Where are the PAs???? Why Paramedics??

[ventana]

Instead of the ER: Paramedics making house calls to chronic patients 

Linda CarrollNBC News contributor

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15 hours ago

Video: Minnesota's North Memorial Health Care system is sending paramedics on house calls with the hopes of reducing emergency room admissions and keep people healthier. NBC's Nancy Snyderman reports.

Emergency rooms — which can cost patients thousands of dollars each visit — have become the primary source of medical care for the uninsured and people with chronic illnesses. 

A Minnesota health care provider is testing a new program in the hopes of reducing ER admissions and keeping people healthier: they’re sending paramedics on house calls to some of the area’s sickest patients who might otherwise end up in the ER. 

The need for such out-of-the-box solutions is clear. In the last year, one in five Americans went to the ER at least once for an estimated 130 million visits. The cost of all those ER visits is staggering, considering that the price for treating some of the most common conditions can range from an average of $750 all the way up to $73,000.

“We don’t screen for insurance at the door,” said Dr. Joey Duren, an emergency physician with North Memorial Healthcare System in Minnesota. “So in our country now, a big thing is that the emergency department is a safety net for people who don’t have insurance.”

Patients with chronic conditions like asthma and diabetes can spiral out of control without regular monitoring and land in the ER multiple times in a single year. The number of repeat patients is often staggering; some of whom visit dozens of times each month, according to North Memorial's chief medical officer, Dr. Kevin Croston.

“What’s really the biggest cost in health care are the chronic conditions where there are readmissions to the emergency department,” Duren said. “We realized we needed to create care that stopped that.”

That’s where house calls from the community paramedics came in. Since the program began last October paramedics have made more than 1,000 home visits, at a fraction of the cost for a trip to the ER. Although North Memorial doesn't have data yet on the savings, officials believe the program will help reduce admissions.

“The role of this community paramedic is helping people get on top of their chronic disease processes so they aren’t getting so sick that they need to come to us in the emergency department,” Duren explained. “We’re controlling their diseases so they can be handled in an outpatient setting versus having to come here or be admitted to the hospital for multiple days because they’ve gotten so far behind in their insulin for their diabetes or their COPD has gotten out of control.”

Chris Anderson is among the first group of paramedics who were specially trained to make house calls. He quickly recognized the value of those home visits.

Video: Chris Anderson of North Memorial Health Care’s Community Paramedic Program explains the benefits of seeing patients in their homes.

“It’s when you get to spend more time with [patients], you get to find out what’s going on, what’s truly bothering them, what they need the most help with,” Anderson said.

The house calls have been a life-saver for folks like 65-year-old Victoria Denbleyker, who suffers from multiple, hard-to-manage chronic conditions, like diabetes, congestive heart failure, and rheumatoid arthritis—problems that used to routinely send her to the ER.

With doctors, Denbleyker said, “you don’t have that much time to really talk to them, even if you get the maximum amount of time, which is half an hour. Sometimes there are too many things going on. “

Without consistent monitoring, Denbleyker’s condition can rapidly descend into the danger zone.

“My system can change in a heartbeat,” she said. “I never know what is coming next. So the fact that they know what is going on with me means a lot.”

The Minnesota project started last October. To figure out which patients might benefit from the program, the hospital searched for anyone who had used the ER nine or more times in a year.

Nine was “the number we had to land on for our own survival mode,” said North Memorial's Croston.

Think that’s a lot?

“We’ve had some patients that were here 23 times in a month,” he said.

Croston said, “readmission rates are down for us as a health system, and that’s largely due to the fact that we’re intervening once they leave the hospital or once they leave the emergency department.”

Barb Andrews, who runs the program, says it’s a new way of thinking about health care.

“It gives us, as paramedics, an opportunity to be proactive rather than reactive,” she said. “The community paramedics empower [patients] to be able to manage their own health better in the home.”

And ultimately, she said, that can “keep them out of the hospital, keep them out of the nursing home.”

[FfIghter23]

Paramedics=Cheap. Not many PA's would take a significant pay cut to do this. I bet these Medics aren't making more than $17-20/hr.

[newguy]

California EMSA is funding trials across the state with paramedics in similar capacities. Europe has fielded similar studies. Relative autonomy and prescribing capability is crucial, which is why almost all of the Euro trials have not shown benefit. This is a role for PAs an NPs, but in very rural areas, I could see medics in a more limited role reporting back to PAs, NPs, MDs with vitals and blood for labs.

