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|Community Paramedicine Is at the Forefront of Home Care Medicine|
Community Paramedicine Is at the Forefront of Home Care Medicine
By Linda DeCherrie, MD
Community paramedicine (CP) provides personalized and coordinated care to patients in their home as an alternative to traditional sites of care, with the goal of improving access to care or avoiding unnecessary hospitalizations and emergency department visits. The term CP refers to many different types of programs. Often, many of these differences arise from differing regional needs and the wide scope of paramedic practice. In addition, there are variable certification requirements needed for physicians who oversee paramedics.
The CP program was started last year at Mount Sinai Visiting Doctors (MSVD) in New York City. MSVD is a large, home-based primary practice that serves 1,700 patients annually. Despite MSVD’s robust on-call and urgent-visit system, we found that patients still frequently went to the emergency room and were unnecessarily hospitalized. The Mount Sinai Community Paramedicine program sought to address this disparity.
Our program works as follows: when an MSVD patient calls with a potential emergency, the on-call MSVD physician can dispatch a non-911 emergency medical services (EMS) unit staffed with specially trained paramedics to evaluate the patient at home without an immediate or automatic transport to the hospital. Paramedics participate in real-time consultation with the MSVD physician over the phone or with the use of video teleconference technology to care for and treat the patient. The physician and the patient or his/ her caregiver share the decision of whether the patient can be treated at home or should be transported to the hospital.
Prior to participating in Mount Sinai’s Community Paramedicine program, physicians and paramedics are required to complete a specialized training program. Physicians are certified with a limited license in online medical control for nontrauma for patients in their practice. Paramedics complete a full-day workshop and didactic training on the care of the frail elderly, supplemented by a day of shadowing home-care providers during their daily rounds.
One of the largest barriers to CP programs is reimbursement. Our program is grant funded by the Fan Fox and Leslie R. Samuels Foundation and the David L. Klein Jr. Foundation. EMS typically is not reimbursed by payers unless a patient is transported to an emergency department (Munjal & Carr, 2013; Morganti, Alpert, Margolis, Wasserman, & Kellerman, 2014). Therefore, alternate funding sources, such as state or grant funding for development and training, are needed. A strong economic case for community paramedicine must be made to demonstrate to public and private insurers the need for reimbursement (Morganti, Alpert, Margolis, Wasserman, & Kellerman, 2013).
Despite this issue, community paramedicine is a novel solution to address the complex needs of patients with high healthcare spending patterns, such as homebound elderly patients. CP has the potential to relieve overburdened healthcare delivery systems and prevent unnecessary use of emergency departments by elderly patients.
Munjal, K., & Carr, B. (2013). Realigning reimbursement policy and financial incentives to support patient-centered out-of-hospital care. Journal of the American Medical Association, 309(7), 667-668.
Morganti, K. G., Alpert, A., Margolis, G., Wasserman, J., & Kellermann, A. L. (2014). Should payment policy be changed to allow a wider range of EMS transport options? Annals of Emergency Medicine, 63(5), 615-626.e5.
Alpert, A., Morganti, K. G., Margolis, G. S., Wasserman, J., & Kellermann, A. L. (2013). Giving EMS flexibility in transporting low-acuity patients could generate substantial Medicare savings. Health Affairs (Millwood), 32(12), 2142-2148.
I would like to acknowledge my colleagues who also contributed to our project and this piece: Kevin Munjal, MD; Deepa Chellappa, MS; and Ramiro Jervis, MD.