The Williamson County (Tex.) EMS Community Health Paramedic (CHP) program was established in 2014 under a federal grant to address high utilization and hospital readmission reduction. A team of four seasoned paramedics moved from EMS to CHP with very little knowledge of where their new journey would lead. Ultimately we addressed readmission reduction with two hospitals, participated in a post-coronary bypass follow-up program with a local cardiology group, and addressed the increased use of EMS by multiple patients in the county.
Our team completed the grant project in 2017. In 2018 we were downsized to just three members. Despite the decrease in staffing, we continued to address high use by way of referrals from our 9-1-1 field crews. A big key to our success has been hard-earned experience: The average tenure of our current staff is 20 years, which contributes to our ability to provide high-quality care to our patients. We find tenured providers can look at the big picture, addressing needs in a calm and strategic way.
I moved into the CHP program lead position in 2019 and immediately began pursuing funding options for sustainability. Little did I know COVID would soon rear its ugly head. While nearly working us to death, it also provided an unlikely opportunity for us to expand our role and secure additional grant funding.
New Roles, New Wisdom
Since March 2020 our CHP team has been attached to the local health district in multiple ways. Our role began with delivering legally binding control orders to the 60-plus long-term care facilities in the county. We then transitioned to being stationed in the health district offices to screen both staff and visitors for COVID-19. We also helped answer questions from an anxious public in the district call center.
Early in April, while delivering a new set of control orders, we identified our first long-term care facility COVID cluster. To this day it remains our second-largest cluster at a long-term care facility. Early one morning, while my team was delivering the new orders, I participated in a meeting to discuss establishing a long-term care facility strike team. Not 12 hours later we were in that facility performing more than 100 COVID nasal swab tests on staff and residents. A week later we set up our second testing site in another facility and have been testing facilities, performing infection-control assessments, and providing guidance since then.
While we were ultimately successful with the response to our first cluster, it was a bit of a, well, cluster! Being a long-time field paramedic, I ran the incident using a loose form of incident command structure (ICS), complete with a facility map and established teams. We rolled into that facility like gangbusters that evening, and the tests were on their way to the lab by the wee hours of the morning. Here is what we learned:
Food—It’s the most important thing you can give teams that are expected to be in full PPE for a couple of hours shoving swabs in people’s noses.
Light—We set up a drive-through testing station around the back of the building, but it got a little sketchy when we realized we had very little light to work in.
Security—Surprisingly, some care facility staff got a little grumpy being told to come to work at 2000 hours after they had gone home or weren’t expected in until 2200 hours. We quickly requested some presence from our local law enforcement after an encounter with a verbally abusive off-duty nursing home staff member.
Planning—I am incredibly proud of this first response. It is probably the most notable response we had during the pandemic. We were able to pull together a team of 20-plus members in less than four hours. We soon realized we should plan more for these events, and the “ready, fire, aim!” response was not the best.
Strike Team Activities
A natural partnership has always existed between EMS and fire, so it was easy to reach out to all our local fire chiefs to request team members for our long-term care facility strike team. Remember, our CHP team only had three members, and EMS was not in the position to provide other members due to staffing constraints.
I received an amazing response from our fire departments. The team was formed in less than a week and ready to respond with little notice. Fire and EMS have an amazing ability and desire to show up and work. This has never been more apparent than with our strike team.
Nasopharyngeal swabs are not a standard skill for EMTs or paramedics, so we established a plan with the health district to send fire personnel to their public testing site for training from their clinical nurses. We obtained personal protective equipment (PPE) from the Capital Area of Texas Regional Advisory Council (CATRAC), which served as a regional provider and clearinghouse for PPE.
We carried tubs of PPE and testing supplies to sites for weeks. We showed up in the early hours of the morning and transformed facilities into moderate-scale testing sites. We utilized staff from facilities to assist in resident swabbing and trained them on best practices and PPE use.
When we left a facility, there was no trace of us ever being on site. I wanted to leave each location better than we found it and ensure the staff and administrators were pleased with our response.
Figures 1 and 2 show the tests completed by the team as well as the infection-control assessments we completed both preventatively and in response to a COVID cluster.
The team was self-sustaining, rarely needing assistance from our partners. The operation soon became so smooth that there was little need for pre-incident briefings. Everyone knew what they were there for. The team came in, did the work, and went home safely. The constant contact with the facilities we tested built trust in the dependability of our team. Our operation also built trust with the health district that would soon lead to an opportunity to continue our response under a new grant-funded project.
The Williamson County and Cities Health District was awarded a grant from the National Association of County and City Health Officials (NACCHO) in October 2020 to build local operational capacity for COVID-19 response in long-term care facilities. Since our CHP program was already doing this work, we got part of the grant. We were awarded $47,000 of a $100,000 grant to develop tools, provide training, and perform infection-control assessments and education in long-term care facilities.
Many of the tools requested by the grant were already established by the health district and strike team, so we moved forward creating a modified infection-control assessment and response (ICAR) tool to be used in at least 40 facilities across the county. We created this using the CDC infection-control assessment tool and Texas’ state COVID ICAR tool.
The goal was to create a sustainable tool that could be used in other responses. It would also be able to assist both the administrators of the assessment and the facility staff with guidance. It is complete with hyperlinks to credible information and guidance from the CDC, EPA, and websites of local oversight authorities.
The team created a monthly survey and pushed it out to all long-term care facilities to track their current situation, needs, PPE counts, and staff/resident census. This better prepares us to respond to their needs.
So what’s next? The NACCHO grant runs through mid-2021, and our team has already been contacted regarding another grant project that involves more CHP-like activities with specific patient populations addressing social determinants of health. Our team will continue to focus on our small population of high utilizers, but we all know that’s not where the money exists. That is what you do for your coworkers to lessen their load and for your patients to teach them advocacy, health literacy, and disease management.
Every community health paramedic team must find its niche. The word community is key here. You build your program around the needs of your community and the groups receiving focus from other stakeholders.
Matt Zavadsky with MedStar Mobile Healthcare has been a pioneer in the community paramedic world, developing a robust program in the Fort Worth area. Naturally I had followed MedStar’s journey during my career in community paramedicine. I met with him early in 2020 and rode with one of the MedStar MIH paramedics.
I was quickly humbled when Zavadsky told me, “You know you’re doing good things for patients, but the payers want to know the value of your program in different ways. They want to know why they should invest in your program and how it will prove either profitable or cost saving to them.” Those were words of wisdom I will carry on this journey and pass on to others.
Find your place and new places and never forget why you’re doing what you’re doing, even if it’s not exactly what you thought you wanted to do. The reward is in the journey.
Amy Irwin Jarosek has been a licensed paramedic in Texas for 22 years. She began her career as a field paramedic at Austin-Travis County EMS and came to Williamson County in 2002. She joined the Community Health Paramedic team in 2014 and became the program lead in 2019.