In 2014, Massachusetts-based Commonwealth Care Alliance (CCA) partnered with EasCare Ambulance Services (EasCare) to launch Acute Community Care (ACC), a community paramedicine pilot program. Made possible under a state-granted Special Project Waiver, the program expanded the scope of practice of paramedics by allowing them to assess and treat individuals in the home rather than transport them to the emergency department (ED). Patients who call CCA’s after-hours urgent care line are assessed by a nurse practitioner or physician assistant to determine whether to dispatch a community paramedic to the patient’s home. Many of CCA’s patients are dually eligible for Medicaid and Medicare and have complex needs, making the ACC pilot an important potential tool for improving care and outcomes for very vulnerable beneficiaries.
To understand key lessons from the ACC pilot, the Center for Health Care Strategies (CHCS) spoke with Matt Goudreau, CCA’s associate director of Acute Clinical Response who was previously chief compliance officer at EasCare, about his experience spearheading this initiative. CCA participates in CHCS’ Complex Care Innovation Lab, made possible by Kaiser Permanente Community Benefit, and CCA and CHCS recently collaborated with Mathematica Policy Research to assess the business case for community paramedicine.
Q: What was the initial response from both patients and paramedics when this program began?
A: Our patients have embraced this pilot completely. Similar to other community paramedicine programs, a large majority of our members say that they had a very positive experience. More than 93 percent believe that the community paramedic coming to their home was as good as or better than going to the ED. It’s not uncommon to have our members say, “You know, I hate going to the emergency room, but I love my paramedic.”
The response from paramedics has also been very positive. Paramedics often venture into other professions because there is limited room for career growth. This is really a shame because so much training goes into this person becoming a great clinician. Community paramedicine allows paramedics to expand their careers, do what they love, and continue to provide excellent patient care.
Q: A distinguishing feature of community paramedicine programs is the expanded range of services that paramedics provide. What do you look for when hiring for this role?
A: When we first started hiring for ACC, we thought the best paramedics would be the most experienced. But it turns out, the best community paramedics are those willing to spend long periods of time working collaboratively with patients. This is incredibly challenging, as paramedics are trained to have a “treat and transport” mentality. In contrast, unless there is a true emergency, community paramedics do not transport patients to the hospital. Instead, they stay in the home to assess and address a patient’s needs.
When interviewing, we assess whether or not the candidate has a strong desire to be a part of this program. To do the work, you need a certain level of clinical expertise, but having the right attitude and understanding that patients want to receive care in their homes are key. It has also helped to incorporate CCA providers — who ask questions from the primary care and behavioral health perspectives — into the interview process to identify the right candidates.
Q: What types of training do you provide?
A: CCA physicians collaborated with EasCare to create a 300+ hour training program for our community paramedics that combines both clinical and simulation-based learning. In partnership with a local hospital, we built four simulated scenarios. The first involves a patient who needs to go to ED, but does not want to. The second is a patient having a behavioral health crisis. The third is an end-of-life scenario that involves patient care, as well as emotional support for the family. And the last is a patient who is stable, but requires additional at-home care. The goal is to transform the paramedics from “technicians” into “clinicians.” The training also includes a heavy focus on behavioral health, because we found that many paramedics lacked training on this topic.
Q: What are some of the most important lessons you have learned in creating this program?
A: One of the key components to any successful community paramedicine program is to not reproduce existing resources — it really needs to fill a gap in the existing health care system. In addition to conducting a gap analysis, I also recommend educating and engaging providers and stakeholders early on about this new resource to garner community support and help build a referral network. Another lesson has been the importance of allowing community paramedics to have real-time access to electronic health records, including the ability to document information. This has been critical, especially when working with high-acuity patients who frequently interact with CCA providers, as it really helps close the patient care loop. Lastly, it is important to validate pilots with solid research to build the case for sustainability. Our recent work with Mathematica Policy Research to explore the business case suggested that increasing patient volume after the pilot could produce net savings given the program’s success in averting unnecessary emergency care.
Q: If we asked you to make the case for ACC, what would you say?
A: The ACC program is focused on keeping people out of the ED, and paramedics are well-positioned to play that role. The CCA beneficiaries that our community paramedics typically see are people living with multiple comorbidities, and their health is so tenuous that they have a tendency to “fall off the cliff” if their needs aren’t met in a timely manner. They also often cannot address their needs within the confines of the traditional health care system. For example, a patient with multiple comorbidities and significant physical disabilities visiting the ED for her tenth urinary tract infection is likely to receive many unnecessary tests, even though all she needs is antibiotics. That’s appropriate care for the ED, but it’s not what the patient needs. As a result, many of these patients hate going to the ED.
Through the ACC pilot, we are able to meet members’ needs by providing comprehensive, person-centered services in the home. Our community paramedics can differentiate between a person who is sick at their baseline, or sick and in need of emergency care. Furthermore, they have a lot of resources available to them in real-time, including conference calls with a nurse practitioner or physician for every patient interaction. They are always adding to a member’s care plan, and ultimately, giving our members additional resources in the home to prevent them from becoming sicker down the road.