Community Paramedicine: Filling Gaps in Healthcare

Community paramedicine is a healthcare delivery model that increases access to services through the use of emergency medical technicians (EMTs) in an expanded role, such as performing patient assessments, assessing and advising on the safety of a patient’s surroundings, and other procedures that can improve a patient’s quality of life. Community paramedics care for patients at home or in other non-urgent settings outside of a hospital under the supervision of a physician or advanced practice provider.

As first responders, EMTs are trained to focus primarily on managing a patient's immediate emergency medical condition. Community paramedics, in contrast, are part of a larger care team focused on ongoing and long-term medical care for patients. After having received the standard EMT training, a community paramedic will receive additional training in health education, monitoring, and services. The Washington State Department of Health maintains a list of approved paramedic education programs, while California partnered with the UCLA Center for Prehospital Care to develop a statewide Community Paramedic pilot training.

Because community paramedics can meet community members where they live, they are better able to identify and address barriers to accessing care and addressing health challenges, as well as broader social determinants of health. Broadly, the goals of community paramedicine are to reduce emergency department visits, hospital admissions/readmissions, and medical costs and to allow people with chronic conditions to continue to live independently. 

The Role of the Community Paramedic

The original intent of 911, or the emergency medical system (EMS), was to provide patient care for acute or emergency events. However, today’s emergency responders are often as likely to respond to calls that are not true emergencies as they are to acute events. While an individual may still need medical care, it might not be the life-threatening crisis that 911 was meant to address. This is particularly true of vulnerable populations that lack access to primary care, including homeless individuals, the un- or underinsured, and residents in medically underserved areas.

Community paramedicine can provide vulnerable populations with the resources they need, avoiding costly emergency room visits and even connecting patients to additional social or behavioral health services in the community. Populations targeted by CP programs include the chronically ill, post-hospital discharge patients, and frequent users of 911. Community paramedics generally focus on:

• Providing and connecting patients to primary care or social services.
• Completing post-hospital follow-up care.
• Integrating care plans with local public health agencies, home health agencies, health systems, and other providers to ensure that services are not duplicated in the community.

Many EMS systems in the United States have community paramedicine programs, including several here in Washington State, though the exact nature of the services provided, how these are provided, and by whom differs according to local needs and existing resources.

Here is an overview of a few programs in Washington state.

Bellingham/Whatcom County

The Bellingham Fire Department's Community Paramedic program was established in 2014 with the aim of reducing EMS calls by identifying frequent 911 users with non-emergent needs and connecting these individuals to more appropriate services. The fire department’s website notes that the program serves individuals with complex medical needs “related to aging, disabilities, mental health, substance abuse, mobility, or homelessness.” 

The program is funded through the city’s general fund, and in 2017, the fire department reported that calls to 911 from paramedicine program clients had decreased from 500 in 2015 to 428 in 2017. A 2016 voter-approved Whatcom County EMS property tax levy, which included funds to expand paramedicine services, will allow the Bellingham program to cover all of Whatcom County (In fact, the Whatcom County Community Paramedic Program announced its launch in September 2019 of this year).

Snohomish County

The South Snohomish County Community Paramedic program began in 2014. Through the program, South Snohomish County Fire & Rescue (SSCFR) partners with Compass Health and area social service agencies to identify and assist frequent users of the 911 system (anyone who calls two times in 24 hours or three times over a 30-day period). Paramedics will follow up with an individual through a telephone call or a home visit to conduct a medical assessment and a home safety survey to prevent falls and other risks. A Compass Health mental health counselor and a peer counselor work out of SSCFR headquarters to assist in responding to behavioral and social service needs. The program is paid for through property taxes that support SSCFR, although it also received a 2-year grant from the Verdant Health Commission.

Camano Island

Begun in 2015, the Camano Island Fire and Rescue Community Paramedic Program targets three demographic groups: the homeless, people living with a chronic illness, and the elderly. Its success is apparent in the 2017-20 Island County Community Health Improvement Plan, which calls for expanded services through a health outreach model based on community paramedicine or use of such approaches as telemedicine, telepsychology, and community health workers.

Changes to State Law

Prior to 2014, EMTs were only authorized to provide care to individuals during an emergency. In 2014, at the urging of emergency responders and health care providers, the state legislature passed SSB 5591, which gave EMS providers across the state the ability to develop community assistance referral and education services (CARES) programs and allowed EMTs and advanced EMTs affiliated with CARES programs to provide non-emergency health services. It also allowed EMS providers to seek grants and private gifts to support the development of local CARES programs. 

When the state received a federal waiver in 2017 to provide incentives to improve the health of Medicaid recipients, one of the incentives targeted was community paramedicine. That same year, E2SHB 1358 was passed by the legislature and signed into law. This law directed the state Healthcare Authority to adopt reimbursement standards for public fire and EMS agencies providing services to Medicaid patients who do not require transport to an emergency department, shifting EMS away from a fee-for-transport model. The Healthcare Authority announced just this past summer that it would begin reimbursing “publicly owned or operated ambulance providers for services provided pursuant to (CARES) programs,” provided the agencies complete the required paperwork.

Funding

As with many new programs, funding is one barrier to starting and running a community paramedicine program, but a new federal program, similar to what Washington State already has in place, could offer some help. In February 2019, the U.S. Department of Health and Human Services announced a new payment model for EMS providers to test out different ways of rerouting 911 calls. Under Emergency Triage, Treat and Transport the Centers for Medicare and Medicaid Services will pay participating providers for:

• transporting an individual to emergency facilities;
• transporting an individual to alternative destinations, such as a primary care doctor’s office or an urgent care clinic; or
• providing treatment in place. 

Given that community paramedicine was designed to reduce costs related to emergency medical care, community paramedicine programs should develop strong partnerships to ensure that medical care is not duplicated across area providers. Programs that can demonstrate the efficient and effective delivery of healthcare and social services to some of the state’s most vulnerable residents will be much more attractive to funders.