and stressed resources at all levels


THE RESEARCHTHE RESEARCH


ALASKAALASKA

Successfully operating over the past 35+ years C i H l h Aid550 Community Health Aides

• ~ 130,000 population 180 ill • ~ 180 villages

• > 300,000 patient encounters


DIGBY NECK NS CANDIGBY NECK, NS, CAN

L d B i I l d th B f F dLong and Brier Islands on the Bay of FundyOnly access is by Ferry1240 people; 50% over age 65p p ; gHwy 217 is dangerous in inclement weather


NOVA SCOTIA COMMUNITY PARAMEDICMODEL

REDUCTION IN REDUCTION IN REDUCTION IN EMERGENCY ROOM VISITS

REDUCTION IN CLINIC VISITS

OVER 5 YEARS© 2014 The Paramedic Foundation. All Rights Reserved.

OVER 5 YEARS

DEMONSTRATION PROJECTSDEMONSTRATION PROJECTS

Minnesota Department of HealthCommunity Health WorkerCommunity Health WorkerFunded by Blue Cross & Blue Shield


SASKATCHEWAN CANSASKATCHEWAN, CANMobile clinic staffed by Community ParamedicsSometimes operates at the Main Clinic to relieve overcrowdingSometimes operates at the Main Clinic to relieve overcrowding


EAGLE VALLEY COLORADOEAGLE VALLEY, COLORADO

January 2010C t P l tiCounty Population

26% uninsured46% in the EMS district46% in the EMS district

Modeled after MN CHW & NC


RESEARCH REPORTSRESEARCH REPORTSDo Emergency Medical Services Professionals Think They Should Participate in Disease Think They Should Participate in Disease Prevention?

Lerner, Fernandez & ShahPEC Jan Mar 2009 Vol 13 No 1 pps 64 70PEC, Jan-Mar 2009, Vol 13, No.1, pps 64-70

87% of EMS Responders support participation in disease and injury participation in disease and injury prevention programs

Surveyed 27,233 NREMT members


Surveyed 27,233 NREMT members

RESEARCH REPORTSRESEARCH REPORTSParamedic Determination of Medical Necessity: a Meta-Analysisy

L. Brown, M.W. Hubble, D.C. Cone, M.G. Millin, B. Schwartz, P.D. Patterson, B. Greenberg & M. RichardsPEC, Oct/Dec 2009, Vol 13, No. 4, pps. 516-527

9 752 Ti l 2 Ab 6 S di R i d9,752 Titles; 214 Abstracts; 61 Studies Reviewed10 papers in the final analysisNPV = 0 91NPV = 0.91Data do not support having paramedics make decisions to not transport


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RESEARCH REPORTSRESEARCH REPORTSEvaluation of an EMS-Based Social Services Referal Program for Elderly Patients

Kue, Ramstrom, Stacy-Weisberg, RestucciaPEC, July/Sept 2009, Vol 13, No 3, pps. 273-279

8-months, real time study6,249 no-transport responses721 eligible encounters; 3% total70 referrals of 698 reviewsParamedic referrals resulted in higher


acceptance 98% v 28%

RESEARCH REPORTSRESEARCH REPORTSEvaluation of an EMS-Based Social Services Referal Program for Elderly Patients


Paramedic referrals resulted in higher acceptance 98% v 28%Paramedics have the ability to

l b h h i ’ accurately assess both the patient’s clinical condition and the environmental context


environmental context

RESEARCH REPORTSRESEARCH REPORTSEvaluation of an EMS-Based Social Services Referal Program for Elderly PatientsReferal Program for Elderly Patients


P i i i k Partnering agencies is a key component for coordination of care and “defragmenting” services


RESEARCH REPORTSRESEARCH REPORTSEMS Insider March 2008

David C. Lipscomb (originally in the Washington Ti )Times)

DC Fire Dept began a program to visit the most frequent 911 callers to reduce unnecessary calls

49,000 unnecessary 911 calls each yearStarted with the 20 most frequent callers -Started with the 20 most frequent callers 10% of 127,000 annual calls

Average of each calling 10 called ~ 6,500 timesEach called approximately 650 times per year or


Each called approximately 650 times per year, or twice a day!

CONCLUSIONSCONCLUSIONS

The development of Community Paramedicine and Mobile Integrated Health Care has been and Mobile Integrated Health Care has been taking place for decadesThe evidence over the past 40+ years has been

i d d ft timixed, and often negativeThe preponderance of evidence over the past 10 years has been overwhelmingly positivey g y pThe economic drivers are impelling the trend toward acceptanceTh t d i f i l t d d d ti


The trends in professional standards, education and professionalism are compelling the trend

THANKYOU!THANKYOU!


community paramedicine the evidence...community paramedicine: the evidence william raynovich,...

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