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UCSF Healthforce Center: Evaluation of California’s Community Paramedicine Pilot Program

16 Aug 2019 6:12 AM | Matt Zavadsky (Administrator)

The latest report from the Healthforce Center and Philip R. Lee Institute for Health Policy Studies at UC San Francisco. 

The full report can be downloaded at the link below, but we’ve included some outcome highlights, specifically because many of you are evaluating the initiation of similar programs, and one, the Alternate Destination – Urgent Care project seems to be similar to one of the interventions included in the CMMI ET3 model.  The experience and findings in the CA model may help potential ET3 participants refine their programs.

https://healthforce.ucsf.edu/sites/healthforce.ucsf.edu/files/publication-pdf/UpdateEvaluationCACommunityParamedicine.pdf

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Evaluation of California’s Community Paramedicine Pilot Program

Author(s): Janet M. Coffman, Cynthia Wides, Lisel Blash,Ginachukwu Amah, Igor Geyn and Matthew Niedzwiecki

Date: August 6, 2019

Community paramedicine, also known as mobile integrated health, is an innovative model of care that is being implemented throughout the United States. The California Emergency Medical Services Authority has sponsored a pilot project under which specially trained paramedics perform duties beyond their traditional roles of responding to 911 calls, transporting patients to emergency departments and performing inter-facility transfers. Healthforce Center at UCSF is conducting an evaluation of the pilot project that was funded by the California Health Care Foundation.

The evaluation found that community paramedics are collaborating successfully with physicians, nurses, behavioral health professionals and social workers to fill gaps in the health and social services safety net. The evaluation has yielded consistent findings for six of the seven community paramedicine concepts tested. All of the post-discharge, frequent 911 users, tuberculosis, hospice, and alternate destination – mental health projects have been in operation for at least two and one half years and have improved patients’ well-being. In most cases, they have yielded savings for payers and other parts of the health care system. Findings regarding outcomes of a project testing the sixth concept, alternate destination – sobering center, suggest that this project is also benefitting patients and the health care system over the course of its first 14 months. The seventh concept, alternate destination – urgent care, shows potential but further research involving a larger volume of patients is needed to draw definitive conclusions.

Conclusion

The community paramedicine pilot projects have demonstrated that specially trained paramedics can provide services beyond their traditional and current statutory scope of practice in California. No adverse outcome is attributable to any of these pilot projects. The projects are enhancing patients’ well-being by improving the coordination of medical, behavioral health, and social services, and reducing ambulance transports, ED visits, and hospital readmissions. The majority of potential savings associated with these pilot projects accrued to Medicare and Medi-Cal and hospitals that care for Medicare and Medi-Cal beneficiaries because Medicare and Medi-Cal beneficiaries accounted for the largest share of persons enrolled in the pilot projects.

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Alternate Destination – Mental Health

·       The three Alternate Destination – Mental Health projects enrolled 2,045 persons between September 2015 and March 2019.

·       The City of Los Angeles launched an Alternate Destination – Mental Health project in late June 2019 and will be included in subsequent updates to this report.

·       Across the three Alternate Destination – Mental Health projects, 28% to 45% of patients screened were transported to the mental health crisis center rather than an ED. In Stanislaus County, an additional 27% could have been transported to the crisis center if the county had more inpatient psychiatric beds or if the crisis center accepted people with private insurance or Medicare.

·       Transport of these patients directly to a mental health crisis center has reduced the number of persons in EDs who need only mental health services, which can help reduce ED overcrowding.

·       Only 2% of patients enrolled in the three Alternate Destination – Mental Health projects (n = 47) were transferred from the mental health crisis center to an ED within six hours of admission. None of the transfers involved a life-threatening condition, and only four of the patients transferred to an ED were admitted for inpatient medical care.

·       In addition to responding to 911 calls regarding mental health emergencies, the community paramedics in Stanislaus County screen “walk-in” clients, who come to the mental health crisis center on their own or who are brought by friends or family, to determine whether they have any medical conditions that might necessitate transport to an ED instead of direct admission to the crisis center.

·       Law enforcement officers in Stanislaus County report that having community paramedics available enhances their ability to respond effectively to persons with mental illness.

·       The three Alternate Destination – Mental Health projects avoided potential costs of $2.2 million by reducing the number of 911 calls that resulted in an ED visit and subsequent transport of a patient from an ED to an inpatient psychiatric facility.

Alternate Destination – Urgent Care

·       The three Alternate Destination – Urgent Care projects enrolled 48 persons from September 2015 through November 2017.

·       One of the Alternate Destination – Urgent Care projects closed in May 2017, and the other two projects closed in November 2017.

·       Enrollment in the Alternate Destination – Urgent Care projects was substantially lower than anticipated because fewer 911 calls than expected met the strict inclusion criteria and many calls for eligible patients occurred at times of the day during which urgent care centers were closed. In addition, clinicians at urgent care centers were reluctant to treat some conditions, such as a dislocated shoulder, that could be treated safety and effectively in that setting.

·       Most patients enrolled had a laceration or an isolated closed extremity injury.

·       During the time period in which the Alternate Destination – Urgent Care projects enrolled patients, two patients (4%) were transferred from an urgent care center to an ED within six hours of arrival at the urgent care center. Nine patients (19%) were transported to an urgent care center and then rerouted to an ED because clinicians at the urgent care center declined to treat the patient.

Alternate Destination – Sobering Center

·       San Francisco’s Alternate Destination – Sobering Center project enrolled 1,627 persons from February 2017 through March 2019. Two hundred and thirty-three patients (14%) were treated at the sobering center more than once.

·       97.9% of patients enrolled in the Alternate Destination – Sobering Center project were treated safely and effectively at the sobering center. Only 34 patients (2%) were transferred to an ED within six hours of admission to the sobering center, and only two (0.1%) were rerouted from the sobering center to an ED because registered nurses at the sobering center declined to accept them. Only two patients were admitted to a hospital for inpatient medical care.

·       Community paramedics participating in the project provide feedback to paramedics on 911 crews on how to screen acutely intoxicated persons to determine if they are candidates for transfer to the sobering center. They are also collaborating with homeless outreach workers to encourage people who use the sobering center frequently to seek treatment for chronic alcoholism, housing, and other services.

·       San Francisco’s Alternate Destination – Sobering Center project avoided potential costs of $551,257 by replacing ED visits with sobering center services. The majority of potential savings accrued to Medi-Cal because the majority of patients enrolled in the project are Medi-Cal beneficiaries.

·       The Santa Clara County EMS Agency and the Gilroy Fire Department launched a new Alternate Destination – Sobering Center project in June 2018, but the project had not enrolled any patients as of March 2019.

·       The City of Los Angeles launched an Alternate Destination – Mental Health project in late June 2019 and will be included in subsequent updates to this report.


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