Chronic Disease Management for the Community Paramedic

The patient was a female in her mid-20s who’d been seen in the emergency department several times in the previous months. While conducting his assessment, the community paramedic asked her what she did when she had an asthma attack.

“First I take both my inhalers,” she said, indicating both the rescue inhaler she was supposed to take for an attack and the maintenance inhaler she was supposed to be using every day.

“Do you take that one every day?” the CP asked, gesturing to the maintenance inhaler.

“No, just when I’m having an attack.”

“OK, what else do you do?” asked the CP.

“I go outside and have a cigarette.”

“OK, why do you do that?”

“I get anxious when I have an attack, and I’ve heard I can make my asthma worse if I get too worked up. Smoking helps me calm down.”

Introduction to Chronic Disease Management

Chronic diseases, such as asthma in the example above, place an enormous burden on the healthcare system. Many MIH-CP programs across the country address chronic disease management to help avoid readmissions and reduce preventable hospital stays. Key to the success of these goals is the patient’s ability to manage his or her own disease, and CPs are tasked with coaching patients through this process. While knowledge deficit is a frequent cause of patients’ poor self-management, chronic disease management requires more than just providing patient education. Other factors known as the social determinants of health often play as great a role, if not a larger one, in the patient’s ability to succeed.  

Social determinants of health are “the conditions in which people are born, grow, live, work and age. These circumstances are shaped by the distribution of money, power and resources at global, national and local levels.”¹ The social determinants of health (SDH) model is a broad perspective on all the factors that may influence a patient’s ability to manage their disease. The model includes the following list of determinants:

• Individual determinants—Individual determinants are individual-level factors, like the patient’s understanding of their disease, behaviors, lifestyle choices, medication adherence, and medical and mental health comorbidities. Most traditional chronic disease interventions stop here, but the SDH model encourages us to look beyond the individual patient and their behaviors to better influence chronic disease management.
  
  
• Social determinants—Social determinants are cultural and interpersonal variables that affect health and lifestyle. Friends and family shape our health behaviors, as do some religious and ethnic customs.
  
  
• Environmental determinants—Environmental determinants are external physical factors that influence a patient’s disease management. For example, living in an unsafe neighborhood might prohibit walking or other forms of recommended exercise. Extreme temperatures in the residence might exacerbate certain diseases like COPD and asthma. Patients who live in a shelter or are homeless will obviously struggle to manage their chronic illnesses much more than others regardless of how much education they get.
  
  
• Transportation determinants—Transportation determinants are the resources and barriers patients have when obtaining goods or services at another location. For example, patients who have mobility impairments or no working vehicle and those who rely on others for transportation may have a harder time keeping key appointments.
  
  
• Economic determinants—Economic determinants are the financial resources and challenges that may influence a patient’s overall health. Many patients lack health insurance. Those who have coverage may not be able to afford the copays, deductibles or co-insurance rates for their medical supplies and appointments. They may also not have enough income to pay their rent, food or other bills, all of which may impact their health.
  
  
• Community determinants—The resources of the municipality, county and state where the patient resides will have a significant impact on the patient’s ability to receive care or support. A shortage of mental health providers and affordable housing plagues many communities across the country. Residents of rural areas often have to travel hours to see the specialists necessary to manage their issues. Even when resources exist to help with one problem (e.g., food pantries to help reduce hunger), they may have problems assisting with others (e.g., dietary or disease-related limitations).

Case Study: Other Findings

In addition to asking the patient to describe her methods for managing her asthma attacks, the CP conducted a more comprehensive SDH-based assessment. The patient not only misunderstood the impact smoking would have on her asthma but also lacked a primary care provider or pulmonologist to help manage her asthma outside the emergency department. She lived in a rent-subsidized house that had several areas of mold growing on the walls and ceiling from a leaking roof. She’d apparently told the landlord more than a year earlier about the leak, but he’d only placed several large tarps over the roof and gave empty promises to fix it soon. The patient was unemployed due to a physical disability but seemed to have adequate transportation resources and food, although barely making ends meet. Fortunately she lived in a community where healthcare and other resources were fairly accessible.

