New Riders of the Purple Sage: Community Paramedicine


Say the word “paramedic” and most people think of the men and women who respond with flashing lights and screaming sirens when someone suffers a medical crisis.

But what if there were a way to provide help before the crisis happens?

Across the country, health care companies are implementing a new strategy to deliver help to the people who need it most, and in some cases prevent needless and costly trips to the emergency room. And it’s paramedics who are providing the help – without the drama of a speeding ambulance.

They are part of the emerging national trend called community paramedicine – an effort where licensed paramedics meet and treat the chronically ill where they live. In many instances they travel just about whenever and wherever needed, from the inner city to rural sprawl, from emergency rooms to homeless shelters.

A New Twist to an Old Tale
It’s a wrinkle in the customary role of paramedics rushing patients to the emergency room. This new model focuses instead on paramedics talking one-on-one with habitual ER users – those who often use costly ER services when a primary care doctor could handle their issue. The paramedics teach these new patients to address their health issues so they don’t require hospitalization and help those who have trouble managing chronic conditions.

In New Mexico the story began in 2014 when the state expanded Medicaid coverage. Suddenly, more than 130,000 adults were eligible for insurance. Some of the new recipients didn’t even have a primary care doctor. In January 2016, Blue Cross and Blue Shield of New Mexico (BCBSNM) began offering health insurance options to those who were eligible. Of the roughly 40,000 who enrolled with the insurer, 400 were flagged as habitually using the ER as their primary care provider.

“We saw people using the ER if not weekly, then up to two to three times a week, up to 27 or more times a month,” said Kerry Clear, who manages the insurer’s community social services program. “When we launched our program, we had 15 high-ER users during a six-month period who accounted for about 686 ER visits alone. Using the ER as a primary care doctor is very expensive.”

Providing a Solution
Realizing that prevention and education are critical to reversing costly, inappropriate ER usage and hospital readmission, the team at BCBSNM had a hunch. In a pilot program, it contracted with two state-based emergency medical service companies to assign a paramedic to each of the 15 members. It was one of New Mexico’s first ventures into community paramedicine, and it was a perfect match. Since they had frequently relied on paramedics to get to the hospital, these members trusted their new medical guardians.

Paramedics visited each of the 15 high-usage members at home for about 90 minutes. They discussed their patient’s medication needs, suggested home-health safety improvements, explained available assistance and checked their vital signs. They even helped find in-network doctors for members who didn’t have one.

The clients saw paramedics as healers rather than paper pushers, Clear said. The results were impressive. We were able to reduce ER visits for all 15 members from 686 visits to an average of 115 visits per month within the first couple of months.

The pilot project’s success prompted BCBSNM to extend community paramedicine outreach to other Medicaid insured who need it the most.

A New Chapter
Ranked in 2015 as the nation’s 37th overall least-healthy state, New Mexico represents a health care challenge. Aside from the obstacles to care created by poverty and other socioeconomic factors, the state faces steep rates of hospital admissions for chronic health issues. These issues include everything from diabetes and heart failure to chronic obstructive pulmonary disease, hypertension and more.

The predominantly rural state also has a shortage of primary care doctors. Recently, it averaged about one doctor for every 1,310 residents statewide. But some counties struggle with a ratio of just one for every 15,700 residents. No matter where they live – city or country – many Medicaid recipients face the isolation of time, distance and poverty when it comes to health care.

To serve its Medicaid members, BCBSNM has contracted with three ambulance companies – Albuquerque Ambulance, American Medical Response and Rio Rancho Fire Department. Currently 18 full- and part-time paramedics serve Medicaid recipients in areas most in need: Bernalillo County, which includes Albuquerque and the nearby East Mountains; parts of Sandoval County, which includes Rio Rancho, Corrales and Bernalillo; Valencia County to the southwest; and Doña Ana and Otero counties to the south, home to Las Cruces and Alamogordo. Their combined territories encompass more than 14,000 square miles – an area larger than Connecticut, Delaware and Rhode Island, combined – with about 5,000 square miles to spare.

According to a 2016 survey, the National Association of Emergency Medical Technicians found that 210-plus agencies in 40 states have created community paramedicine programs. More than 80 percent of the programs in effect two years or longer reported success in reducing costs, 911 use and ER visits, the survey found.

BCBSNM has seen similar success. Since January, contracted paramedics have visited more than 1,100 high-ER users and Medicaid recipients recently discharged from the hospital. Of those visited, repeat visits to the ER have dropped 61 percent while hospital readmission rates have dropped to where just 9.7 percent of the members are readmitted The company is hoping soon to expand community paramedicine to San Juan County and the cities of Santa Fe and Taos.

Riding into the Sunset
“As paramedics, we see people from all walks of life,” said Amy Kettleson, a paramedic with Albuquerque Ambulance.
“We’ve been asked by clients to meet at fast food restaurants because they live out of their car and that’s a convenient location for them. A lot of the people we meet have been in a difficult situation for a while. We are happy to meet with them where they prefer and to just talk.”

It’s not uncommon for paramedics to visit Albuquerque’s three homeless shelters. In fact, it can take a bit of sleuthing to track hard-to-reach members. Kettleson said a member repeatedly agreed by phone to meet but then always canceled the visit beforehand. Finally, Kettleson showed up at his home unexpectedly, introduced herself and he agreed to discuss his health. “He was so thankful afterward,” she said.

“If there is a common thread among the high-ER users we’ve seen, it’s that they are struggling with alcoholism or drug abuse and sometimes homelessness,” said paramedic Shelley Kleinfeld of American Medical Response. “The youngest I’ve seen is a 6-month-old and the oldest an 80-year-old. Just about everyone we meet to discuss their health and their options are thankful. They like the reassurance that someone cares and drops in on them to see how they are doing.”

 

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