With Community Paramedicine, House Calls Are Making a Meaningful Comeback

Health Systems like Essentia Health are using specially trained EMS teams to help recently discharged patients and those with chronic care needs stay out of the hospital.

One of the biggest care gaps occurs when the patient leaves the hospital. The care team can send along instructions for care management, send texts or emails or make phone calls, even schedule follow-up care, but there's no guarantee those directions will be followed.

At Essentia Health, those patients are now getting house calls from paramedics.

The 14-hospital health system covering parts of Minnesota, Wisconsin, and North Dakota has been using community paramedicine since 2014, and has seen reductions of almost 60% in 30-day readmissions, with ED visits and hospitalizations cut in half up to three months after discharge. Brendan Krupich, the health system's community paramedic program manager, says the program has reduced costly ED and rehospitalization costs while helping patients with ongoing and acute chronic conditions improve their health and wellness at home.

"They have a continuity of care that they didn't have before," he says. "We're seeing them at home now instead of [the emergency room] and helping them to stay there."

Community paramedicine programs, part of an array of outpatient services known as mobile integrated health programs, change the paradigm of providers waiting around for patients to come to them. Most health systems with MIH programs identify patients as high-risk returnees (sometimes called "frequent flyers") and schedule visits to the home after those patients have been discharged.

Healthcare organizations across the country have been launching community paramedicine programs to reduce ED and clinic traffic, cut down on hospital admissions, and take pressure off 911 services and EMS departments swamped with unnecessary or preventable calls. They're also taking aim at soaring care management costs for Medicaid and Medicare Advantage populations, many of who either avoid healthcare visits and preventive health services or wait until it's an emergency. A 2009 Institute of Medicine study indicated roughly $750 billion was being spent on preventable services, amounting to about 30% of the nation's total healthcare costs for that year.

"We were seeing a lot of people who just waited too long" to connect with their care team after leaving the hospital, Krupich says. Some, he says, are too stubborn to seek additional care, while others don’t think their concerns are serious enough to warrant a phone call or trip to the doctor. In today's economy, the sting of another medical bill hangs over the household.

Krupich launched his program with a one-year state grant, aiming to cut 30-day readmissions in half. Patients were identified through the EMR, and scheduled for home visits from specially trained paramedics who are employed by the health system (some programs use their own paramedics, while a majority work with local EMS and ambulance departments).

"We really needed to get buy-in from home health [agencies], and that took a while," he says. "We weren't replacing what they were doing."

In fact, MIH and community paramedicine programs can supplement home health services. They also can be used in acute care at home programs, fulfilling that in-person link and giving patients a personal connection to their care management plans. The goal is to connect patients to their care plans in a more meaningful way, encouraging them to follow doctor's orders and embrace healthy habits.

Krupich says his community paramedics go into a patient's home focused on emphasizing such things as medication adherence, exercise, and nutrition. While there, they can also identify and perhaps address social determinants of health, as well as connect the patient with community health and social services resources, including behavioral healthcare.

"Honestly, that's a large part of what we're doing now," he says. "We can't claim all the successes, as there are a lot of moving parts in this."

Krupich says the program is well-received by patients and providers alike because it reinforces the human touch in healthcare, giving the health system an opportunity to get more acquainted with the people they see so often in the ED. The key, he says, is training EMS staff to make those connections and understand what patients need at home.

“I refer to them as a bit of a Swiss Army Knife,” Chris Anderson, MD, Essentia's EMS medical director, said in an August 2023 news release issued by the health system. “Their skill sets are broad and they often work under the radar because their patients interact with practitioners less frequently once the community paramedic establishes a relationship.”

"Essentia's community paramedics play an indispensable role in reducing cost of care by decreasing ED and hospital admissions," Anderson added. “Our community paramedics often develop lasting relationships with their patients, which allows patients to better understand and participate in their own care."

The challenge sustaining these efforts, Krupich says, is funding. Essentia Health has received grants to keep the community paramedicine program going, targeting expensive benchmarks for certain chronic care populations like those living with diabetes. The Centers for Medicare & Medicaid Services (CMS) does not reimburse health systems for community paramedicine visits, and recently ended a pandemic-era alternate payment model that would have reimbursed for some programs that divert care from the ED.

But the tide is shifting, as more health systems look to reduce unnecessary expenses in the ED and focus on making hospital beds available for those who need to be treated in a hospital. Krupich says the Essentia Health program has reduced unnecessary hospitalizations and readmissions, and some payers, such as Blue Cross Blue Shield, are taking notice.

"We are moving forward," he says. "I see us taking more of a proactive approach to EMS services. We've been so reactive for so long and haven't done anything to fix it."