CP Interventions for Chronic Disease Management

CP programs can have a dramatic impact on helping patients overcome these barriers, despite their complex nature, by designing interventions that address each type of social determinant.

Individual-level interventions

1. Patient education—Education alone will not usually be enough to help patient better manage their disease, but it is still a vitally important component of a successful disease management intervention. Keep in mind, however, the focus of the education should be on teaching at the level of the patient’s needs and literacy. Below is a list of some of the objectives you may want to target when providing education.

1. Patient understands the disease—There’s no need to delve into a paramedic-level pathophysiology course to explain the disease to the patient. Instead focus on the symptoms, triggers and consequences of not adhering to their healthcare provider’s treatment plan.
2. Patient practices the recommended lifestyle and behavioral changes—Some chronic illnesses require drastic changes in the patient’s lifestyle to be compliant with their care plan. For example, CHF self-management includes medication compliance, monitoring fluid and salt intake at every meal, monitoring weight on a daily basis, stopping smoking and increasing physical activity. Helping the patient incorporate those behaviors into their daily routine will greatly improve their health. Keep in mind that the patient is likely to need more than just education to make these changes.
3. Patient follows a symptom-response plan—One of the most helpful actions a CP can take is to work with the provider to create written instructions for the patient to follow when they start to experience worsening symptoms. Symptom-response plans are frequently provided as a traffic light graphic, with green describing the course of action when the patient is asymptomatic; yellow describing what to do as symptoms or results of their self-monitoring begin to change outside of desirable parameters; and red describing what to do in cases of exacerbations.
4. Patient demonstrates proper self-monitoring behaviors—Some chronic diseases (asthma, diabetes, high blood pressure, CHF) may require the patient to monitor certain parameters. The CP may have to help the patient understand how to use the devices involved and find a reliable way to perform the monitoring with enough regularity to control their disease.
5. Patient sufficiently understands the purpose and side effects and demonstrates correct use of the medications for their disease—Patients who don’t understand (or care) why they take each medication are more susceptible to making errors when taking the medication. In addition to teaching the patient about the purpose of the medication, the CP should also ensure that the patient takes the correct dose and appropriately administers the medication, particularly when it’s injected or inhaled.
6. Patient correctly teaches the medical plan and use of equipment—Patient education specialists recommend having the patient teach the provider (CP) about each of the points above. Known as the teach-back method, having the patient explain the information or demonstrate the use of a device is the best way to ensure the patient truly understands the correct information. Simply asking the patient, “Do you know what this is for?” may elicit false assurances from patients who are too embarrassed to admit they don’t understand something they feel they should.

2. Medication inventory/reconciliation—A medication reconciliation involves analyzing all the prescription and OTC medications and supplements taken by the patient. A medication inventory can be taken by any level of CP practitioner. However, determining the potential interactions and/or identifying duplicative medications is beyond the scope of most paramedics. The interaction analysis is best left to the patient’s physicians or pharmacists, particularly when changes in medications are warranted. When the patient doesn’t have an established physician who can play this role, your EMS medical director may help provide some temporary guidance.

Social support interventions

CPs can help patients with chronic conditions by building a social support system. At times that may mean CPs not only help the patient but also help the patient’s caregivers find resources and support. Elderly couples are particularly vulnerable and a common example of caregivers who need support. A patient’s elderly spouse may normally provide all the assistance necessary, but as soon as the spouse has a medical issue of their own, the patient deteriorates due to their inability to support themselves. Caregivers of any age can feel overwhelmed, depressed and anxious, as they are often on call 24 hours a day without respite. Helping build a more robust support network for the caregiver can help improve the patient’s ability to manage their disease at home.

Patients referred to CP programs often also lack primary care providers. Helping the patient find a trustworthy provider who can supervise all aspects of their care can be tremendously helpful in avoiding unnecessary hospitalizations. Known as patient-centered medical homes, these systems ensure the patient has a provider who coordinates the multiple medications, specialists and procedures the patient needs.

