In these exciting early days of community paramedicine/mobile integrated healthcare, there’s a lot of room to experiment. What interventions by whom, where and with what patients, will lead to better outcomes and lower costs? Let’s test some ideas and find out.
A new project in California’s Orange County, led by Anaheim Fire & Rescue, is among those using nurses in the field in an effort to reduce transports of and emergency department use by low-acuity patients who can safely be treated otherwise. They ride on what’s called the Community Care Response Unit (CCRU).
“There are two areas we’ll be looking at,” says Chief Randy Bruegman. “One is the impact on our patient care, and the second is the impact on our deployment model. Part of our strategy has been to look at how we can increase the effectiveness of our patient care, but also how we can reduce the impact of our suppression units just being tied up so long on low-acuity calls.”
In fact, over the last five years, Anaheim has seen a 16% rise in 9-1-1 calls for medical emergencies, even as its fire-related calls dropped by 11%. Last year 85% of its more than 30,000 calls were medical, and around 35%–38% of those were nonurgent.
“Our ERs right now are completely overimpacted with nonacute calls,” says Capt. Dave Barry, the department’s EMS director. “They can have people sitting on gurneys for three or four hours in the ER, waiting for a bed. If that person can be treated at home and referred to their physician in the next day or two, that’s a great benefit to our system. It frees up ambulances and frees up our 9-1-1 system for someone in full arrest or having a heart attack, or a fire that might be coming down the street, as opposed to somebody who has an infection that could be treated other ways.”
Other partners in the program include Care Ambulance, Kaiser Permanente Orange County and the Metro Cities Fire Authority (Metro Net), the local emergency communications entity. The nurse model was pioneered in Mesa, AZ, and Gary Smith, MD, who provides physician oversight for the Mesa Fire & Medical Department, is licensed in California and handling medical direction for this project as well.
The CCRU will field a crew of a fire captain/paramedic and a certified nurse practitioner. For the first three months of the project, which started May 31 and will run for a year, it will answer alpha-level calls alongside the standard paramedic engine/truck and ambulance response. Its crew can treat and release patients and/or refer them to primary care. If that initial period goes well, it will then respond solo, its crew with the same disposition options but also able to summon BLS or ALS care as needed.
Adding the nurse has been a success story in Mesa, which replaced one of the two paramedics on its Community Care unit with a nurse practitioner or physician assistant in 2012. That provided latitude for things like suturing, testing for UTIs, giving flu and tetanus shots, and writing prescriptions in the field, preventing even more ED visits. The Centers for Medicare & Medicaid Services has now given the city $12.5 million to expand and study its program.
The Affordable Care Act, along with those rising call and ED volumes, prompted some rethinking of things in Anaheim like everywhere, and its leaders concluded a model like Mesa’s made sense.
“When we started our strategic planning process in 2011,” says Bruegman, “the ACA was still going through the courts, but it was clear EMS was going to become an integral part of this new healthcare delivery system. So we started to look into what others were doing across the country. Expanding the paramedic scope of practice wasn’t an option here, but as we did our research, we ran across what Mesa was doing, and we thought that model really fit what we wanted to do and would actually probably be the easiest to implement, given all the state regulations and different groups that have some ownership in the process.”
The department sent key personnel to Arizona to observe things firsthand and gauge viability. When those returns came back favorable, it began the process of aligning local partners. Leaders found a receptive one in Kaiser Permanente, which, despite representing only a minority market share in Orange County, kicked in $210,000 to help get things started.
“We think it serves the greater good,” says Todd Newton, MD, regional chief of emergency medicine for KP in Southern California. “What we’re trying to do is have a positive impact on the system like they’ve seen in Mesa. ER visits are up everywhere, and we think caring for people in more appropriate settings, where they get the best service, with the least impact on the system as a whole, and more affordably, makes the most sense.”
In the Anaheim program’s first two months, it had 86 patient contacts, with crews treating and releasing almost half. Their complaints have included things like infections, postoperative catheter problems, lacerations needing suturing and unexplained swellings.
The nurses are “remarkably good at history and physical,” says Newton, “sometimes even superior to physicians.” And an unanticipated benefit has been their access to those docs.
“If we’re on site with a patient and doing a treatment or assessment, they can actually call in to the doctor’s office, and I don’t think we’ve had a situation where they haven’t actually talked to the physician,” says Bruegman. “As paramedics, we can’t do that—there’s no way we’re going to get to a doctor. But they can talk directly to one. A lot of these are postsurgical patients, and that’s been a real benefit. Most of the time the doctor will say, ‘Don’t take them to the emergency department. Let’s have them come to my office tomorrow morning.’ That’s a great benefit to the patient. And we think the benefit to the healthcare system is that it will really improve the individual experience of care, but also reduce the per-capita cost.”
Anaheim’s CCRU program is expected to cost around $500,000—pretty lean as these things go. The savings? Well, Mesa has saved more than $3 million with its effort, Smith noted in support of the Anaheim program. In Orange County, ambulance bills typically run around $700–$1,000, and total bills can double or triple that with ED tests and treatment. Bruegman estimates the cost of the CCRU at $500–$600 per call.
That potentially adds up to quite a local savings, the demonstration of which will be an essential component of whether the program continues after its initial year. The other keys will be patient safety, naturally, plus how well it frees up Anaheim Fire & Rescue crews.
Says Bruegman: “If we believe at the end of the pilot that this is having a positive impact on our overall deployment system—allowing our suppression units, our ALS units to be in service more often—then I think it’s a strategy we can go back and articulate to our city management and elected officials, and be able to fund at least a portion of this unit going into the future.
“Just as important, the feedback we’ve gotten from the patients has been really positive. A lot of these folks are seniors, and the last thing they want to do is go to the emergency department at 7 o’clock at night and sit there for several hours and wait to be treated and released.”
Adds Newton: “Right now we’re keeping more than 40% of the patients being seen by this team out of the ER. I already consider that a success. Every one of those beds is freed up for a sicker patient. If you can keep 1,000 patients out of local ERs, that pays for itself many times over.”