How Arkansas’ First MIH-CP Program Got Off the Ground

In less than three years, Baxter Regional Medical Center’s EMS team has reduced readmissions by 3% through the first pilot community paramedic program in Arkansas. The program at the Mountain Home hospital involves a community paramedic providing follow-up care to discharged inpatients, discharged ER patients and “prehospital” patients—referrals from the hospital and ER that don’t qualify for home health.

The program’s impact has been significant, saving the hospital thousands of dollars in readmission penalty fees and reducing unnecessary 9-1-1 calls and nonemergent visits to its Cline Emergency Center, while also teaching patients how to self-manage their medical needs.

Gerald Cantrell, director of ambulance services for BRMC, and Dan Snyder, director of the community paramedic program, birthed the concept for the mobile integrated healthcare/community paramedicine (MIH-CP) program in 2011.  

In 2012 the pair led a group of paramedics to Fort Worth, TX, to observe MedStar Mobile Healthcare’s successful MIH program, which earlier this year received a Best Practice in Healthcare award from Modern Healthcare magazine. Returning with good ideas, the group discussed how they could most impact readmissions. At the time Arkansas was near the top of the list of states most penalized by Medicare for preventable readmits.

When initiating research on the types of patients who access the ER most often, Cantrell and Snyder, like many others, surmised the majority simply misused the system and used the ER as their primary care provider. “Instead, a majority of ER patients had ongoing issues and simply needed guidance on how to manage their health,” reveals Snyder.

Research also showed that in 2012, BRMC reported 10% of 12,000 patients discharged from the hospital were readmitted within 30 days, and approximately 600 of those patients were discharged without follow-up care. “We moved quickly, knowing the penalty for readmission would jump from 1% to 3%,” says Snyder.

Having identified two groups of patients most impacting the hospital, Snyder and Cantrell knew paramedics weren’t trained to teach these patients long-term in their homes. Snyder led a group of 11 paramedics to University of Arkansas for Medical Services in Little Rock for 250 hours of additional training.

When the pilot program was launched in 2013 with skeletal funding from the hospital, they were only seeing a few patients. The learning curve was steep for the team, the patients and even the hospital physicians. The path to success was littered with obstacles. Not many people knew about the program. “The first year, we were very slow,” admits Snyder. “If I called a doctor’s office, they were like, ‘Who is this?’ and many times I didn’t get a call back.”

Home health providers were curious about paramedics’ role in the new program.

“Home health was our biggest obstacle,” says Snyder. “They’re a little bit territorial and thought we were duplicating services. We were only seeing patients they wouldn’t see.”

Also, naysayers cautioned Cantrell and Snyder against trying to attempt too much with the program.

“We heard ‘Don’t do this’ or ‘Don’t do that’ and ‘Don’t try to do those patients because it won’t work,’” says Snyder. “Gerald and I, along with others in the state, knew a change to the scope of practice would have to occur in order to move the community paramedic program forward in Arkansas.”

Cantrell and Snyder drafted proposed legislation to create a licensure program for community paramedics. State Rep. Scott Baltz (D-Pocahontas), a retired fire chief and former EMT, sponsored the proposal, House Bill 1133, which passed unanimously in 2015.

Implementation

Perhaps the most favorable implementation of the community paramedic program involves the way CPs approach patients about their medical care.

“We learned early on that instead of going into patients’ homes and dictating care plans, we would ask, ‘What can I do for you? What do you most want to change?’ We let them guide us,” says Snyder. “I tell the guys (on the team), if you don’t let them do that, they’re going to turn off their ear and not listen. What we found out is that if I let that patient decide for himself, he’ll buy into my program, and now I can teach that person. I can coach him. If I want to bring other things in line, I’ve built that trust.”

The program has received a fortunate boost with a pair of grants from the local Blue & You Foundation. The funding helped BRMC expand its market, cover many previously uncompensated expenses and acquire technology for homebound patients. Snyder is also applying for a USDA federal distance learning and telemedicine grant to provide up to 50 patients with home monitoring systems to provide telemedicine services.

“We are working with Medtronic to utilize their ZephyrLife Home system to monitor our patients,” says Snyder. The system will perform a four-lead EKG, boasts a spirometer and glucometer and keeps track of vital signs, among other features, from the program’s office or a smartphone.

Now linked to the hospital’s EHR and with word of the program spreading, doctors’ offices return calls to Snyder typically within an hour for inquiries on medication, care management, appointments and education and coaching advice. “They trust us in the field,” notes Snyder, and the success rate for preventing readmissions has climbed from 91% to 94% since the start of the program until now.

Last year 221 patients were enrolled in the program, which is done through referrals by EMS staff after first patient contact, Cline Emergency Center staff, hospital staff and primary care physicians. The program now has three vehicles in its fleet, including a wheelchair-accessible van. If a patient needs a prescription, a community paramedic will make the trip to the pharmacy and, upon delivery, instruct the patient on use of the medication.

One area that needs expansion will soon be addressed, Snyder says hopefully: For now, he is the only full-time community paramedic at BRMC. His staff consists of seven part-time CPs. “As we run our program, we’re going to need more full-time community paramedics on a daily basis,” he says. 

And as to advice for others from a program that was first in its state?

“I give talks about our program all over the country, and people often ask ‘Where do we start?’” Snyder says. “I tell them to just pick a place and start. You can’t do it all at once anyway.”