North Memorial is celebrating a year of breaking new ground in health care with the launch of its community paramedic program. More than a decade in the making – it took 15 years to execute and an extra year to fund – North Memorial’s community paramedic program is the first of its kind in Minnesota and one of the first in the nation. What sets North Memorial apart from similar community paramedic programs popping up around the country? Thanks to efforts led by North Memorial administrators, Minnesota is the only state that has "certified" paramedics and receives reimbursement. It’s a program that gets back to the basics with a model of delivering health care from which thousands of Minnesota patients will benefit.
Preparing the Way
North Memorial’s community paramedic program takes emergency-trained paramedics and puts them in the slow lane for a day or two a week. Instead of racing to the scene of accidents or emergencies, the medics make scheduled visits to the homes of frail and elderly patients, or those with chronic conditions like diabetes. Visits are coordinated through doctor offices and clinics, and supervised by emergency systems medical directors, as a way to prevent expensive emergency department treatments.
When experts examine the trend of skyrocketing healthcare costs, they often look at emergency department usage as a place of overspending. “So many patients end up in the ER because of simple but frightening mistakes like mixing up medications or not getting timely treatment for an infection,” says Mark Bixby, MD, medical director of Clinical Services at North Memorial. “Many of these patients are not home-bound, so they don’t qualify for home health benefits. However, they still might need some medical care at home now and then.”
According to Dr. Bixby, a typical patient in the community paramedic program is someone who may frequently be seen in the ER, but may not have a way to receive follow-up care once they’re back home, or may not have anyone at home to take care of them until they’re back on their feet.
With just a call from a primary care physician or referral from the emergency department, a community paramedic can administer lab tests, take vital signs, give a general assessment, or follow up on hospital discharge orders. Since paramedics are armed with medical training, years of experience, and are used to entering people’s homes with care and respect, they have a unique set of skills for this kind of work.
“The community paramedics do lots of assessing,” says Dr. Bixby, who helped develop the clinical portion of North Memorial’s community paramedic training program. “Their underlying EMT training is already helpful. We’ve added to this more education on chronic disease management, medication compliance, and home safety, like fall risks and dizziness balance assessments. They’re also trained to implement the instructions from the primary care provider.”
There is definitely a difference between crisis care and bedside examinations, so the additional training model for medics was carefully outlined in 2011 legislation. Everyone from state representatives, to nursing and home health professionals, to competing health organizations participated in years of discussions and negotiations that resulted in certification procedures for the community paramedic.
“We decided we needed to enable this into law so that our program would be differentiated from the home health act,” says Buck McAlpin, director of Government Affairs at North Memorial, who helped shape the law that defined community paramedic certification. “We have a large medical assistance population in the North Memorial service area and throughout Hennepin and Ramsey counties,” he says. “We knew there are a lot of things that don’t qualify for home health visits. We knew that to decrease the cost to take care of those patients, there are some practitioners that better fit that role.”
Part of the 300-hour community paramedic training curriculum includes mapping health needs in underserved areas. Rural populations have an especially acute need for health care access. A patient might be able to care for his or her daily needs, but getting a ride to a doctor or clinic is difficult. Situations like these show a real gap in care that the community paramedic program can fill.
The Funding to Fill the Need
Once the certification legislation was passed, then came another hurdle: finding a way to pay for the program. In theory, community paramedics would save long term costs, but there was a short term need to fund the visits. A law that passed just last year gives coverage through Medicaid, and the set fee schedule will inform managed care rates for other insurers and health care institutions.
McAlpin and other proponents of the community paramedics program believe that the development of fee agreements is bringing the movement full circle. “A lot of people assume a community paramedic program is an ambulance model doing primary care. That is just not the case. Ours is a primary care model first that uses ambulance practitioners,” he says. “North Memorial’s is the only entity in the state, and one of the few in the country, to offer a fully integrated model that has certification, a payment methodology, a primary care referral system, and a fully implemented program.”
As the largest hospital-owned pre-hospital care system in the country, with more than 750 paramedics, North Memorial is well versed in paramedicine. The organization now has 15 employees who are dual-trained in emergency and community paramedicine.
North Memorial has been championing the program from its inception knowing that fiscal responsibility would be crucial to broad acceptance. According to Mike Parrish, Vice President, Emergency and Enterprise Operations at North Memorial Health Care, “We’re not afraid to try new risk models around reimbursement and we want to offer additional services to make sure that everybody who has a relationship with the North Memorial system has access to some type of health care practitioner.”
Bixby agrees. “I think it furthers the concept that people need and should receive care from a team, not just one provider,” he says, “so it really expands this concept of team care.” Dr. Bixby also sees that the business of healthcare has to be successful as well. “North Memorial is pretty forward thinking in seeing this need and this resource in the community paramedics,” he says. “There’s this whole cadre of people who don’t qualify for home care but will still benefit from these additional services.”
Now that the North Memorial community paramedics program has completed a year of outstanding service with over 1,200 visits since its October 2012 launch, more health care providers are taking a look at how the program can fit into their provider networks. But the biggest reward of the program has been on a more personal level.
“We get letters all the time from folks who say how pleased they were with the care from our community paramedics,” says Parrish. “So all the work to bring the community paramedics program to life – from curriculum building to certification laws to general acceptance of a brand new way to give care – has really been worth it.”