A small but growing number of hospitals around the country are finding that paramedics can do more than just "scoop and run." Places such as Wake County, N.C., are making use of more experienced advanced-practice paramedics, or APPs, to carefully coordinate care and get patients to the right setting, rather than funneling them all to costly and scarce emergency department beds.
"We're not trying to compete with existing entities," says Brent Myers, M.D., the medical director of the Wake County EMS System in Raleigh, N.C., who helped develop the APP program. "We're not trying to supplant somebody else; we're trying to supplement and provide the best care for our patients."
The primary duty of Wake County paramedics still is responding to emergencies, but Myers estimates that emergency medical technicians only spend about 20 percent of their time on urgent calls. The second element of the program involves using APPs — who are required to have a minimum of 1,000 patient encounters and attend to about a dozen cardiac arrests each year — to divert nonurgent patients away from ED beds and into more suitable sites, such as mental health facilities or substance-abuse centers. All told, APPs have diverted some 200 patients with no adverse outcomes, and opened up 2,500 ED bed hours at local hospitals.
"We have tried to, on all levels, intercede and help patients arrive at the place that's closest to where they are and the most appropriate for them to be seen," says William Atkinson, president and CEO of WakeMed Health & Hospitals, also in Raleigh. "All the way around, it reduces the cost to the patient; it reduces the cost to the system; and it reduces the cost to the emergency providers."
The third element of the program involves partnering with a local primary care group and assisted-living facilities to treat older patients who have fallen, before they end up in the ED. Thus far, about 230 patients have consented to take part in the program, and APPs have responded to 33 who had fallen. Sixteen of those falls didn't require a transport and, instead, a primary care physician followed up and visited the senior at the assisted-living facility.
Myers, who's something of a guru in mobile integrated health care, says that few county health departments are using paramedics in such a fashion — less than 1 percent, he suggests. Interest is growing, though, as hospitals look to move away from uncoordinated, episodic care; however, hospitals need to have the workforce to make it happen and incentives for paramedics who often are only paid for ambulance-based transport.
"[Of] the places that are trying this, I'm not aware of any that have started and gone backward," Atkinson says. "I think it is the wave of the future. Now, this is the tip of the spear, for sure, but this isn't going backward."