Bringing medicine home
Paramedics make follow-up house calls as part of pilot program
As a paramedic for about 15 years, Aaron Mathrole has saved countless lives with rapid interventions and speedy transport to the hospital. Even amid the rush, he can get a sense of the patient’s surrounding circumstances.
The elderly man with chest pain, halfway off the recliner in a cramped den/kitchenette. The young woman twisting with spasms beneath a tree at City Plaza. There’s surely more behind their diagnoses than why somebody called 911, but since ambulances are emergency response vehicles and their crews are first responders, that’s where Mathrole has always focused.
Mathrole is one of nine paramedics with Butte County EMS who have been trained in community paramedicine. When he’s not assigned to 911 response, he provides nonemergency care to patients across the county recently discharged from Enloe Medical Center following treatment for congestive heart failure or heart attack.
This supplemental care is part of a statewide pilot program from the California Emergency Medical Services Authority and the California HealthCare Foundation. Eleven other EMS providers are participating—some also targeting cardiac care, others focusing on areas such as tuberculosis and mental health. The program launched in July and will run for two years, at which point an independent research team from UC San Francisco will evaluate the efficacy.
The goal: to convince state officials to allow California to join Colorado, Maine, Minnesota, North Carolina and Texas in implementing community paramedicine.
“The idea behind growing it is to provide better care as an EMS system,” said Mathrole. “We already drive ‘code 3’ to a patient and help them in their time of need. Now we’re trying to help them on the back side; keep them out of the hospital, make them feel more comfortable at home, be able to fix their minor ailments at their house without them having to go to the hospital.”
Currently, state law—specifically, California Code of Regulations Title 22—allows EMS providers to bill only for transportation services and doesn’t permit paramedics to deliver in-home care. Community paramedicine would revise this legislative and financial model. For now, the services Mathrole and others provide through the pilot project go unpaid to Butte County EMS.
Neal Cline, the program’s local leader, sees both medical and fiscal rationale that should appeal to governmental decision-makers. Cline is a flight nurse who works jointly for Butte County EMS and Enloe.
“The reasons we’re doing this are to bring access to people who don’t have it,” he said, “and also stem this tide of health care out of control.”
Noting that “emergency departments are the most expensive health care in the world,” particularly in California, and serve as a safety net “for people who have nowhere else to go,” Cline said that community paramedicine offers alleviation for ERs overflowing with patients who don’t truly have emergency medical needs.
Since July, Butte County EMS has served about 225 patients through the project. Readmissions to Enloe within 30 days—for any reason—have decreased dramatically compared with last year: 24 percent for heart attack patients, 60 percent for heart failure.
“We’re exceeding our goals on those,” Cline said.
When wearing his community medicine hat, Mathrole follows up with his patients by phone and makes home visits when he determines in-person contact would prove beneficial.
He adds three to five new patients a week. Meanwhile, others roll off his list because the project parameters stipulate that community paramedics interact with each patient in a 30-day window, the idea being that the medic will fill the gap between hospital discharge and the start of in-home health.
Butte County EMS as a whole adds three to five patients a day.
Mathrole’s initial call, made two days after the patient leaves the hospital, acts as an introduction as well as a check-in. How are you feeling? Do you have all prescribed medications and equipment? Have all doctor’s appointments been scheduled and transportation arranged? Do you need any other help or questions answered?
When visiting, Mathrole will make sure the home is safe, ensuring that everyone has free movement throughout the residence and that the patient has ready access to medicine. He’ll also check prescriptions for potentially harmful pharmaceutical interactions.
For the next 18 months, Mathrole and his Butte County EMS colleagues have a limited scope, but already he sees potential beyond heart patients.
“The way health care is changing, the community paramedic is becoming more and more of a necessity,” he said. “Hopefully, after this two-year pilot program is over, we’ll be able to figure out how to expand it.”
Mental health represents a vital frontier. Currently, patients placed under a 5150 hold—i.e., involuntary confinement—require a medical evaluation that often precedes the psychiatric or psychological evaluation. Moreover, ambulances can transport a patient only to a hospital ER to receive payment. By allowing paramedics more latitude in assessment and transportation, Mathrole and Cline explained, lawmakers can alleviate a big burden on emergency facilities.
This and the other elements of community medicine constitute a challenge that paramedics are eager to embrace.
“We always wish we are able to do more,” Mathrole said. “I think we recognized the need for this, but we didn’t really realize [before the project] exactly what that need was. Once we got the training, we looked back and went, ‘Wow, I could have been doing all this stuff for so long, and it would have been so helpful.’”