[MedicinePower]

My first job as an EMT-B was for $8.75/hr. Paramedics are paid, on average, $18/hr. The very senior paramedics are paid about $25/hr, but that's uncommon. I don't think you'll be able to find PAs who would be willing to work for those wages, sadly.

[ventana]

the paradigm needs to shift from fee for service to $$ saved to the system

 

I do not agree with giving medics a "license to practice medicine" and suddenly compete with PA and NP - sorry PA school is JUST BARELY enough to get your name on a script pad, and although I have some amazing medic friends they simply do not have the knowledge and training

 

I do see that the local Hospital ER might well be able to bill for this service, - heck I have a home visit practice and bill all the time for house calls and the reimbursement is not that bad - why not have large inner city hospitals hiring a PA and a driver to do this?  

 

ER makes money and deceases throughput times (less congested)

Frail patients that don't need ER level services stay away from the ER

Patients are not subjected to the ER for 6-12 hours for simple complaints

PCP's might like it as it stops the huge ongoing waste of work ups on otherwise well patients

Insurance companies like it - cause it costs a lot less

 

 

Just takes the system realizing that the ER is the most expensive and worst place to get PCP services

[GetMeOuttaThisMess]

I would love to offer such a service to a group of internists or family practice physicians. Spend the day making house calls and not have to worry about weekends or after hours call. I have also tried to figure out a way to do the same thing but in an office setting just seeing overflow, same-day patients. Maybe see about eight people a day. What a nice gig; especially if it were tied into the concierge type practice. Use T-System on a pad and sync with the practice after hours.

[Friction]

I know Mesa FD, outside of Phoenix, was playing around with the idea of PA/Medics making house calls to cut down on the volume local EDs were receiving... looks pretty cool to be honest. 

 

http://www.azcentral.com/community/mesa/articles/20130418mesa-trv-medical-response.html

[EMEDPA]

why is an np staffing the "PA Unit"?

[Gordon, PA-C]

My thoughts:

 

Paramedics are adrenaline junkies.  No way in hell are they going to be satisfied doing "house calls" for chronic patients (i.e. drunk, homeless people).  Can you imagine a real field paramedic talking to one of the "house call" paramedics?  

 

Regular paramedic:  "Hey man I got to intubate a 7 month old!  How was your day?"    

 

House call paramedic:  "I got to talk to a couple of diabetics about using their insulin correctly."

 

Regular paramedic:  "LOL have fun with that"

 

 

From the article:

 

"The physician-assistant unit, which periodically has been rotated among stations to measure where it’s most useful, runs for 10 hours Tuesday through Friday and responds to an average of five to seven calls a day. Burgett said people call about everything from flulike symptoms and cuts to urinary-tract infections, back pain, strains and sprains."

 

There's no way in hell you can support a PA salary/benefits on 5 to 7 calls per day.  Double that number and you MIGHT get close.

 

The economics dont make sense -- UNLESS the hospital/ER is paying these units directly AND these units are responding ONLY to uninsured people who would otherwise run up outrageous bills at the ER.  Why would the hospital/ER want to divert its regular paying customers (i.e. people with insurance) away from the ER?  That makes them less money.  It only makes sense to block the uninsured leeches who cost the ER a lot in uncompensated care.

 

 

[dmdpac]

Unless the cost savings from seeing these people in the field is greater than what they'd lose by treating all these people in the ER (without insurance or ability to pay). 

 

I don't actually know what the numbers involved would be.  I'm just thinking out loud.

[Medic207]

Many many things going on with this concept.

 

There are many experiment projects happening now all across the country. The project is physician led and hospital administration driven. Right now the projects are all pretty much underfunded or are operating on grants with hopes for a funding source. Also, the tap dancing around liability is quite a show. There are big concerns that if the responders are hospital employees then any response constitutes a potential EMTALA violation. The rules of engagement are still being determined. If free healthcare responses are being offered that takes the wait out of the ED visit, I'm pretty sure it will become popular by the consumer.

I have a term for that called the Pills on Wheels system.

 

To answer the OP question about where are the PAs...well EMS is at the tip of the spear (so to speak) and are already responding. The logic is to help EMS make transport vs non-transport decisions. My opinion would be that PAs could be involved in the system, but we would be an additional cost, vs the fact we are already paying for the responders. I agree wholeheartedly that trying to make medics into PAs by waving a magic wand won't happen. There is a ton of work on this to make it happen and know body knows if it will save anyone any money at any point in time.

