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Rhode Island Agencies Introducing MIH-CP Programs
April 28--BURRILLVILLE -- The Pascoag woman is a busy young mother, a diabetic whose blood-sugar level can swing wildly enough to knock her unconscious.
Sometimes she's "close to death" as Pascoag emergency medical technicians rush to her home, says the village's fire chief, Harold Carter.
"It's not good when we get there," says Carter, who has a simple plan for addressing the problem: Help the woman manage her blood sugar levels before they get out of control.
While that might sound like common sense, providing such medical care in non-emergency settings is unprecedented for paramedics and emergency medical technicians in Rhode Island.
But the right preventative medical outreach to people like the diabetic woman can prevent lots of emergencies, says Carter. That's good for patients, of course, he says. It also reduces hospital trips by Pascoag's emergency personnel, freeing them to help more people, and it may lower the department's costs, too.
It's an idea that's gaining traction across the country, and the Pascoag Fire Department plans to launch a trial program Monday, assisted in no small part by new language that was written into Rhode Island's statewide protocol for emergency medical services on March 1.
At the other end of the state, the Westerly Ambulance Corps plans to introduce a similar program soon.
All of this activity falls under the auspices of a new state-issued protocol that authorizes certain EMTs and paramedics to step outside their traditional roles to practice "mobile integrated healthcare." In some situations, the protocol gives EMTs greater leeway to provide emergency treatment at the scene without taking a patient to the emergency room.
"We're excited about it," says Carter. "I think it will work. We're going to do it on a test basis and make sure it's something we can afford."
Where it started
The earliest versions of mobile integrated healthcare, also known as community paramedicine, were practiced in Alaska in the 1950s and in New Mexico in the 1990s. The basic idea in New Mexico was that EMS personnel could devote downtime to providing certain types of non-emergency health care. Since then, similar types of care have been practiced in Minnesota, Texas, Maine and elsewhere, in rural and urban settings.
"We're seeing them pop up across the country in a variety of different ways," says Ryan Kelley, a senior editor with the Journal of Emergency Medical Services.
One technique in Fort Worth involves a tablet device.
The paramedics can present certain patients to a physician by video conference. Based on the doctor's instructions, they might schedule a taxi ride to the hospital or to a doctor's office.
In northern Nevada in 2012, an emergency medical services agency launched a grant-funded community health program that included a phone hotline for people to pose health-care questions to a nurse, according to a report in EMS World Magazine.
Over three years, the overall program helped patients avoid more than 6,200 emergency-room visits. That included 1,000 cases where patients would have ridden an ambulance to the hospital. The savings to patients and the health-care system was more than $9.6 million, according to EMS World.
In Wake County, North Carolina, a program involving people with behavioral health problems caught the attention of some Pascoag EMS personnel.
The emergency medical personnel took on extra training and equipped themselves to steer people with behavioral-health problems away from emergency rooms and toward psychiatric facilities or substance-abuse clinics, according to the Raleigh News & Observer.
In one year, the program saved $500,000 in hospital and related costs, the article says, and over two years prevented 764 emergency-room visits.
When emergency medical services aren't busy at hospitals they are closer to the communities they serve. That closeness means quicker response times. Minutes matter.
"For each minute that goes by after cardiac arrest, the chances of survival decrease 10 percent," says the president of the Sudden Cardiac Arrest Foundation, Mary Newman.
"I think the general concept is very good," she says.
Some experts believe certain people, including individuals inclined toward hysteria, are less likely
to overuse the emergency-medical system if they have greater engagement with personnel and feel their health needs are being met.
"Social engagement" by providers in non-emergency situations can help prevent a 911 call down the road, says Jason Rhodes, who serves as Rhode Island's emergency medical services director, a post within the state Department of Health.
Emergency medical personnel can operate EKG machines, take vital signs and draw blood for analysis, Rhodes says. With guidance from a doctor on the phone, they can provide some types of care that would otherwise take place in a more expensive, less convenient hospital setting.
An EMT can often help a patient who is suffering from an asthma attack and then coordinate an appointment later that day with the person's primary care provider, bypassing an emergency hospital transport, Rhodes says.
