Michigan Community Paramedicine Program Shows Slow But Steady Growth

A three-year community paramedicine pilot program that began last August is showing promising signs in Michigan.

The EMS Division of the Michigan Department of Health and Human Services approved the CP program to run in Washtenaw and Livingston counties. Huron Valley Ambulance, a nonprofit community ambulance service, covers Washtenaw, western Wayne and southwest Oakland counties, while Livingston County EMS provides service throughout Livingston County. The program is supported by the St. Joseph Mercy and University of Michigan health systems.

The project currently provides care primarily for 9-1-1 calls of nonacute patients. The aim is to have a community paramedic respond to the call, assess the patient alongside the regular EMS crew and determine if the patient’s illness or injuries can be taken care of in their home. The aim is to reduce costly patient transfers to the hospital when the patients do not have life-threatening symptoms.

Robert Domeier, MD, medical director for the EMS system in Washtenaw and Livingston counties and an emergency physician at St. Joseph, is overseeing the program. He also provides oversight of the education and training component.

“We want to try to keep people from having to go back to the hospital after an emergency, but we also want to prevent them from having to go to the ER in the first place,” Domeier says.

To that end, when there is a nonacute care call, an ambulance as well as one of the CP dedicated units—known as Echo units—can be dispatched.

“The CPs are in single-person licensed ALS units that also can respond to assist at other calls,” Domeier says. “They have all the standard emergency paramedic equipment and medication, plus some additional medications. They can administer the first dose of antibiotics if needed and then follow up with the physician and patient to get a prescription ordered.”

The CP units also have video equipment that provides two-way communication between the CP/patient and attending physician.

“The doctor can see what’s going on with the patient and can ask questions to assess them,” Domeier says. “They also can ask us questions, and we can instruct the CPs on what needs to be done, what kind of medications to give and follow-up instructions.”

The community paramedic units are required to have the following equipment:

• Pulse oximeter;
• Blood pressure/pulse monitor;
• Cellular telephone;
• Glucometer;
• Community paramedic unit medication box;
• Foley catheters of various sizes;
• Wound care equipment;
• i-STAT blood analyzer;
• Monitor/defibrillator with pacing and 12-lead ECG capability;
• Standard ALS medication box;
• Alcohol breath detectors;
• Bathroom scale;
• Infant scale;
• Oral/rectal thermometer.

“They can do blood draws to check hemoglobin levels and take an electrolyte panel,” Domeier says. “They can test it and send the results to the ER physician. The CPs also can start IVs. These are things that can be dealt with at the patient’s home instead of making them go to the ER.”

The CPs also are charged with providing places for patients to receive follow-up care if needed, and to help them access primary care physicians if they do not have one. If necessary, a CP can personally schedule a follow-up visit with the patient.

“Right now we are doing the low-acute 9-1-1 calls, but we also have contracted with some nursing homes to do some out-of-hospital care,” Domeier says. “We’ve been approached by some of the hospitals to have CPs look in on postdischarge patients, or at least certain ones that they identify as needing some extra follow-up. Some nursing homes also are taking notice. Nursing homes typically call 9-1-1 to have patients transported, but they are seeing the benefit of keeping the patients on-site if possible. The guys have point-of-care testing available, and that can help the physician affiliated with the nursing home.”

The POC testing so far has involved blood draws and urine samples on nonacute patients. The CPs also are allowed to administer the first dose of an antibiotic if an ER doc determines it’s needed. Then the doc and CP can coordinate having a prescription written that the patient has to fulfill.

The community paramedics receive six months of training using a curriculum Huron Valley created, which was modeled after the Minnesota CP program. Domeier says approximately 20 people from Huron Valley’s and Livingston’s ambulance services have gone through the extra training.

“These are really dedicated people doing this,” Domeier says. “I’ve been impressed with the unique ways they are coming up with to deal with some of the situations. They all are very good at problem-solving and figuring out ways to deal with patients and their situations. And the feedback has been positive. The patients like the people caring for them and the fact that they can stay at home.

“There have been times where the hospital will purposely tell a patient they have to come back after they’ve been discharged. That’s because the doctor wants to make sure there is some follow-up. But with the CP program, the CP can do the follow-up visits and make sure the patients are doing OK.”

Funding

Domeier says that while the focus currently is on the nonacute 9-1-1 calls, there is room to grow the program. But funding is an issue. For the 9-1-1 calls, Washtenaw and Livingston counties both provide some financial assistance. Huron Valley also charges $180 for a CP visit. The state does not currently provide funding for the project, but there is a Michigan EMS Act, and part of the three-year project is to determine if the CP unit should be incorporated under EMS oversight.

“It is far less money having a CP on-site than paying for an ambulance transport and an ER visit, which can be more than $2,000,” Domeier says. “We aren’t getting the big wallet to pay for expanding the program, but it takes time. This started as a proof-of-concept project. We have to show some success and how it can save money. I believe insurance companies will see the financial benefits to paying for an in-home CP visit versus a trip to the hospital. As we develop a bigger customer base, insurance companies, nursing homes and the community are taking notice. There’s a lot of interest overall in the state of Michigan for CP. Michigan is taking a proactive approach to having better outcomes for patients.”

Susan E. Sagarra is a writer, editor and book author based in St. Louis, MO.