Taking the Medical Mountain to Mohammed

Glendale tested a pilot program bringing paramedics’ emergency care into people’s homes.

For seven years, paramedic Gil Mejia was accustomed to the fast-paced action of emergency care: the quick response, the swift assessment of a patient in need, the near-immediate transport to a hospital or care center. When offered a chance to spend more one-on-one quality time with patients — especially seniors — Mejia raised his hand in a flash.

“When you are responding to 911 calls, there is no time to be personable. We are trained to follow certain steps in certain situations,” says Mejia. The Glendale paramedic participated in a statewide pilot program last year that could change the landscape for emergency care by expanding from ambulances and hospitals into patients’ homes. “So many of the people I met over the year made me feel like part of their family, offering me coffee and lunch,” says Mejia. “They would tell me, ‘No one has ever spent this much time with me.’ They were very grateful for the program. It was a very humbling experience for me.”

Called “community paramedicine,” the program expands the role of Emergency Medical Service (EMS) providers to use their life-saving skills in deeper and more extensive interactions with the public. That could be especially helpful for seniors, invested in their own or a loved one’s medical care, who may have great difficulty getting to a hospital. Across the country, community paramedicine has been embraced by many states as a way to provide better care while avoiding boosting the already sky-high costs of insurance and hospitalizations. In 2014, the National Association of Emergency Medical Technicians identified more than 100 community paramedicine services in the country. That number has grown to more than 260 today.

Working with other social-welfare providers, community paramedics can target a variety of health issues; they can help “repeat callers” with chronic conditions that prompt them to dial 911 time and time again, avoiding visits to the already crowded (and pricey) emergency room. Projects elsewhere in California focus on alternative destinations, with paramedics transporting patients to locations other than hospital ERs, such as urgent care clinics, behavioral health facilities or sobering centers.

These new projects allow California to dip its collective toes in the water, testing how a new approach by paramedics would work in the state’s diverse communities, from densely urban to vastly rural. “There is a national movement to transition to expand the role of EMS providers,” says Harold Backer, director of the state Emergency Medical Services Authority. “California is not in the forefront, since we have more restrictive status for paramedics that limit the scope of their work to the scene of the emergency, in transit and at the hospital. But we have outlets to test new roles, and that’s what these pilot projects are all about.”

California’s pilot programs (funded with individual cities’ budgets) have varied in focus, but the goal has been the same: Dispatch paramedics – those friendly, welcoming faces – to prevent a medical crisis rather than respond to one. “Think about it,” says Backer. “Paramedics are perfectly suited to bridge the gap. They go everywhere, are on 24/7 and are trained to deal with anyone – homeless people, substance abusers, etc. It makes sense to use them and their expertise and have them collaborating with existing services.”

California pilot programs ran the gamut from targeting frequent 911 callers and offering alternative destinations to collaborating with hospice nurses for home care and working with public health officials to help monitor tuberculous patients. “Community paramedicine may be a more effective use of our time and resources,” says Glendale Fire Chief Greg Fish. In 2016, his department received 19,446 calls, of which about 86 percent were medical in nature, Fish says, adding, “This idea also lets the patients hold their own health in their hands – and we are there to coach them along.”

The City of Glendale sponsored two pilot projects that ran from September 2015 to September 2016. The one involving alternative destinations enrolled only 12 patients; officials suspect the paperwork load turned off more potential participants. The other project, however, was more successful, enrolling 154 patients with congestive heart failure for home follow-up care after their discharge from Glendale Adventist Hospital. Since these patients typically have high readmission rates, paramedics like Mejia made home visits within three days of the patient’s discharge to make sure they were following doctors’ recommendations and that their lifestyle and home environment were fostering recovery. Follow-up care after congestive heart failure is critical, says Mejia, adding that after a hospital stay, people are often confused and/or weak and “don’t  take their medications properly, don’t make follow-up appointments or revert back to unhealthy eating habits. Some don’t have the support system they need at home to help them make the changes they need to make.”

Mejia first met the patients – most between 70 and 78 years old – in the hospital, told them about the program and got their consent to participate. He spent time visiting them in the hospital, so when they met later in patients’ homes, he would be a familiar face. Bilingual in Spanish and English, Mejia also had an Armenian translator with him when necessary.

His home visits were a stark contrast to his typical emergency response workload. Instead of rushing against the clock, Mejia would spend on average two hours at patients’ homes. “Each patient had a different set of needs and you had to tailor your visits to their needs and their mental stability,” he says.