"I think there's a great opportunity for a lot of benefits throughout the community," Rhodes says.
How they can help
Pascoag rescue Capt. Thomas Smith's preparations for launching the state's first community paramedicine program involved forming partnerships with physicians, with Fatima Hospital in North Providence and also with Well One Medical & Dental Care, a health-care provider that serves about a quarter of Burrillville's population.
The Fire Department, which serves about 9,000 Pascoag residents, did a community assessment and found that common problems requiring EMS transport included behavorial-health problems, drug and alcohol abuse, respiratory illness and diabetes.
Under the trial program that Smith helped develop, Pascoag's EMTs will do things like help people who overdose on opiates get drug counseling soon after an emergency incident.
They will visit diabetic patients to help them manage their medications, in consultation with their doctors.
Eventually, after about three months, these patients gain control over their blood-sugar levels and they won't need such oversight, Smith says.
The engagement of Pascoag EMTs, working closely with doctors, can help them reach that degree of control and independence sooner, with fewer middle-of-the night emergencies and trips to either Landmark Medical Center in Woonsocket, 14 miles away, or to Rhode Island Hospital in Providence, about 22 miles away, Smith says.
As part of their program, members of the Westerly Ambulance Corps are hatching plans to help certain at-risk people, often elderly people, make use of walkers, navigate their homes and avoid falls, says Capt. Kenneth Richards III of the Westerly Ambulance Corps.
Such paramedicine programs can have impact throughout the state at some point, not just in more rural areas, say Kelley and other experts.
Rhode Island, with a single set of emergency medical protocols and geography that makes statewide meetings easy, is well-suited to carrying out reforms to its emergency medical system, says Dr. Kenneth Williams, who practices emergency medicine at Rhode Island Hospital and serves on the state's ambulance advisory board.
"We are a uniquely and excellently positioned test bed for this," he says.
Making it pay
The finances behind the trend, nationally and locally, are in flux.
In Pascoag and Westerly the hope is that community paramedicine can pay for itself by eliminating emergencies, which happen at all hours of the day and cost more resources.
At the moment, emergency medical services are paid for hospital transports but they are not paid for their efforts to avert emergencies. Nevada is the only state where Medicaid and Medicare insurance pay for such programs.
Some say private insurance companies should consider rewarding programs that reduce costly medical emergencies by providing non-emergency care that's less expensive.
For example, Rhodes says he hopes Rhode Island's startup programs can achieve enough cost savings to make that case.
Another part of the financial equation involves the financial incentives for doctors and hospitals. Their close cooperation with EMTs and paramedics is key, say experts.
A major financial incentive for hospitals was written into the Affordable Care Act. The same 2010 law that created Obamacare essentially penalizes doctors and hospitals when patients are discharged and then readmitted within 30 days.
"They have a vested interest in making sure those patients are not readmitted," says Kelley. Republican proposals for replacing Obamacare did not target these incentives.
As for the doctors, some of their employers, including Well One in Pascoag, also have financial incentive to collaborate.
"More and more we're being asked to coordinate care," says Well One's chief executive officer, Peter Bancroft.
"More and more," he adds, "we're going to be held accountable for the patients' total cost of care," he adds.
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Noticeable changes in EMS protocols
Effective March 1, 2017
* Authorized EMTs and paramedics can step outside their traditional roles to practice "mobile integrated healthcare," an approach that can reduce ambulance trips to the emergency room. In some situations, the protocol gives EMTs greater leeway to provide emergency treatment at the scene; in other cases, the treatment may be preventive, designed to avert future emergencies.
* Lights and sirens on ambulances and fire rescue trucks are only for "time-sensitive interventions."
* EMTs and paramedics will try to resuscitate a patient for up to 30 minutes before transporting or even moving the patient.
* Backboards are no longer used for immobilizing patients, which means more comfortable transits on stretchers
SOURCE: John Pliakas, member of Rhode Island's Ambulance Services Advisory Board, primary author of the state's revised protocols for emergency medical services
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-- mreynold@providencejournal.com
(401) 277-7490
On Twitter: @mrkrynlds
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