Texas Paramedics` House Calls Highlight of New Health Care Approach

Dec. 15--William Jones sat on a brown sofa in his small, cluttered living room, as a paramedic rolled up his jean leg and pulled down his sock, revealing a limb swollen with fluid.

The 77-year-old's faulty kidneys concerned paramedic Nivea Wheat.

"We might need to get you in to your doctor," Wheat told Jones.

Several feet away, Morgan Clark, another paramedic, sat at a wooden kitchen table, methodically sorting some 10 different types of medication for Jones' heart problems, kidney disease, diabetes and other health problems into a color-coded pill box.

It's an unusual role for paramedics who are used to seeing a patient for 15 minutes in the back of an ambulance. For about two months now, Wheat and Clark have visited Jones' house every week, checking his blood sugar, taking his blood pressure readings, setting up appointments with his doctor and helping Jones find a home health nurse.

These relationships are becoming increasingly common as health care organizations push to reduce reliance on the costly emergency response system.

Wheat and Clark are part of a new six-member group in the Montgomery County Hospital District, an adaptable team of paramedics that helps patients who repeatedly find themselves in the emergency room navigate a dauntingly complex health care system and identify more proactive approaches to their health.

They're calling the program "community paramedicine."

"Obviously for much of the population, 911 is a great service. For the heart attacks, the strokes, the trauma, it's a great system, and we do that very well here at MCHD," said Andrew Karrer, who is running the district's community paramedicine program. "But for a lot of individuals, that's not necessarily what they need. They need other options."

'Back and forth'

While still new and untested in many areas of the country, emergency response providers are increasingly creating similar programs. Harris County Emergency Corps, an emergency response provider for north Harris County, started a community paramedicine program in the summer, which it calls "mobile integrated health care."

A few months ago, Fort Bend County announced a similar program.

Matt Zavadsky, a spokesman for MedStar in Fort Worth, one of the earliest adopters of the community paramedicine program that consults with others throughout the country, said according to his organization's research, there are about 230 different community paramedicine programs in the country. When Fort Worth started its program in 2009, there were only three, he said.

"People are seeing that these programs can have a really big impact," said Richard Bradley, chief of the EMS and disaster medicine division at University of Texas Health Science Center at Houston.

Partly driving the proliferation is a desire to improve patient outcomes. Patients in these programs receive more intimate instruction and care, rather than being treated by multiple doctors in an ER.

But Zavadsky said a bigger impetus is likely the passage of the Affordable Care Act, also known as Obamacare, which penalizes hospitals for readmissions and creates a financial incentive for proactive programs like community paramedicine.

A goal for the MCHD is to reduce 911 calls from frequent users, Karrer said.

While he said that in its first year, almost two-thirds of the patients who worked with community paramedics reduced their 911 usage, there's not enough data to say whether the program is working.

"We just want to see we're moving in the right direction for these individuals," he said.

That goal has meant paramedics playing a variety of new and unique roles -- from health care adviser to social worker to therapist -- for a segment of the population that has been "falling through those cracks" in the health care system, he said.

Some patients they visit have only an elementary school education and can't understand the pages of verbose medical instructions they receive after being discharged from the hospital. Some are uninsured and don't have primary-care physicians. Some have severe anxiety or other behavioral health problems.

They all see 911 as their only option to access the care they need, Karrer and his team said.

Jones would repeatedly end up in the emergency room after fainting due to low blood sugar because he didn't take his insulin shots or medication properly. "I've been back and forth in the hospital forever," Jones said.

Managing 42 patients

To pinpoint whom to contact, Karrer looks at who has called 911 between 10 and 35 times in the past six months. Then paramedics contact those individuals and ask if they'd like help, an offer they've found has been overwhelmingly appreciated.

"The single most common thing people tell me is, 'I've never had someone explain this in common terms before,'" said Cathy Kraus, the case manager for the program.

So far, paramedics in Montgomery County are managing 42 patients, up from 26 last year when the program started. After hiring four paramedics this October, the goal is to reach 120 patients and 145 the year after that, Karrer said.

That number pales in comparison to the need in the county. Based on the 911 data he looks at, Karrer estimates there are likely thousands of people overusing the system.

At Jones' house, when Clark swings open the door of the fridge, it's filled with gallon jugs of milk, regular and chocolate, orange juice and a bottle of Dr Pepper, which, upon some light interrogation, Jones coyly admits drinking from time to time.

But the beverages risk dangerously elevating Jones' blood sugar, so Wheat volunteers to bring him some Crystal Light or another, healthier drink. With other patients, paramedics in these programs might do groceries, help them with their electric or water bills, or simply show up and provide a regular social presence in patients' lives.

"We're kind of doing a reboot on our thinking of what is this role of the ambulance, what is the role of the heath care providers that are on it," said Chivas Guillotte, vice president of clinical services for the Harris County Emergency Corps.

At least for Wheat and Clark, the ultimate goal isn't to be waiting on Jones indefinitely. Their job is to connect him with the right resources and, eventually, get him off the high-frequency 911 user list.

But for Jones, the paramedics are a mainstay in his life. There are tight embraces and kisses on the cheek when Wheat and Clark enter and leave his house.

"I hope I can stay in contact with y'all," Jones said.

"I don't have nothing else."

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