Who Will the Community Paramedics Be?

Last week I was in Washington DC for EMS on the Hill Day.  Unfortunately the meetings with our representatives were cancelled because a predicted but unrealized snow storm.  NAEMT anticipated that the government may close, and offered presentations about how healthcare reform will affect EMS reimbursement and the development of two Community Paramedic programs.  Soon there will be strong financial incentives in place to manage patients out of hospitals, and the days of us hauling everyone to the emergency department are numbered.  The question is how we will adapt.

Learning about who healthcare will be reimbursed in the future, with bundled payments for only evidence-based care, is scary.  The emergency department is the most expensive place to receive healthcare, and an ambulance is the most expensive way to get them there. Unnecessary transports will not be reimbursed, but that is all we know how to do now.  Hospitals also get penalized when patients with certain chronic conditions return to the hospital after discharge, so there is a huge financial incentive to prevent 911 calls from being necessary.  That’s were Community Paramedics come in.

Advanced Practice or Community Paramedic Programs address the needs individual communities.  In Wake County, NC, and Fort Worth, TX, their programs focused on urban EMS problems, such as repeat callers with chronic conditions, substance abuse, and psychiatric emergencies.  Some patients are visited in their homes in order to prevent a future 911 call, and others are directed to facilities other than a hospital.  Both have demonstrated saved EMS unit hours, ED bed hours for sicker patients, and money from prevented hospital readmissions.

In rural areas, EMS providers fill in identified healthcare gaps.  According to the Community Healthcare and Emergency Cooperative, Community Paramedics may provide primary care, dental care, public health, disease prevention, and mental health.  In Eagle County, CO, Community Paramedics follow up with patients in rural areas after they are discharged from the hospital, who would otherwise not have access to a physician to follow up.

The presentation included some great examples of how Community Paramedics improved patient outcomes without transporting them to the hospital.  Once Community Paramedic discovered that a retired judge had been prescribed Coumadin by three different doctors.  Another COPD patient was able to walk her dog for the first time in weeks after a Community Paramedic discovered she was not taking her Advair properly.  The healthcare cost savings were staggering.  Independent health economists estimated that over $1,000 was saved per visit, which was consistent across all of the pilot programs.

In his portion of the presentation, Chris Montera expressed a desire for the Community Paramedic program to offer a clinical promotional opportunity for working paramedics that incorporates formal education.  This is based on a standard curriculum developed by several heavy-hitter EMS educators, and is taught by accredited colleges and universities as part of a bachelor’s degree program

Everyone in the room appeared to be excited about this.  One of them was Art Hsieh, who wrote about it on EMS 1:

Other lessons I learned? The community paramedicine concept is here to stay. The sessions related to the expanded role of the field provider were packed.

There were numerous examples and case studies of systems providing a wide array of new services, many that have resulted in improved care and lower cost to the patient. In my 30 years of practice, I have not felt this much excitement from so many colleagues.

While I share his excitement, I am concerned about convincing people outside those sessions about what a good idea this is.  There are several roadblocks.  Many of us signed up for emergencies, which is loosely defined as patients who are about to die.  Everything else is considered a waste of our precious time on the clock.  Paramedic initiated refusals today are often done in the interest of us getting back in service, not the best interest of the patient.  How will paramedics in tiered systems  embrace doing more for traditionally BLS patients?  How will communities covered by a shrinking number of volunteers be able to handle additional responsibilities?  How will fire-medics accept more medical duties that move them further from  suppression?  If services do not track simple clinical performance measures today, such as cardiac arrest survival, how will they track when it is safe for Community Paramedics to not transport a patient?

These roadblocks will be overcome, both by forward thinkers within EMS and financial forces outside.  Our current business model is unsustainable.  Some services and people will not survive, and that is okay.

I’ve written before that there has never been a more exciting time to be in EMS, and Community Paramedics are a big part of that.


  1. Download our Paramedicine Guide on our site. The way safe “treat and release” is achieved is by collecting pertinent data and using decision support. This method is used in Europe, but we utilize telemedicine as well. There is also an effort by IAFC on mobile healthcare that is currently one of the top considerations for the Bloomberg Innovation grant award. Details are at http://www.lifebot.us.

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