Community paramedicine: Unclogging ERs by helping people at home

Three years ago, Grady Health System in Atlanta was getting thousands of 911 calls from people with mental health problems. Some were calling up to 30 times a month for emergency help.

Grady Memorial Hospital
Grady Memorial Hospital

A large majority of these people were transported by ambulance to the Grady Memorial Hospital ER, said Michael Colman, vice president of EMS Operations at Grady.

But he added, “A lot of the patients didn’t need to go the ER.” Sometimes a patient’s problem was rooted in something as ordinary as not having a prescription refill, or not understanding the medicine or how it was administered.

So Grady started a program to get these people the everyday help they needed before their condition deteriorated to the point of requiring emergency services.

This form of non-hospital care is part of a national trend often called “community paramedicine.’’

These paramedics function outside their usual roles of emergency response and transport, focusing instead on measures that can reduce inappropriate use of emergency services.

Unnecessary ER visits are more than just a nuisance. Emergency services are expensive to provide and meant to be used only as necessary.

Community paramedicine can help resolve a problem in a person’s home or neighborhood before it gets worse. The goal is to reduce trips to the ER and often prevent some patients who recently were released from the hospital from having to be readmitted. The latter tactic can save a hospital money, because Medicare now penalizes facilities with high readmission rates.

These services help patients who are called “frequent fliers’’ because of their many emergency room visits.

Grady’s Colman said many EMS personnel and paramedics are not trained to deal with patients with various mental health problems. So Grady has teamed up with the state’s Georgia Crisis & Access Line, run by Behavioral Health Link, which provides a mental health social worker who can help determine what a patient’s problem is, and how to deal with it.

Paramedic Tennyson Thomas and Candice Almond, a licensed professional counselor, make community mental health visits for Grady Health System.

The program, whose personnel now make visits in an SUV and not an ambulance, has cut mental health trips to Grady’s ER by hundreds a year, Colman said. It has meant an estimated $400,000 in savings to the health system, he added.

“Patients are better served,’’ Colman said. “We’re being proactive rather than reactive. It’s always just little small things to help these people out.”

Ellyn Jeager of Mental Health America of Georgia praised this approach. “Anything you can do to reduce reasons for people to come in [to an emergency room], it’s a smart and proactive thing to do,” she said.

Making life better for the patient

Grady recently also launched a community paramedicine program for people with health needs other than mental illness.

Hospitals nationally have started such paramedicine programs as ER visits continue to increase. One of the biggest drivers of that increase is a lack of access to primary care, said Dr. Howard Mell, an assistant professor at Wake Forest Baptist Health in North Carolina.

A patient with asthma may have health insurance but no primary care doctor to call, and when a prescription runs out, the person may have a severe asthma attack that turns into an actual emergency, Mell noted this week.

A person with schizophrenia who has no medicine ‘’will head into crisis,” he added.

But if they’re taking their medications properly, “we can stop them from coming to the ER,’’ said Mell, a member of the American College of Emergency Physicians.

He said a major challenge remains in getting insurers to cover these home visits.

“Grady should be applauded for taking the steps it’s taking,’’ Mell said. “Everybody is looking at strategies to address this problem. Even smaller hospitals are looking at access to care for their populations.’’

Hospitals can’t prevent car crashes and similar medical emergencies, Mell said. But they can help people manage medications better so health issues don’t turn into emergencies.

The problems that Grady is working to address are not just urban problems. Rural Georgia hospitals are pursuing similar strategies.

Gov. Nathan Deal’s rural hospital stabilization committee has designated four areas in Georgia for a pilot project. The program supports a “hub and spoke’’ model to relieve the burden on rural hospital emergency rooms. It would use telemedicine-equipped ambulances to facilitate remote diagnoses of patients in rural areas.

A goal is to reduce the number of people in emergency rooms, and to lower hospital readmissions.

Matthew Thornton, a paramedic, and Dr. DeAnn Bing visit patients in their home for Grady.
Matthew Thornton, a paramedic, and Dr. DeAnn Bing visit patients in their home for Grady.

More recently, Grady has done similar work dealing with patients with other health issues.

A physician goes out in an SUV with a paramedic, responding to 911 calls of low severity. The doctor can check medicines and blood pressure, connect a patient with a pharmacy, and draw blood, Colman said. “It’s new, it’s evolving,’’ he said.

A patient may need follow-up care, or a refresher on medication instructions.

Many have recently been discharged from the hospital and are “at high risk of coming back,” Colman says.

And the problem may not need a “medical” fix at all, he adds. The team may find a hazard in a patient’s living environment, such as an unstable rug on the floor of someone who just had knee replacement surgery.

“The advantage we have – we can deal with people in their house. It’s hard to put a price on this,’’ Colman says.

“Patients are intrigued and interested when a doctor shows up. They’re excited they don’t have to go to the ER.”