Life as a Community Paramedic: Lessons from Year One
Primary care has entered the paramedic’s vernacular with the rise of community paramedicine as a cutting-edge model of healthcare.
Just over a year ago, I sat down with Dave Johnson of Hennepin County Medical Center EMS. We discussed what it meant to be a community paramedic (CP), his experience in one of the first CP education programs in the country (at Hennepin Technical College), and the leadup to becoming HCMC’s first full-time community paramedic. I recently caught up with Dave once more to hear about the successes, challenges, and lessons from his first year as a community paramedic.
Community paramedicine aspires to address the needs of certain demographics that consistently fall through the cracks. As of August 2014, HCMC EMS employed 6 credentialed community paramedics, with 12 more in the clinical phase of their training. Johnson says he sees people questioning the long unchanged models of prehospital care and making a shift. “Medstar down in Fort Worth changed their agency name,” says Johnson. “It used to be Medstar EMS, and now they’re Medstar Mobile Healthcare. They’re realizing that this is how other organizations are going to evolve.”
HCMC’s CP program has been well received by the community, says Johnson. Other healthcare providers appreciate having CPs around because they’re a dynamic resource for the patient. In turn, patients are happy to have a phone number that connects them with a real person (rather than a phone system). Patients have also expressed great satisfaction with being cared for in their own homes. Avoiding that trip to the hospital is in the best interests of everyone involved, says Johnson.
Providing preventative care to people who commonly rely on EMS is one of the primary goals of the CP program, and Johnson is already seeing its success.
“We have one woman who we’ve worked with for the past year, who had six heart failure admissions in the first eight months of last year. The statistics say that if you’re admitted for heart failure more than three times in one year, your life expectancy is about two years,” explains Johnson. “But this woman who we’ve been working with for a year now, she hasn’t been to the hospital once for heart failure since we started following her.”
Adopting community paramedicine has not come without its challenges, however. Since CP is such a different model of care, it’s been difficult to measure the program’s success. The performance of a typical EMS provider can be measured through a number of different statistics: number of runs and transports, response time, etc. Community paramedics have a more qualitative impact on patients. According to Johnson, “We’re trying to identify, are we increasing these people’s use of the pharmacy? Are we keeping them out of the hospital? Are they staying out of the ED? Are they just more satisfied with the health care they’re receiving?”
Johnson also notes that there are challenges balancing the old and new models of healthcare. “We’re in a weird spot because our hospital exists in two different worlds: we exist in the traditional fee-for-service world but we also exist in the world where healthcare is moving...the total cost of care concept, where you make more money for providing better care, not more care.”
HCMC’s program has balanced these spheres by providing a set budget for each CP patient. If a provider goes over their budget, they bear the responsibility for any missteps. On the other hand, if a paramedic stays below their provided budget and keeps the patient out of the ED, the program turns a profit. There are still some challenges in monetizing this model, however. As Johnson puts it, they’re trying to figure out “how exactly the hospital gets paid for not getting paid.”
HCMC is working with payers to demonstrate value and the reasons why they should support the CP service. A compelling strategy for creating clear value is the potential of embedding a CP in specialty clinics and homeless shelters. One particular shelter in Minneapolis has seen an exceptional increase in call volume: in 2009, the shelter had 500 calls. This year, Johnson reports that they’re on pace to receive 1400. Community paramedics could be the answer to this overextension of resources: working in the shelter, they could provide in-house primary care as well as a traditional, critical care role.
Dave Johnson says he has found great professional satisfaction in his new role at HCMC, but admits the work is not without its challenges. In particular, it’s difficult to work with a patient week after week and fail to make progress. “It’s not just drop ‘em off at the ER, not my problem anymore, good luck. You actually get to see these people. You get to see the consequences of an intervention, and you get to see people either fail or succeed,” says Johnson. “Emotionally, you still take a lot of that work home. Realizing how to maintain that sort of work-life balance has been stressful over the past year.”
Despite these new challenges, Johnson says working with patients in their homes, as well as running 911 calls, has been very rewarding. “You’re not just a community paramedic when you’re working as a CP. You’re a CP all the time you’re working as a paramedic.” He sees a model of divided care--working two weeks as a CP, and two weeks on the ambulance running calls--as the future of paramedicine.
During this interview, Johnson and I were joined by paramedic Brian Spence of Stevens Point, Wisconsin. He was on a CP “ride-along” of sorts, shadowing Johnson to get a sense of how HCMC’s program functions. Like Johnson, Spence is an early adopter--in fact, he’s poised to be the first community paramedic in the state of Wisconsin. “If Dave’s program’s in its infancy, mine hasn’t even been born yet,” jokes Spence.
He explains that while he’s learning a ton from these ride-alongs, his program will probably look completely different from HCMC’s. “Where they’re focusing on working a lot with the homeless, we don’t have a lot of homeless. My focus is going to be more on the mental health side,” clarifies Spence. He praises HCMC’s insight in not applying too many regulations on such a young program, as well as their willingness to share the lessons they’ve learned launching their program. “It’s not territorial,” says Spence. “And traditionally, Fire, EMS: this is mine, you can’t have it.”
It’s this spirit of collaboration and sharing--first from Fort Worth to the Twin Cities and now onwards to Wisconsin--that’s allowed community paramedicine to flourish in the past few years. While the new model of care is still developing in young programs like HCMC’s, it shows great potential to address key pain points in the national transition to a new model of healthcare.