Kenneth W. Kizer, M.D., was a firefighter when paramedicine was emerging in the Los Angeles area and, as director of California Emergency Medical Services Authority in 1983, he wrote the regulations for paramedicine in the state. Now he is a thought leader in population health — and an advocate for community paramedicine in value-based care.
You have defined community paramedicine (CP) as “a new and evolving method of community-based health care in which paramedics function outside their customary emergency response and transport roles in ways that facilitate more appropriate use of resources and/or enhance access to primary care for underserved populations.” What is the state of CP currently?
KIZER: I’ve seen paramedicine evolve from its earliest days to where it is now, and I think community paramedicine is perhaps the next big evolution for paramedicine.
There are programs in varying stages of development in more than 20 states and more than 150 communities. The programs are spreading pretty rapidly, and I think they will continue to do so.
Community paramedicine is an important component of population health management and the new emerging value-based health care economy because it fills gaps in the typical health care delivery infrastructure that are especially relevant to value-based payment.
The focus of CP programs varies widely — from paramedics providing directly observed treatment for tuberculosis patients at their homes to providing transportation to health care facilities other than emergency departments and many other concepts.
What do you consider to be the most promising applications for CP?
KIZER: The programs that respond to the 9-1-1 superusers hold a lot of promise for better utilizing scarce emergency care resources, including ambulances and hospital emergency departments. We know that in many communities some people call 9-1-1 multiple times per week when what they really need is help with basic primary care or other support services. Many of these persons may be homeless or have mental health needs or other problems that are not always better managed in the ED.
Another type of program that I think is going to prove to be very helpful is one that provides follow-up care after a hospital discharge or an ED discharge. These programs serve patients before they can get in to see their usual provider or — probably more often — until they can establish a relationship with a regular health care provider.
I also think CP programs that provide in-home care for frail elderly persons who have multiple chronic conditions and may have limited mobility are going to be quite successful. These patients may have cognitive issues that impair their ability to comply with medication or other treatment regimens. They may lack transportation. And too often their only resource is to call 9-1-1 and take an ambulance to the hospital ED, when their needs could be much more economically and effectively — and I would argue, compassionately — dealt with by paramedics who come in to help them with their medications or wound care or whatever their individual needs may be at the moment.
Despite its obvious merits, telemedicine has been slow to gain widespread adoption until recently. Do you expect CP to have a similar slow path to reaching its potential?
KIZER: Community paramedicine shares many of the same barriers and challenges that telemedicine does, although it has some things working to its advantage that I think will speed up its widespread implementation.
For many providers and patients, telemedicine is a really new way of delivering or receiving care and it requires the provider to buy new technology, which people then have to become familiar with. By contrast, paramedics are an already existing and very large workforce that is well-integrated into local communities and very well-trusted and highly regarded by the public. Another advantage that CP has is the rapid evolution to a value-based economy in which it can fill a clear and demonstrated need. CP provides a bridge between primary care and emergency care and can fill gaps in the underlying health care delivery infrastructure that exist in so many communities across the country.
One of the barriers for the widespread adoption of community paramedicine is the limited data about safety, efficacy and long-term outcomes. Many different models of community paramedicine have arisen independent of each other to address particular local needs. As a result, there is a lot of variability in exactly what CP programs do, so it is difficult to compare outcomes from one program with outcomes from another — or to combine data from different programs to analyze CP in the aggregate. Various programs have demonstrated they have reduced 9-1-1 calls, ED visits, hospital admissions and readmissions, and emergency transport charges, but those data are not as compelling as what either Medicare or other health care payers generally want to see before they decide whether they’re going to cover a new service.
And that leads to another barrier — reimbursement for services — that CP shares with telemedicine. Most of the CP programs to date have been developed out of grant monies or other short-term funding. And some of the programs have closed shop because they were not economically viable in the long term. The interrelated problems of outcomes data and reimbursement have to be addressed for CP to move forward.
In response to a recommendation from your report — “Community Paramedicine: A Promising Model for Integrating Emergency and Primary Care” — California authorized several CP pilots. What is the purpose of these pilots?
KIZER: In California and a few other states, paramedics’ scope of practice is defined both by what they do and where they do it, unlike most other health care workers for which the scope of practice is just what they do. Our recommendation was that the state needed to do pilots to establish safety, efficacy and outcomes data as a basis for changing the state laws to permit community paramedicine.
There are 12 pilots underway. The largest number of those have paramedics providing transportation to destinations other than a hospital ED, such as a mental health clinic, an urgent care clinic, a doctor’s office or a sobriety center. Another group of pilots allows paramedics to provide follow-up care after an ED or a hospital discharge.
Other pilots are experimenting with different models of community paramedicine. The pilots are still underway, and an assessment should be completed in 2017.
How does CP fit into the current health care delivery system?
KIZER: Emergency medical services are clearly a well-established and essential part of the health care delivery system, but are often viewed as outside of the usual care delivery system. Many physicians who don’t interface with the emergency care system don’t really understand paramedics or how the pre-hospital care system works.
Physicians and health system leaders need to see CP as a very promising model of community-based care that can help to support their population health management goals and their clinical integration goals and help them to thrive in a value-based health care economy.
THE KIZER FILE
- Serves as founding director of the Institute for Population Health Improvement in the UC Davis Health System
- Engineered the turnaround of the Veterans Affairs health care system, including deployment of the largest electronic health record in history, during his tenure as under secretary for health in the U.S. Department of Veterans Affairs from 1994 to 1999
- Led efforts to establish quality performance measures, evidence-based health care safety practices and public reporting of performance data when he served as founding president and CEO of the National Quality Forum, 1999–2005
- Headed the California Department of Health Services from 1984 to 1991, leading the state’s response to the HIV/AIDS epidemic, establishing its groundbreaking tobacco control program, implementing the largest population-based cancer registry and the largest birth defects monitoring program in the world, and founding the "5-a-Day" for better health nutrition program later adopted by the National Cancer Institute
- Elected to both the National Academy of Medicine and the National Academy of Public Administration
- A fellow or distinguished fellow of 11 professional societies
- Co-founder of the Wilderness Medical Society, a former U.S. Navy diver, and an expert on diving and aquatic sports medicine and the medical aspects of wilderness activities