Look for paramedics in primary care, public health roles, especially where resources are scarce
Emergency medical services are looking for a shot in the arm. They hope to get it by delivering immunizations, providing primary care, and taking on expanded triage responsibilities. For many communities, the shift in orientation better reflects what residents need, and the fact that a huge portion of so-called "emergency medical service" does not call for lights and sirens.
"Our whole system is tied to moving people. What we’re finding out is that’s not always a good idea," observes Barak Wolff, chief of New Mexico’s emergency medical services (EMS) bureau.
EMS to become fully integrated’
Instead, EMS systems are refashioning themselves as front-line providers, particularly for rural or underserved communities. The next century’s EMS system will be "fully integrated with the overall health care system" and will "contribute to the treatment of chronic conditions and community health monitoring," according to an EMS agenda for the future published in the February 1998 Annals of Emergency Medicine. The consensus document, three years in the making, was commissioned by the National Highway Traffic Safety Administration in cooperation with the Health Resources and Services Administration.
The challenge for EMS has been to win the recognition and reimbursement that comes with the additional responsibilities. The more spectacular gains have been in smaller or relatively isolated communities.
The snow-skiing resort of Red River in north-central New Mexico has it all—great slopes, restaurants, nightspots—but, until recently, there was no physician. Of necessity, EMS providers there became what the local fire chief calls "closet primary care providers." By the early 1990s, though, chief Ron Burnham saw an opportunity to improve the quality of his system. Supported by grants and working with health care providers 40 miles away in Taos, he developed a curriculum to teach paramedics the basics of primary care, public health, and triage.
Giving poor customer service
"Before, we had two choices," says Mr. Burnham. "We could load them into an ambulance and take them to a hospital emergency room, or get a signed refusal of care if they didn’t want that. Well, that’s not very good customer service."
Now, when people present to the EMS system, one of four scenarios unfolds:
1. The patient is transported by ambulance.
2. Paramedics take a medical history, and, at the scene, contact either the system medical director or the patient’s own doctor for further direction.
3. The patient is evaluated, given some "temporizing therapy," and referred to follow-up care.
4. The patient is managed by a paramedic without referral to or immediate consultation with a physician. Charts of all the patients in this fourth category undergo chart review by a physician.
Although Medicare and Medicaid do not pay for non-transport EMS care, fees from direct patient billing and some third-party payers are enough to cover the program’s modest personnel and training costs, Mr. Burnham says.
The response from the community has been "overwhelming," says Mr. Burnham, raising the daily number of calls from one or two to 18 to 20. "And from a medical point of view, it’s been safe," he says.
The very success of the program may have slowed its growth. After a beefed-up EMS system made it less scary to be a solo practitioner in Red River, the community of 500 permanent residents secured a few hours each week on the schedule of a primary care physician in July of 1998. Mr. Burnham says it’s "fine" that the number of daytime calls to EMS has declined somewhat since then. He maintains his system isn’t in competition with other providers; the real concern now is making sure the tiny town is ready for the 12,000 winter residents who flood the area.
"The success of the program usually is dependent upon the availability of local resources," says American Ambulance Association administrative director Mike Harmon. "Where local resources are scarce, these projects seem to do better." Mr. Harmon’s Sacramento, CA-based association generally supports the development of so-called "expanded scope" emergency medical services and has developed training material to instruct EMTs and paramedics on basic primary care and similar services.
Testing assessment skills
When the proportion of uninsured patients grew to about 30% of their transports, officials with Rural/Metro Medical Services of Central New York in Syracuse looked for a way to reduce the load and improve care. Beginning in early 1999, paramedics specially trained in assessment skills, while continuing to operate as usual, will document instances in which they would have treated and referred the patient to follow-up care. Rural/Metro expects the trained paramedics to match the judgment of a physician panel at least 90% of the time as well as outperform colleagues without such training.
The additional training is designed to give paramedics the skills to recognize and treat nonemergency conditions that can be stabilized until a visit to a physician the following day. For example, earaches alone account for between 800 and 1,000 of the system’s 32,000 transports annually, says Mike Addarrio, general manager of Rural/Metro.
The catch is that no one is offering to pay for such services, at least not yet. Rural/Metro picked up the $50,000 tab for the study and hopes to get the attention of Medicaid and managed care officials with the results, which are due in late 1999.
Unlike New Mexico, where state law specifically allows EMS systems to make a case for an expanded paramedic scope of care, New York limits the flexibility of paramedics to triage care at the scene. State regulations require that EMS systems honor a request for transport to a hospital, even when it does not seem to be clinically indicated, Mr. Addarrio says.
All Jan Warfield wanted from her local fire department in Austin, TX, was a place to hold an immunization clinic. The outreach coordinator with the state’s Division of Immunization thought the idea couldn’t miss—the bells, fire trucks, maybe even bunker gear would attract kids like a magnet.
"Once I started talking to the paramedics, I realized they could give the shots themselves," says Ms. Warfield.
Now she’s sold on the idea. Austin’s 38 firehouses provide convenient and safe places to hold the clinics, and the site is certainly a lot more fun than a health department clinic. Similar efforts are under way in Corpus Christi and Harker Heights, she says.
The fire departments are not paid to provide immunizations, but the clinics provide another way for the fire department to document its value to the community, Ms. Warfield says.
Officials in Orange County, NC, are convinced their efforts are saving local taxpayer dollars, even though Medicare and Medicaid don’t recognize the $100 charge for their non-transport treatment and referral services. Reducing the number of transports during the last two years has allowed the county-owned system to avoid about $800,000 in the costs of buying, equipping, staffing, and housing two new ambulances, says Nick Waters, the county’s director of emergency management.
The county uses paramedic-staffed sedans when a careful screening of the call suggests there is no need for haste. A system of fire trucks and ambulances for first response and transport still are in place for emergency calls, but the use of lights and sirens has decreased 80% under the new protocols.
"We will roll lights and sirens on those calls where response time makes a difference. Most of the time it doesn’t make a difference," Mr. Waters says.
Using 12-hour shifts
The Orange County system also is rethinking the traditional 24-hour shift, which assumes paramedics will nap or relax between calls. Shifts are 12 hours long, but they’re full. Between calls, for example, paramedics may visit the homes of new parents to provide safety and health information as part of the system’s "Welcome to the World" program. The effort has been very successful not only in providing care but also in getting the community used to paramedics in a nonemergency role, says Mr. Waters.
Clinical outcomes improved since the new triage system was implemented in the fall of 1996, with the county’s out-of-hospital save rate on cardiac arrests rising from 6% to 20%. Orange County’s treat-and-release protocols for nonemergency care free up ambulances and skilled personnel to better respond to the most critically ill in the community, Mr. Waters says.
The county began billing Medicare, Medicaid, and private payers for transports when it restructured operations. Officials are using the new revenue to offset the costs of the nonemergency sedans, additional equipment, and contracts with local volunteer squads to staff a slimmed-down ambulance schedule.
"It is the most effective, efficient approach to patient care, and at some point, Medicare, Medicaid, and insurance are going to realize it," Mr. Waters says.
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