As the coronavirus pandemic continues to strain the entire healthcare system, one unique EMS specialty is being called upon to help: mobile integrated healthcare and community paramedicine (MIH/CP). While some MIH/CP programs in fire departments and EMS agencies are nascent and still finding their best fits for communities, many others are well-established and have improved patient care, lowered costs and improved overall population health.
EMS World talked with five leaders in the MIH/CP space about the issues facing their communities, what roles are best served by community paramedics, and what recommendations they have for how MIH/CP can serve during this pandemic.
Daniel Gerard, MS, RN, NRP, EMS Coordinator for Emergency Medical Services for the Alameda Fire Dept., Alameda, Calif.
Anne Montera, MHL, BSN, RN, Public Health Consultant, President, Caring Anne Consulting, Gypsum, Colo.
Jonah Thompson, BA, NRP, CP-C, Mobile Integrated Health Operations Manager, Allegheny Health Network, Pittsburgh, Penn.
Michael Wright, NRP, MIH Manager, Milwaukee Fire Department, Milwaukee, Wisc.
Matt Zavadsky, MS-HSA, NREMT, Chief Strategic Integration Officer, MedStar Mobile Healthcare, Fort Worth, Tex.
EMS World: What role does MIH/CP have in the pandemic that is different than traditional EMS?
DG: Time is a constant that we battle against: trauma, cardiac, stroke emergencies. For the CP, the ability to spend more time with the patient is crucial. CPs have the opportunity and the time, to assist with screening, vaccination, treatment, and follow-up. This is a boon especially for people who are on home quarantine or home isolation. The CP can make the house call and reach patients who have been typically underserved in the community. Some of our populations are medically fragile. Especially for those patients who are socially and economically disadvantaged, CPs provide a modicum of care that during this pandemic is sorely needed.
We should have an increased footprint in the community to perform public health screenings/fever checks, and when allowable, collect samples for screening services in order to diagnose COVID-19. When making a home visit, we should conduct a screening for every resident of the household for COVID-19, to include a fever check, health screening form and physical assessment (complaints of cough, fever, or sneezing; shortness of breath/difficulty in breathing of unknown etiology; past medical history; age; etc.). This is an especially important activity if there is more than one at-risk individual who lives there. If within the CP’s scope of practice, we should collect a swab/sample for COVID-19 for everyone who has signs and symptoms.
MZ: MedStar’s medical director developed a process to effectively use the Medical Priority Dispatch System® (MPDS) to help manage low-acuity calls that may be COVID-related. MPDS has “Card 36” which is their Pandemic/Epidemic/Outbreak protocol. We have developed a process by which low-acuity Protocol 36 callers with the ability to access on-line resources are directed to a few web-based screening resources in our community. For low-acuity callers without the ability to access the internet, we will send a single person resource (CP or other) to assess the patient and provide recommendations for further screening, if necessary.
However, we are currently in a payment conundrum: if we are going to begin the practice of not transporting many patients, we will not be paid for these calls. The whole country is having trouble with staffing right now due to so many factors; this is a perfect time for Center for Medicare and Medicaid Services (CMS) to say, “Let’s start the ET3 pilot projects now and we’ll do the paperwork later.” Or, allow agencies to be paid for the A0998 HCPCS code (ambulance response, treatment and no transport) so agencies do not suffer a revenue loss while doing the right thing for the patient, and while they are helping to decompress the healthcare system.
JT: CPs are critical assets every day and even more so during a pandemic. Many frontline leaders may be tempted to see them as a pool of personnel available for surge capacity or to help cover gaps in the schedule. Not only would this be a disservice to these paramedical subspecialists, but it would also actively impede effective community response.
MIH/CP programs target the disproportionate utilization of healthcare services by our most clinically and socially vulnerable community members. The prototypical MIH/CP patient is likely to fall into one or more of the high-risk categories for infection with COVID-19 and development of COVID-19 illness. Vulnerable and high-risk populations are more susceptible to difficulties associated with social distancing, commodity rationing, shut down of essential services including public transportation and community centers, exponentially magnifying the effects of any disaster. In a pandemic where measures may have to be implemented and maintained for weeks or months, our vulnerable neighbors are the second disaster waiting to happen.
We should work closely with case management and hospitalists. If large numbers of patients require hospitalization, most will get better and be discharged. Discharge and the decisions around when they can go home to continue to convalesce will be difficult. Based on many of the models available and the reported experience of our colleagues in Italy and elsewhere, the ability to discharge someone safely may be the difference for the patient who receives all possible interventions or is subjected to triaged care. CPs could be a key part of that process, ensuring a warm handoff and safe landing at home while addressing barriers to self-management.