Mejia monitored vital signs and checked for any possible complications that might require a return trip to either doctor or hospital. He examined the discharge papers, making sure the patient had the correct prescriptions and doses; if not, he made arrangements with the local pharmacy, doctor and insurance company. And he organized the medications (“That was always a huge endeavor”), and confirmed that patients had not only scheduled their follow-up doctor visit but, if necessary, arranged transportation. Mejia also assessed patients’ physical environments: Could they easily get around? Do they have a family to support them? Do they live alone? Is there a neighbor who helps out? Regular home health-care visit? What’s in their kitchen? Are they eating the right kinds of food?

“I would show them how to read a label, especially pointing out sodium levels,” says Mejia. “A lot of them were surprised to realize what they were eating had a lot of sodium in it. As with their medication, once you explained what each one did physically for them, you could see the light bulb go off when they made a connection. Doctors often don’t have time to get down to the details with patients.”

This kind of personalized attention to detail is what will make paramedicine even more effective, says Sandra Shewry of the California Health Care Foundation, which funded the final evaluations of California’s pilot projects. “I think this is the next wave of the future,” she says. “The secret sauce here is using trusted health professionals, especially when seniors want to stay longer in their own homes these days.”

UC San Francisco researchers’ evaluations of last year’s projects show promising successes; the data is expected to be used to develop two state bills, currently in their early stages, that would expand the kinds of services paramedics may provide. Both AB 820, introduced by Assemblyman Mike Gipson (D-Carson), and AB 1650, proposed by Assemblyman Brian Maienschein (R-San Diego), are what are known as “spot bills” – they indicate the author’s interest and intent to make a proposal on a topic but do not contain all the details.

Maienschein explains why community paramedicine could be an important advance, especially when it comes to seniors’ health. “AB 1650 will help increase access to care, while also reducing the overall cost of healthcare — two issues that especially affect the senior population,” he says. “By preventing excess trips to the emergency room and pairing patients with a health care advocate, community paramedicine will protect and promote the well-being of seniors throughout the community.”

But not everyone agrees: Legislators may face pushback from medical organizations that have historically objected to community paramedicine expansion, arguing it may be detrimental to patient care. “We oppose expanding the role of paramedics beyond their current scope of practice because it potentially endangers public health,” says Don Nielsen, Government Relations Director of the California Nurses Association. “The pilot projects for community paramedicine were unnecessary public health experiments that allowed paramedics to undertake care currently performed by physicians, RNs and social workers, without the additional training to acquire the level of expertise and skill needed.”

Elena Lopez-Gusman, executive director of the California Chapter of the American College of Emergency Physicians (CALACEP), says she doesn’t object to paramedics offering services to patients in their homes soon after they’re released from the hospital. “That’s additional care and we aren’t opposed to that,” she says. “But we look at risk assessment and the concept of taking those with mental illness or who are chronically inebriated to facilities other than an ER. They deserve the same care as other patients and shouldn’t be singled out.”

Most medical groups will not take a definitive position – pro or con – until the bills’ details are in print, probably this summer.

Paramedicine for civilians is actually a relatively new idea. Emergency medical services originated in war; in ancient Rome, aging centurions were tasked with removing the wounded from the battlefield and tending to them. Fast forward to the makeshift field hospitals of the Civil War, where triage was introduced; likewise, helicopters (medivacs) were used in World War II and the Korean War to evacuate injured soldiers.

It wasn’t until the 1960s that mobile medical care was provided to the general public; initially, nurses accompanied other medical professionals in the field. Following the passage of the Wedsworth-Townsend Act in 1970, Los Angeles County and City established the country’s first paramedic programs, followed by cities, states and countries around the world.

The concept got a big boost from the fictional 1970s television series Emergency! which followed paramedics on the job in L.A. County. When the show first aired in 1972 there were only six paramedic units operating in three pilot programs; by the time the show ended in 1979, paramedical teams operated in all 50 states.

These days, paramedicine may be poised for a new paradigm shift – and paramedics like Mejia are eagerly awaiting their prospective new duties. “I see the need and how we can make a difference for our patients, many who are senior citizens,” he says. Mejia shares the story of one home visit with a patient who needed to vent considerable frustration for about 20 minutes before getting down to business. “He knew I wasn’t there for that, but he looked me in the eye afterward and said, ‘Thank you for listening. You took the time to hear me and I appreciate it.’ That to me says it all.”