A new role for paramedics: treating patients at home
QUINCY — The sun was setting as paramedic Matthew Michaud arrived at the second-floor apartment where Jamal Lee sat in pain.
Lee, who uses a wheelchair, had a urinary tract infection, a sore groin, a headache, and spells of feeling hot and cold. But instead of taking Lee to the hospital, as most paramedics would, Michaud treated him at home.
Over the course of more than two hours, as a Superman movie blared on the bedroom TV and Lee’s children played video games in the next room, Michaud checked his breathing, blood, and urine. He surveyed the part of Lee’s body that hurt and took pictures. He gave Lee some medicine.
Michaud is among a small number of paramedics in Massachusetts working in pilot programs that allow them to treat patients with urgent medical needs at home, a practice that soon will be more common through money included in the recently approved state budget.
Under the supervision of physicians, and with special training, these paramedics — part of an emerging field known as community paramedicine or mobile integrated health — can examine patients, administer medications, and provide care instructions.
The goal is to avoid unnecessary and costly hospital visits while treating patients where they are most comfortable.
These programs, proponents say, can be particularly helpful for patients who are frail, elderly, have chronic conditions, live in remote areas, or need care at night when doctor’s offices are closed.
The concept has critics who worry whether paramedics have the right training to treat patients at home. But many in Massachusetts have high hopes and argue that expanding the role of paramedics is an important strategy for slashing health care costs and improving patient care.
“As we think about how we can improve the value of care — making sure individuals get the health care that they need at a reasonable cost and at superb quality — the mobile integrated health program is something I’m very excited about because it has the potential for doing that,” said Dr. Monica Bharel, the Massachusetts commissioner of public health.
With an additional $500,000 included in this year’s state budget, the Department of Public Health is hiring five people to run the state’s mobile integrated health program and expects to begin accepting applications this fall. In August, health officials adopted new state regulations that govern these programs.
Paramedics responding to emergencies are generally required to take sick patients to a hospital, unless the patient refuses to go. But the new state rules waive this requirement for medics who are part of mobile integrated health programs.
Similar efforts are underway in many other states, though Massachusetts officials say their initiative will be the most comprehensive in the nation. As it is implemented, they are likely to draw on the experience of two local ambulance companies, EasCare and Cataldo, which have been experimenting with programs over the past four years.
EasCare Ambulance sends specially trained paramedics to see patients of Commonwealth Care Alliance, a Boston-based medical provider and insurer that manages care for low-income patients with chronic health issues who are covered both by Medicare and Medicaid.
Commonwealth Care is paid a set amount of money to manage care for its patients. So when patients avoid expensive hospital visits, the company saves money.
Under this pilot, patients who feel sick can call a number, and then a nurse decides, based on the severity of the symptoms, whether the patient should get a visit from a paramedic that evening. (The alternatives: wait until the next day for an appointment with a provider or go to the hospital right away.)
Since late 2014, paramedics have completed more than 2,300 home visits for Commonwealth Care patients with lung disease, heart failure, chest pain, dehydration, UTIs, and other medical issues. About 82 percent of the time, paramedics were able to treat patients at home. Other patients were deemed sick enough to be sent to hospitals.
All the avoided hospital visits have saved Commonwealth Care at least $6 million, according to company officials. They estimate that paramedics can treat patients at home at one-third the cost of hospital emergency rooms.
“This replaces an urgent care visit, this replaces an ER visit,” said Dr. John Loughnane, the chief of innovation at Commonwealth Care.
“The paramedics are my eyes and ears,” Loughnane added. “They can take a picture and upload it. They take direction of what I think is the appropriate [evaluation and treatment plan].”
Paramedics have treated patient David Drayton at his apartment in Roxbury about half a dozen times this year. If they hadn’t come, Drayton said, he would have gone to the emergency room.
“I don’t want to go the hospital, sit in the ER all day,” said Drayton, 41, who is quadriplegic and said he has frequent UTIs and stomach pain. “They can do it right here for you. I think they’re a big help.”
Lee, the Quincy patient, feels the same way. He has had health problems since a gunshot wound three decades ago caused a spinal cord injury that cost him most of the use of his limbs.
The 47-year-old tries to stay active — he drives and looks after his children. But on a recent day this summer, he felt too sick to bring himself to his nurse practitioner’s office, and he didn’t want to go to the hospital.
So Michaud, an EasCare paramedic, was dispatched to check on him. When Michaud arrived, he asked Lee a series of questions.
“Pain?” he asked. “On a scale of 1 to 10, how bad [is it]?”
“About 7 to 9,” Lee replied, propped up in bed.
Michaud drew some blood and analyzed it instantly with a handheld device. He took a urine sample and made room on the kitchen counter to test it. Then he stepped out to his ambulance — a Ford Escape SUV — to confer with the doctor and nurse practitioner on call about what to do next.
Michaud returned inside to give Lee an IV antibiotic for his infection. There are no IV poles in Lee’s bedroom, but Michaud found a nail on the wall that served the same purpose.
Lee was still in pain. But “mentally,” he said, “I feel like I’m doing something about what’s going on. If you have to just deal with it, that’s depressing.”
The expanded role for paramedics such as Michaud is in some ways similar to what visiting nurses have been doing for many years. But nurses typically visit patients on regular schedules — not for emergencies. And while nurses have higher levels of training, they don’t carry the stock of medicines that paramedics have in their ambulances.
“Paramedics are very good at walking into a room and determining whether somebody is sick or not sick, just by looking at them and their environment,” said Scott Cluett, director of mobile integrated health for EasCare Ambulance. “Previously, working on an ambulance, they were just hooking and hauling — grabbing somebody in the street and bringing them to the ER. Now we’re really involved with that patient’s care, and it’s very rewarding.”
Ambulance companies stand to benefit from the new state rules that allow them to grow their business with these new programs. The programs also might appeal to health care providers and insurers that have a financial stake in managing the health of their patients and are trying to reduce costs.
More than 40 percent of emergency room visits are thought to be avoidable; they involve patients with problems that safely could be treated in less costly settings, according to state estimates.
“Reducing readmissions and reducing visits to the emergency room is really what the program is about,” said Dennis Cataldo, vice president of Cataldo Ambulance Service.
Cataldo Ambulance launched a pilot program with Beth Israel Deaconess Medical Center about four years ago. Most of the patients treated by paramedics in that program avoided hospital visits, Cataldo officials said.
But not everyone likes the idea.
Donna Glynn, president of the Massachusetts chapter of the American Nurses Association, a professional association, said nurses — not paramedics — should be treating patients at home.
“Paramedics aren’t trained in chronic care management,” she said. “A paramedic is just jumping in, putting a Band-Aid on something, and leaving.”
At the Home Care Alliance of Massachusetts, which represents home care agencies, executive director Patricia Kelleher said she supports programs that help patients avoid emergency room visits, but she worries about duplication of home care services already done by nurses.
Doctors who work in emergency departments, meanwhile, are concerned that paramedicine programs might keep at home some patients who need or want to go to the hospital, said Dr. Scott Weiner, president of the Massachusetts College of Emergency Physicians.
“It all depends on the details,” he said.