How can MIH/CP be immediately utilized and/or how is MIH/CP already being utilized for the pandemic?
DG: CPs should be helping with screening/assessment of patients in long-term care facilities, skilled nursing facilities, daycare centers or in shelters for signs and symptoms suggestive of COVID 19. CPs should be reaching out to the homeless to provide screening services where they happen to be if they are residing outside of a shelter and are undomiciled. Another opportunity for CPs is as a force multiplier for your occupational medicine staff. They are in the field every day, they can hold a 'sick-call' every shift change and screen staff for fever, cough, etc. and follow-up with staff who are sent home ill or who are on self-quarantine or self-isolation.
AM: All of the CPs in Eagle County, Colo. are on call to go perform COVID-19 testing. They are also following up on all of the telemedicine patients so that we give these patients a second set of eyes through the video platform to make sure they are doing okay.
MW: CPs should be helping with in-home or fixed-location testing. They should be conducting welfare checks on the elderly and assisting those with chronic disease who need medication refills.
MZ: Patients who are symptomatic and homebound could have a CP check in once or twice a day by phone or in person.
At MedStar Mobile Healthcare, our CPs recently began helping those with food insecurity or who are medically fragile. People are out of work and economically-challenged, so we’ve done an outreach for these folks, establishing a relationship with food banks to deliver meals and food packets to vulnerable community members.
How are you using telehealth during the COVID-19 pandemic? What advice would you give to agencies who might want to expand or attempt the use of telehealth right now?
DG: We were not going to use telehealth as of yet because of HIPAA issues and because of the expense of the technology that would be required to be HIPAA-compliant. Since the Department of Health and Human Services (DHS) has suspended HIPAA compliance issues relevant to telehealth, this will allow us to now look at it in a different light and perhaps institute a simplified version at some point in the future.
AM: Last week, we developed a way for three counties in Colorado (Eagle, Garfield and Teller) paramedics to use telehealth. When paramedics arrive to a patient who has symptoms of a respiratory illness, the providers stay in the ambulance, connect to the patient via text messaging and then on a downloadable telehealth app. They explain to the patient why they need to stay outside and then use the video telemedicine from the cab of the ambulance without needing to don any personal protective equipment (PPE) or enter the patient’s home.
Paramedics monitor them through video and ask questions about their activities of daily living: how are they eating, staying hydrated, etc. all without physical content or risk. At a cost of about $200 per call for PPE, this saves money and resources.
If the patient needs immediate medical attention, then they don PPE and enter the home.
In Eagle County, the medical director put forth a protocol that allowed paramedics to assess patients via telemedicine with a head-to-toe “virtual” assessment on the app. Then based on their findings and expertise, the paramedics make that decision if they need to transport the patient.
What are the skills, knowledge, training and attitudes that MIH/CP providers can bring to support the health of the public right now?
DG: A CP’s ability to perform advanced assessments is paramount. The assessment and re-assessment are important tools on a longer trajectory to successfully manage a patient, over days, weeks, even years. CPs can spend the time determining patient needs and capabilities to manage their health at home, without the pressure of having 9-1-1 calls stacked up and dispatch asking CPs if they are available. Observing patients’ living conditions, family interactions, home cleanliness and hazards, social structure, environmental issues, etc. help determine a patient's risk status.
JT: As paramedical practice continues to refine itself as a profession, we need to acknowledge that our subspecialists of CPs, Flight and Critical Care Paramedics, and others are best employed in their highly specialized roles. The value that these advanced clinicians bring to the entire continuum of care and healthcare system cannot be overstated.
MW: CPs have a unique ability to communicate complex issues to the people in terms that they will understand. The greatest enemy to thwarting any widespread issue is accurate, verifiable, and timely information. No different than firefighting—when the public runs away from the fire and we run towards it, MIH/CP has the same opportunity, especially when there is no emergency. There is a huge need for these skills.
MZ: I’d answer this question for those agencies that do not yet have an MIH/CP program: EMS agencies throughout the country are being asked to find ways not to bring every patient to the hospital or to find an alternative destination. More importantly, all of EMS needs to be invited to the table for these local and regional daily briefings and planning meetings. Get yourself to the table. This is a moment for EMS to positively impact communities.
Interviews have been edited and condensed for clarity.
Hilary Gates, MAEd, NRP, is the senior editorial and program director for EMS World.