From 2000 to 2010, emergency department visits increased 20 percent — from 108 million to 129 million — according to a 2013 report from the Robert Wood Johnson Foundation.
In 2009, 45 percent of Medicare beneficiaries arriving at hospitals by ambulance were never admitted to the hospital, but they still cost the Centers for Medicare & Medicaid Services $1.98 billion.
ED overuse and misuse are major problems that not only lead to higher health care costs (and readmission penalties under health care reform), but also longer wait times and lower patient satisfaction.
Some hospitals have tried educating consumers about the importance of primary care and the appropriate use of urgent and emergency care. But as long as the ED remains a safety net for people — a place they can go for convenient care, emergency or not — ED misuse will continue.
However, there is an emerging care model that hospitals and health systems can implement to help alleviate overcrowded EDs: community paramedicine.
Community paramedicine, also known as mobile integrated health care-community paramedicine, or MIH-CP, uses local emergency medicine technicians and paramedics to provide services outside of their traditional emergency response and transport roles. It shifts emergency medical services from being solely reactive to incorporating proactive measures that ensure the most efficient use of the EDs — all to reduce inappropriate use of local emergency care resources and improve the overall health of communities.
Each MIH-CP program should be tailored to a community's unique health care challenges and should not duplicate or compete with existing health care services. An MIH-CP program should strive to fill gaps in a community’s care. To achieve this goal, there are three common models of MIH-CP.
Triaging and in-home care. One way an MIH-CP program can reduce ED admissions is by triaging patients who are on a “frequent caller” list before they ever get into an ambulance. When a paramedic responds to a 9-1-1 call from a flagged number, instead of automatically transporting the caller to the ED, a paramedic will conduct an initial assessment — check vital signs, ensure that medications have been taken, and so forth. This assessment will help the paramedic to determine the most appropriate care path.
If it is an actual emergency, the patient will be transported immediately to an ED. However, if it is a nonemergent call, the paramedic can evaluate the situation, contact the patient’s primary care doctor, if available, and determine next steps — all while avoiding an unnecessary and expensive ED visit.
According to a national survey presented by the National Association of Emergency Medical Technicians, 81 percent of MIH-CP programs surveyed that have been in operation for more than two years have reported success in lowering costs related to frequent 9-1-1 users.
In Mesa, Ariz., for example, 9-1-1 calls average around 55,000 per year; more than 10,000 are low acuity or nonemergent in nature. To provide more appropriate care for these residents, the city of Mesa now uses transitional vehicles, staffed with a paramedic and a nurse practitioner or physician assistant, to provide more comprehensive primary care in the caller’s home.
Chronic disease management. An MIH-CP program also can reduce ED volume by proactively managing patients with such chronic conditions as diabetes, heart disease or asthma. These patients’ conditions can escalate quickly into emergencies — and hospital readmissions — if not properly managed.
With an MIH-CP program, EMS providers can make house calls to check on these patients: ensure that they are taking medications properly, perform basic blood and vital sign tests, and answer questions or concerns. This expanded paramedic service not only benefits the hospital through reduced ED visits and hospital readmissions, but also benefits the patients, as the delivery model will help to improve their overall health and ability to care for themselves.
New Hanover Regional Medical Center in Wilmington, N.C., used its hospital-owned EMS to start a community paramedicine program that targeted frequent users of 9-1-1, typically patients dealing with chronic diseases. In 2013, the program identified a young woman who had made 22 inpatient visits and 10 ED visits within a 12-month period — all relating to a manageable chronic disease. Its community paramedicine program established a relationship with her, which resulted in her having only two inpatient visits between October 2013 and the end of July 2014.
Extending primary care. A third way an MIH-CP program can improve the overall health care delivery system, and thus reduce ED volumes, is by expanding primary care to those patients with limited access to health care providers.
In Eagle County, Colo., concerned leaders established a community paramedicine program that collaborates with social services, nursing and other health care providers to provide outreach services to their rural communities. Through the program, county residents have access to disease management, well-baby checkups and even prenatal care.
Extending primary care through MIH-CP also could involve hospital discharge follow-up care. EMS providers can make scheduled house calls to review discharge instructions with patients, ensure that medications are being taken properly and assist in scheduling follow-up appointments with primary care providers.
An MIH-CP program also presents two important business development opportunities, especially for rural and critical access hospitals. First, creating an MIH-CP program positions a facility as more than just an ED: It’s a community health resource. Overall health and wellness is a significant component in today’s health care environment, and it is a highly marketable message.
Second, an MIH-CP program establishes a strong connection between a hospital and the local EMS. This connection will help to ensure that rural facilities and critical access hospitals don’t get passed up when emergencies occur. Through the partnership an MIH-CP program will create, emergency medical services will fully understand a rural facility’s capabilities and will, therefore, feel comfortable bringing patients there for care. While the ultimate goal of MIH-CP is to decrease ED overuse, appropriate emergency care is still an important entry point for rural hospitals to connect with patients.
Health care leaders should consider the following factors before developing an MIH-CP program:
Run the numbers. Encourage all team members to fully explore the cost savings of implementing an MIH-CP program.
Get everyone on board. Involve medical staff, the quality team and local emergency medical services in all aspects of the program evaluation process.
Learn from the success of others. Examine best practices throughout the country.
Be strategic. Integrate MIH-CP into your organization’s overall strategic organizational plan.
Lowering the number of inappropriate ED visits by providing preventive and primary care can improve the health of your community and lower costs. A proven way to do this is to implement a mobile integrated health care-community paramedicine program.
Michael Milligan is the president of Legato Healthcare Marketing in De Pere, Wis.