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October 3, 2016
Calif. community paramedicine program aims to ease ER overcrowding
The Modesto Bee
MODESTO, Calif. — During a recent shift, American Medical Response paramedic John Perino was dispatched to a residential care home where a woman was experiencing a psychotic episode; she’d torn down blinds and was trying to break the window.
Perino evaluated her and cleared her to be taken directly to the county’s crisis center, bypassing a trip to an emergency department.
“It is not uncommon for that patient to go to the ER and end up sitting there six, seven, eight hours before being transported to the behavioral health center,” Perino said.
She’d be triaged behind patients with immediate medical needs but still take a bed in the emergency department while waiting, adding to the backlog.
That is the route ambulance companies in California have to take under current state regulations. Paramedics must transport people to hospitals first so that they can be medically cleared by a physician, said Mike Corbin, clinical manager for American Medical Response Stanislaus County.
But California’s Office of Statewide Health Planning and Development, through a pilot program, is allowing five AMR paramedics in Stanislaus County to sidestep state regulation to help better serve the mentally ill here and ease the burden on overcrowded emergency departments.
Called community paramedics, the senior AMR paramedics taking part in the program were selected by a panel of health officials and underwent nearly 200 hours of additional training. They work under the auspices of the medical director of the Mountain Valley Emergency Medical Service agency that serves Stanislaus County, Dr. Kevin Mackey.
During the year the program has been in place, they have evaluated 627 patients. More than a quarter of them, 169, were transported directly to the county’s mental health facility.
The community paramedics use an algorithm to determine where to transport. Two hundred and fifty-eight patients had to be taken to the emergency department because they had medical issues like high blood pressure or an open wound, were not between the ages of 18 and 59, had recently used drugs or alcohol, or were violent.
The remainder met the criteria to bypass the emergency department but other factors prevented them from going. They either had private insurance or there weren’t any beds at the county facility.
Only the county’s 16-bed mental health facility in Ceres – which takes Medi-Cal and indigent patients – is participating in the program. Much larger Doctor’s Behavioral Health Center, with 67 beds, on Claus Road in Modesto could not participate because it is barred by some state and federal regulations since it is licensed as a department of Doctors Medical Center and not a free-standing acute care hospital, said hospital spokeswoman Carin Sarkis.
The costs for the mentally ill population served by the county are the burden of the taxpayer, but the community paramedic program results in a cost savings because “you don’t have the cost of the emergency room visit, which is about $5,500, and you don’t have a double ambulance transport cost of $2,000,” said pilot program project manager Lou Meyer.
It also frees up paramedics by eliminating a second transport from the emergency department to the mental health facility and on occasion puts police officers back in service who might otherwise be transporting a nonviolent person who was placed on an involuntary psychiatric hold.
Modesto police Chief Galen Carroll said it is a step in the right direction, but he said officers are responding to more “5150” involuntary hold calls this year compared with last and spending more time – over an hour – on those calls. Officers still have to respond to those calls because the community paramedic does not have the authority to put someone on a 5150 hold, a designation derived from a section of the California Welfare and Institutions Code that gives law enforcement that authority.
Community paramedics programs are already in place in several states like Texas and North Carolina, which Mackey studied to implement two protocols of the Stanislaus pilot program, which is one of 12 in the state but the only one focused on mental health.
“The major focus in community paramedicine is to ease the burden on the health care system, ease overcrowding at hospitals, and to keep patients healthy and at home,” Mackey said.
For example, ambulance companies in San Jose and three Southern California jurisdictions are doing home visits to follow up with patients to ensure they are taking their medicine correctly or regularly checking their blood sugar so they avoid future medical emergencies.
Community paramedics in Ventura County are working with hospice to avoid having those patients sent to emergency departments during the final days of their lives. Meyer said often family members who haven’t been involved in the life of the terminally ill person until the end will call 911.
UCSF Medical Center in San Francisco is doing an independent evaluation of the data, which will be used to support regulatory change to make community paramedicine a reality throughout the state.
“Once we have data that shows the efficacy of these programs, we are prepared to go to the Legislature in 2017,” Meyer said.
The pilot project ends Nov. 14, but Meyer has submitted a request to continue the programs through the legislative process.
The program came with a one-time grant of $16,000 from the California Health Care Foundation to assist with the data reporting requirements and training. Beyond that, AMR is shouldering the costs associated with the program, since none of the community paramedic services at this point can be billed to a patient’s insurance.
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