Environmental interventions

When a patient with a chronic condition lacks a safe environment, the results can be catastrophic. CP programs targeting patients with chronic diseases should scan their environments for conditions that could trigger an exacerbation of their disease and to assess the challenges facing the patient. The assessment could include observing the food sitting in the kitchen to determine whether it adheres to the patient’s dietary restrictions or whether the patient is malnourished. CPs should also search for conditions that breed insects or toxins (e.g., indoor smokers, mold) that may exacerbate respiratory issues.  In situations where trigger mitigation is not a viable solution, CPs should focus their intervention on helping the patient find the best solutions available within their existing environment.

Economic and community support interventions

CP patients often lack the economic resources necessary to follow their treatment plan and as a result are labeled “noncompliant” by their care team. CP programs cannot independently provide all of the food, funding and other resources needed by their patients. Two of the most important functions of the community paramedic in helping patients find these resources are working as a patient navigator and a patient advocate. As a patient navigator, the CP finds local service organizations, determines the scope of services they provide, understands the eligibility requirements for the programs and facilitates patients through the enrollment process to get the services or goods as quickly as possible. In addition to local resources, national organizations dedicated to helping patients with particular diagnoses may already have a network of resources in place to assist.

Patients cognitively and emotionally capable of managing the enrollment process on their own should be encouraged to do so. The CP may need to function as the patient’s advocate for those who lack the ability or materials necessary to do the work independently.

Chronic Disease Competencies

The SDH assessment and interventions described above will help patients avoid repeat trips to the hospital as they acquire the resources they need to manage their conditions on their own. Developing a web of community resources to fill in gaps is one of the most critical components of a successful intervention. However, building trust and rapport with the healthcare providers and social services agencies that can help requires that CPs become better versed with aspects of the chronic disease that may not have been discussed in their original EMS educational programs. While EMS providers are experts at managing disease exacerbations, the daily management of chronic conditions is not commonly discussed in EMS classrooms. To fill in our own knowledge gaps, CPs should reach out to specialists who manage the chronic conditions and seek training in the following chronic disease competencies.

• Pathophysiology—CPs need to understand the physiological impact of the disease process, its symptomology and the consequences of not adhering to treatment plans.
• Pharmacology—CPs should familiarize themselves with the drug classes commonly used in treatment for the chronic conditions and the common doses and proper administration routes for the medications.
• Lab values—CPs should understand the labs typically run for patients with that chronic condition and the desirable results for each patient.
• Clinical interventions—CPs should understand the various diagnostic and clinical procedures available to patients who suffer from the disease.
• Lifestyle changes—CPs should be able to articulate the lifestyle changes (including adherence to self-monitoring practices) recommended for the disease.

Case Study Conclusion

The CP working with the asthma patient served as both a navigator and an advocate to help the patient better control her disease. In addition to educating the patient about using her inhalers properly and the dangers of smoking when having an asthma attack, the CP connected her to smoking cessation resources that could be helpful should she decide to quit. As important, the CP worked with the patient to find a local PCP who developed a symptom-response plan for the patient. The CP reviewed this with the patient in her home after the doctor’s appointment. The patient was offered but declined assistance from the local food pantries, and very much appreciated the CP’s phone call to her landlord about the leaking roof. Apparently having an outside agency call on the patient’s behalf was enough motivation for the owner to make good on his promise to fix the roof and mold issues. While it was not clear which of the interventions proved most useful, the patient’s healthcare utilization dropped considerably after the CP’s multifaceted interventions.

Reference

1. World Health Organization. Social determinants of health, https://www.who.int/social_determinants/en/.

Dan Swayze, DrPH, MBA, MEMS, is the vice president for the Center for Emergency Medicine in Pittsburgh, PA.

Anne M. Jensen, BS, EMT-P, is the Resource Access Program coordinator for San Diego Fire-Rescue Department and Rural/Metro of San Diego. With an inclination toward technology, she emphasizes meaningful patient care, using technology to expand capacity to serve and mitigate risk. Email ajensen@sandiego.gov.