Five Questions With: Ariella Bak, Gainesville (Fla.) Community Paramedicine Program

EMS World continues to hear from forward-thinking agencies implementing MIH-CP programs serving at-risk populations in communities both large and small. In 2018, the city of Gainesville, Fla., initiated a community resource paramedic (CRP) program, in which a paramedic and resource coordinator visit patients in their homes and focus on mitigating social determinants of health to resolve misuse of the emergency system. The CRP program educates patients on health and well-being using innovative tools within a patient-centered framework. Early observations include a 50% reduction in ED visits, a 44% reduction in missed or canceled primary care visits, and a 58% reduction in admissions to the hospital.

EMS World spoke with Ariella Bak, CRP program coordinator, to learn more.

EMS World: Can you briefly describe the origination of the Gainesville CRP program and your involvement with it?

Bak: The concept originated in 2014 with Gainesville Fire Rescue’s (GFR) Chief Joseph Hillhouse and Lt. David Sutton recognizing that 9-1-1 crews were facilitating the cycle of taking the same patients to the hospital. To mitigate some of these 9-1-1 calls, GFR sent a unit twice a week to Dignity Village, a collection of tents surrounding a homeless shelter, where the crews would distribute medical supplies and intervene during acute non-life threatening emergencies.

I joined in 2016 as a volunteer after completing EMT school and finishing my second year studying public health at the University of Florida. A GFR paramedic and I set out to visit recurrent users of the 9-1-1 system with the sole mission of helping people. We began to establish processes based on people’s needs—for example, not being allowed past the front desk of a clinic to speak with a physician led to us writing a letter explaining the patient’s situation and attaching a form for the physician to sign. This became standard for each patient enrolled in the CRP program.

I volunteered 40 hours each week for over a year before receiving pilot funding in 2017 from the University of Florida. The pilot year was spent testing processes, establishing community relationships, and overall helping prove the CP concept in Gainesville.

What is the patient population in your service area and why did you feel the CRP program could work?

In 2017, over 189 Gainesville residents called 9-1-1 more than 5 times in a single year, with 39 of those patients calling more than 10 times in the same year. Gainesville Fire Rescue sought an innovative strategy to break this cycle of poor health and facilitating cycling to and from the hospital. Upon conducting a community needs assessment, it became evident that despite Alachua County having an abundance of social resources, Gainesville residents were not connected to them, often leading to an unresolved social issue catalyzing medical symptoms. The target population during the first iteration was simply people utilizing the emergency system who were in need and accepting of services. The CRP program saw a wide gamut of patients: insured, employed/unemployed, uninsured, homeless, addicts, medically complex patients and more.

How do patients enter and move through the program? How does staffing and reimbursement work?

The CRP program partners officially with four primary care clinics through UF Health, which ensures constant communication with their RN health coaches and physicians who can make referrals. GFR’s first responder crews also have the option of selecting the CRP referral box in our internal reporting system, triggering a referral directly to me. Lastly, community partners can refer patients for a wellness check or the case-management branch, where we will begin an intense process including medical and social interviews with the patient, family and caregivers.

From its inception, GFR has provided overtime paramedics with proper training to conduct home visits. This model continues. After many months of lobbying, the city of Gainesville moved forward with adding a permanent job position—CRP program coordinator—complete with benefits and competitive pay. This search was posted nationwide. I was fortunate to interview and earn the position in late 2018. I’m now hoping to bring on two more employees responsible for managing patient care.

What challenges did you encounter getting the program operational?

What has always and continues to threaten the program is funding. While sustainable funding would be ideal, I refuse to allow this to hinder our patient care. Upon inception, there was zero dollars allocated toward this program. I worked for free for over a year. In 2017, the University of Florida and the city of Gainesville partnered with us on a series of research grants, of which the CRP program was funded as a pilot. Right now, much of my responsibilities include applying for grants.

What advice would you have for other departments looking to establish a similar initiative in their communities?

No two programs are the same. What works in one area will not always work in another. Listen to your community by administering a needs assessment. Reach out to other program pioneers—I am always willing to help other programs in the state and country build upon internal processes. When we started, my team conducted a literature search to contact other program directors. We were met with open arms and even adopted most of our forms and documents from other programs—we merely changed the department logo. Partnership is key to every program, so establish those strategically and early.

Jonathan Bassett is editorial director of EMS World.