The final day of the NAEMSP annual meeting featured a half-dozen rapid-fire morning presentations on various aspects of mobile integrated healthcare/community paramedicine.
Medical direction—NAEMSP President Brent Myers, MD, began with a look at medical direction for MIH-CP programs. He broke it down by three basic approaches: the traditional method of standing orders, protocols, and online medical control; the emerging nontraditional approach in which medics are joined by other professionals and can receive guidance from non-EMS physicians; and a nascent PA/nurse practitioner-style model whereby community paramedics consult with medical direction but can practice more or less independently.
Traditional models can still be found in a lot of MIH-CP programs: MedStar’s diuresis protocol, Wake EMS’ high-risk refusal procedure, and Reno’s urgent-care protocol are examples. Where interprofessional teams function under this framework, integration must be purposeful and thorough. Arrangements can vary; Myers cited one system in Florida where medics actually supervise nurse practitioners. “Interprofessional teams can be assembled and operate in the real world,” he assured attendees, the large majority of whom had or were planning MIH-CP programs in their agencies.
A bit more novel is EMS providers working directly with patients’ primary care physicians. This can present a different challenge: Medics are used to giving reports to ED docs in a certain way, but primary care docs will likely have different questions and concerns. Here again it’s important to sit down and get on the same page before you take flight. Myers’ system, Wake EMS in North Carolina, created an arrangement with a primary-care group to treat simple-fall patients from assisted living. The program has reduced falls by 50% with no negative outcomes.
The PA/NP model is still rare, Myers said, but warrants consideration in how we consider MIH-CP medical direction in the future.
Sustainability—MedStar’s Matt Zavadsky, president-elect of the NAEMT, spoke on the financial sustainability of MIH-CP programs. He cited the NAEMT’s newly conducted second survey of such programs and noted that many more systems are now acknowledging their costs. Forty percent of those respondents reported having no financial support for their programs beyond grants.
That challenges programs to demonstrate their value to a range of potential payers who might be convinced to fund programs. That includes hospitals, home health, IPAs, hospice groups, post-acute care agencies, third-party payers, ACOs, and managed-care organizations. State-level Medicaid programs can be among the most agile payers, Zavadsky noted, because they don’t require Congress to act. Some states (Arizona, Minnesota, Nevada, New Mexico) are now paying EMS that way to treat and refer select patients to destinations besides emergency departments. Private insurers are also beginning to pay for such services.
“The payer’s perception of value is really the most important part of this,” Zavadsky said.
Palliative care—Alix Carter, MD, of Canada’s Dalhousie University, addressed an MIH approach to palliative care. Of palliative-care patients, she said, 70% want to spend their dying days at home, raising a need for ongoing care in that setting. Palliative approaches can reduce both costs and aggressive interventions—a valuable role for community paramedics.
Challenges in this area include protocol alignment, medics not knowing their patients, and a lack of clarity in care goals. So when Nova Scotia’s emergency service began its palliative care program in 2015, it required writing practice guidelines focused on symptom management, broad educational groundwork, and a program for managing special patients (managed through a database of patient wishes). The province’s medics strongly believe palliative care ought to be among their activities, Carter said.
Psych patients—Kevin Mackey, MD, medical director for California’s Mountain-Valley EMS, shared the results of a CP psych clearance pilot being conducted in Stanislaus County. Community medics there can refer patients without other medical problems directly to psych facilities. Of the first 1,000 patients treated under the pilot, 285 were eligible for and accepted for such referral, and just 12 had to be sent to emergency departments within the first six hours. Reasons involved behavioral changes, blood pressures out of the psych facility’s acceptable range (EMS’ range was broader), and lack of needed treatments like CPAP.
Of those 12, however, 5 were discharged home and 7 returned to psych care. None had to be admitted to a hospital because of an acute medical problem, meaning medics had correctly screened the sick from the not-sick. That proved the program could be run safely, Mackey said, but improvements were needed in communication with the psych facilities, data exchange, CP turnover, and facility management understanding the potential savings.
Continuing education—Dan Swayze, DrPH, of the Center of Emergency Medicine of Western Pennsylvania, addressed continuing education for MIH programs. He broke down the need by the three familiar domains of Bloom’s Taxonomy: cognitive (what do providers need to know?), affective (what should they value, and how should they act?), and psychomotor (skills performance).
Things like patient assessment and triage fall under the cognitive domain. Swayze and colleague Anne Jensen developed a mnemonic for assessing the needs of community paramedicine patients, CP MERITS. This stands for:
Meals (do patients have adequate food?)
Environment (what is their housing situation?)
Records (some lack even the basic ID needed to apply for various programs and assistance)
Triage in the CP setting, Swayze suggested, may be better approached by evaluating a subject’s situation as ideal, sustainable (not perfect but working for now), unsustainable (for example, about to lose their home), and immediate (e.g., homeless). Systems of care encompass system structure (knowing the hours, services, enrollment needs, insurance policies, etc., of assistance organizations), culture (knowing the “languages” of different stakeholders; not everyone defines emergency the same way), and craft (knowing, for instance, that one person at a partner organization may be helpful and reliable while another is less so).
The psychomotor domain of MIH-CP may involve using new devices and performing new tasks like obtaining blood or urine samples. The affective domain, meanwhile, is the most important but also the most overlooked. CPs require a therapeutic rapport with patients, professional boundaries (CPs have been known to give needy clients their own money or property), and alertness to signs of compassion fatigue (which inevitably results without those well-defined boundaries).
The time you spend on MIH-CP con ed is up to you. Useful methods include review of QI data and use of standardized patients. But if you’re wondering where to begin, Swayze related a question posed to him by EMS legend Walt Stoy, director of the University of Pittsburgh’s emergency medicine program: If you had to lay off half your CP workforce, whom would that be, and why? Swayze’s reasons included poor documentation, poor communication skills, and lack of followup.
That, Stoy told him, is where to focus your con ed.
High utilizers—Finally, Kevin Munjal, MD, looked at pitfalls in evaluating high-utilizer programs. He cited three studies that showed reductions in ED use and EMS transports by patients in such programs but noted that all three evaluated just one group of subjects. This raised the possibility, he said, that results were skewed by the common statistical phenomenon of regression to the mean.
What that means is that a variable that’s extreme on first measurement will tend to be closer to the average on subsequent measurements. In other words, a dramatic decline in EMS/ED use may be less dramatic when measured again.
This, Munjal said, can affect any research where the selection variable (e.g., being a high utilizer) is the same as the outcome variable being measured. There are three ways to compensate:
Add a comparison group;
Take more measurements before and after;
Stagger introduction of your measured intervention so study cohorts are their own control.