[EMEDPA]

PAs in the field is not a new idea. a few places have tried pilot programs and articles such as this one from JAAPA 2005 have been around for a while:

from jaapa in 2005:
 

Fast track in the field: Another option to ease ED overcrowding
Emergency department (ED) overcrowding is becoming a serious problem in the nation’s hospitals. Many are forced to go on ambulance diversion status because of a shortage of bed space, clinicians, or resources needed to take care of patients. Patients who seek care in the ED often require ED evaluation and are there appropriately. There is, however, a subset of patients who use the ED for conditions that are neither emergent nor, at times, even urgent. Many of these patients do not have access to a primary care provider, or they live in communities lacking adequate free medical resources for the uninsured or underinsured, so the ED becomes their only choice. One option that meets the needs of patients, hospitals, and emergency medical services (EMS) providers is to create a system by which these patients are seen outside of the ED yet receive the same high-quality care from the same providers that they would in an ED setting.

Fast track in the field

The EMS community is advocating for advanced training for paramedics to perform these functions. But, why not use PAs in emergency medicine to fill this void? They already have the requisite skills and experience, and they could rotate between working in the field and in their home EDs.

Many PAs in emergency medicine started their careers in medicine as paramedics and would welcome the opportunity to use their new skills outside the ED setting. I have spoken about this concept with a number of my PA colleagues who previously worked in EMS. The consensus was that they would enjoy the opportunity to return to the field and be able to concentrate on a single patient at a time instead of the six to eight patients that are followed at one time in the typical ED setting. Some unpleasant aspects of being a paramedic would be absent from this system, such as carrying heavy patients down multiple flights of stairs and being awakened in the middle of the night for low acuity cases. These are among the chief reasons many PAs leave EMS to go to PA school.
This system would also benefit EMS because they would no longer have to transport patients with minor complaints to the ED. The large number of nonemergent 911 calls has been a significant cause of burnout and frustration among EMS personnel. The system I am proposing would allow paramedics to focus on what they do best—treating truly emergent patients in the field setting.

How would it work?

The concept would initially utilize a trial ambulance team of one PA and one basic EMT/driver and would be staffed only during the busiest hours of the day. The team would not respond directly to 911 calls but would be summoned after an initial decision by paramedics that the patient was nonemergent and met criteria for field treatment and release. The criteria might involve such complaints as minor lacerations, upper respiratory infections in otherwise healthy persons, prescription refills for noncontrolled medications, ingrown toenails, and so forth. EMS and members of the field group would agree on these criteria in advance. The ambulance company could still bill for a home response and any supplies used, while the hospital ED could bill for the PA’s time and any hospital supplies (such as suture sets) used in treatment.

If a single unit saw a patient every 30 minutes for 8 hours, 16 fewer patients would arrive at the ED and 16 more emergent ambulance calls could be made. Some patients might initially be thought to be appropriate for field treatment and later be found by the PA to need further evaluation. These patients could then be transported nonemergently to the local ED by the PA unit and checked in there in the same fashion as a typical walk-in patient. A busy area could use more than one unit or staff it for more hours daily.
This system would be practical only in a busy metropolitan area where ED overcrowding and a strained 911-response system are daily issues. While using PAs in the field in other settings is an option, there would be no clear benefit to local hospitals or emergency services through such utilization.
Patients would also benefit from such a system. Currently, patients with low-acuity complaints face long waits in EDs, sometimes as long as 4 to 6 hours or more. Field treatment would allow rapid evaluation and treatment of their minor injuries and illnesses, greatly increasing patient satisfaction. Follow-up visits would be done by the same “city call” physicians who see unassigned ED patients after their discharge from the hospital. The patients could also be given a list of local resources, such as primary care providers in the community and social workers who can arrange for federal or state health coverage.

Benefits on many levels

In this system, there would be no decrease in revenue to either the hospital or the EMS company. Members of the team would be paid by their normal employers at their normal rate of pay. No changes would need to be made to the configuration of the ambulances used. The PA could simply carry a tackle box with supplies and a few noncontrolled medications, such as antibiotics. All the pieces are in place for this to work, with very little preparation time involved. The staffing already exists. Oversight would continue per current practices. The supervising physicians of the ED PAs would review the PAs’ field documentation in addition to their regular ED charts. The PAs’ malpractice policy from the hospital would be amended to include work in the field. Hospital EDs would be able to allocate their resources more appropriately to evaluate sicker patients in a shorter amount of time.

This is only the outline of a concept. I hope that this model can be tested in busy urban areas to determine its effectiveness at decreasing ED wait times and improving service to those in need of medical care.

[fakingpatience]

Many many things going on with this concept.

 

There are many experiment projects happening now all across the country. The project is physician led and hospital administration driven. Right now the projects are all pretty much underfunded or are operating on grants with hopes for a funding source. Also, the tap dancing around liability is quite a show. There are big concerns that if the responders are hospital employees then any response constitutes a potential EMTALA violation. The rules of engagement are still being determined. If free healthcare responses are being offered that takes the wait out of the ED visit, I'm pretty sure it will become popular by the consumer.

I have a term for that called the Pills on Wheels system.

 

To answer the OP question about where are the PAs...well EMS is at the tip of the spear (so to speak) and are already responding. The logic is to help EMS make transport vs non-transport decisions. My opinion would be that PAs could be involved in the system, but we would be an additional cost, vs the fact we are already paying for the responders. I agree wholeheartedly that trying to make medics into PAs by waving a magic wand won't happen. There is a ton of work on this to make it happen and know body knows if it will save anyone any money at any point in time.

 

 

 

I was looking into creating a community paramedicine program at the EMS agency where I worked, so perhaps I can shed some light on the EMS side of it.  

 

Our main mission was to reduce the frequent fliers and hospital bounce backs.   The idea was the community paramedic (who was not on a street truck, just a fly car, so no need for 2 staff), would visit those frequent callers every so often (2 weeks- month) and just check in on them at home, ensure they have been keeping up with their health (taking their medication appropriately, that they didn't run out, and they understand how they are supposed to be taking it), and also just be someone there for them; any who has worked in medicine knows that a number of patients go to the emergency room out of loneliness.    For patients' who are hospitalized with a risk of bounce back (main one here is CHF), the paramedic would visit the patient in the hospital on the day of discharge to obtain information from the patient and the hospital staff.  They would then make visits to the patient and determined intervals (next day, next week, next month for example), to check on how they are doing, and that they understand and are following the discharge instructions.  Another goal of this is to catch a patient before they get bad enough to need another hospitalization.  

 

Visits would be billable to a patient's insurance, as they received an "ALS assessment."  This is similar to how many EMS agencies already bill for treat and releases.  However, you are right, currently it is primarily funded through grants.  

 

To be successful, you need to have buy in from the local hospitals and doctors offices.

 

In the research I have done, I have never heard of there being possible EMTALA violations if the community paramedic is associated with a hospital, in fact the more successful programs are EMS agencies that are hospital based, as the hospital has a clear monetary reason to want this to succeed.  

 

As far as sending the community paramedic on 911 calls, there is 1 big problem.  Regardless of how BS the complaint is, if the patient wants to go to the hospital, we cannot refuse transport.   They could respond on the alpha and omega coded calls, and attempt to resolve the complaint at home, however if the patient remains determined that they want ambulance transport to the ER, an ambulance must be called.  

 

I agree that this role would much better fit a PA, the average paramedic training is geared towards emergent complaints, and crisis prevention, this is looking at long term illnesses and management.

 

(Oh, and as far as pay, I'm making $11/ an hour as a paramedic, $20 would be a really high average!)

[EMEDPA]

11/hr as a medic is on the low side in 2013 for many metro areas. our medics make 15-20/hr, 1.5x for o.t., etc

our senior medics(>10 yrs) make 65k/yr without extra shifts. there is a lot of automatic o.t. built into the schedule every week so a lot of their hrs are at $25+/hr.

this is why I always wonder about the folks who accept super low ball offers as new pa grads in the 50-65k/yr range. some of our er techs make that....

[fakingpatience]

Yeah, our pay here (in a rural area) is awful; basics make minimum wage.  My pay was a little higher, but they reworked the pay and I got a pay cut.  The good thing is that, along with ethical and legal issues at the company have finally pushed me to further my education and work towards PA school.  

[GetMeOuttaThisMess]

I would see the cost being split between the local municipal EMS system and the EM group at the base hospital who would most likely be the employer as I see it. As a fringe benefit, do ride-alongs with the 911 service if the municipality would agree. Save the system on EMS transports thus saving dollars to the city and the EM group could still bill for the pt assessment. I'd love to do it. It would have to be a fairly large municipality to justify it. Mine is at ~250K residents outside a U.S. top 10 population base and are looking at available options (not this type though that I'm aware of).

[Medic207]

Actually there really are some cases of EMTALA issues with hospital based systems that has something to deal with the lack of direct medical command/authority. I cannot recall the exact details but it's there, and I really think it deals with smaller based systems. I had to deal with these cases when I was an EMS administrator and was developing policy for a hospital based EMS system. But I regress that was a few years ago, maybe 10.