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Breaking News: The Next Big Thing: Paramedicine for Burdened EDs

Shaw, Gina

doi: 10.1097/01.EEM.0000413154.85430.dc
Breaking News
Specially trained paramedics, like San Francisco's Niels Tangherlini, left, are an amalgam of EMS, social work, and community medicine, intervening with chronic ambulance users, overwhelmingly homeless men

Specially trained paramedics, like San Francisco's Niels Tangherlini, left, are an amalgam of EMS, social work, and community medicine, intervening with chronic ambulance users, overwhelmingly homeless men

Like many paramedics, Niels Tangherlini, now a paramedic captain for the San Francisco Fire Department, found himself frustrated over the course of a 20-year career in the field. “I worked in New York, San Francisco, and Oakland, and I kept seeing the same thing: high-risk, high-need populations like homeless people, chronic alcoholics, isolated seniors, and people with chronic medical conditions,” he recalled.

“These people were overwhelmingly the greatest users of emergency medical services and hospital emergency departments. I'd see the same person four times in a shift. I'd take them back to the ER, and shrug my shoulders. We'd give them just enough to stay alive, and send them back to the street or their little one-room place.”

Rather than accept the status quo, Mr. Tangherlini got a degree in social work hoping to figure out some way to change all that. And in 2004, with the election of San Francisco Mayor Gavin Newsom, he got the chance. “The city latched onto the idea that frequent EMS users were keeping us from getting to life-threatening calls,” he said.

The city set up a separate unit within its EMS service, the Homeless Outreach and Medical Emergency (HOME) team, which was essentially composed of Mr. Tangherlini and various practitioners from public health and human services programs who would ride shotgun in the ambulance. Together, they would roam the streets of the city, finding and intervening with the chronic ambulance users — overwhelmingly homeless men.



Mr. Tangherlini developed a network of connections to get these people into treatment. “We rapidly became the number one source of referrals to medical detox in the city,” he said. “I was the initial ‘find you, engage with you during a crisis, stabilize you, and hand you off’ person, just like the traditional vision of paramedic work, only the handoff would be to get them into a treatment program and get a case manager involved.”

If he heard of an emergency department on diversion, he would show up and ask if there were any patients he could take to find services. “We noticed an unbelievable drop in diversion rates,” he recalled.

What Mr. Tangherlini had tapped into was a growing trend in emergency medicine known as community paramedicine. Whether in large cities, where emergency departments are overwhelmed with “frequent fliers” not in need of true emergency care or in rural areas where EDs and community clinicians are few and far between, specially trained paramedics are taking on a new role that is a sort of amalgam between EMS, social work, and community medicine.

The term “community paramedicine” is new, but the concept is not. “It dates back as far as the late 1980s,” said Gregory Mears, MD, an associate professor of emergency medicine at the University of North Carolina School of Medicine. “There was a project in Red River, New Mexico, where paramedics in remote areas were trained to provide basic medical care because there were no physicians or nurses nearby. They almost had a clinic type of atmosphere within their station. If they responded to an emergency and it wasn't significant, rather than driving a couple of hours to the hospital, they'd stop at their station, get a physician on the phone, and treat the patient that way.”

In the 1990s, Dr. Mears served as the local medical director for Orange County EMS, which serves the Chapel Hill area in North Carolina. “We had a treat-and-release policy, in which EMS didn't necessarily take every patient to the hospital. For events that did not require emergent care, patients could either be treated at home and then follow up with their doctor, or the paramedics would arrange for alternative care.”

That strategy was combined with an injury prevention project called “Welcome to the World.” EMS worked with the local health department to identify every newborn in the county, and paramedics would contact the parents with an offer to come by to do an injury prevention check for things like smoke detectors, hot water temperatures, and safe cribs.

San Francisco's Mr. Tangherlini also started one of the first EMS-based asthma outreach teams in the nation, serving the city's poverty-stricken southeastern neighborhoods. “We heard that kids had to wait six months to get asthma testing at hospitals, so we bring a spirometer to the housing projects. We give a printout of the results to parents, and if they don't have a doctor, we help them find one,” he said. “It's now a voluntary program, with a lot of paramedics coming in off duty.”

These programs have been developed largely based on special interest and the energy and belief of founders like Mr. Tangherlini. “As a result, they're very specific and tailored to the local system,” Dr. Mears said. “It's not a templated approach. It requires a lot of customized efforts. But at the national level, when you're looking at trying to decrease volume in emergency departments or more appropriately treat some patients at a clinic as opposed to the ED, that's where there's more scrutiny and there need to be larger studies.”

That may become possible soon, thanks to a program from the Centers for Medicare and Medicaid Services called the Health Care Innovation Challenge. This initiative will award up to $1 billion in grants to applicants who can implement the most compelling new ideas to deliver better health, improved care, and lower costs to people enrolled in Medicare, Medicaid, and CHIP, particularly those with the highest health care needs.

That seems like a perfect fit for community paramedicine, which has struggled with funding in the past. “Right now, EMS only gets paid when they transport a patient. If these programs are done well and you could get reimbursed in some other model, that could be a huge cost savings for the health care industry,” Dr. Mears noted.

One group that is busily finalizing its application to the Innovation Challenge is the Community Healthcare Emergency Cooperative and its Community Paramedic Program, an educational initiative under the auspices of Minnesota's North Central EMS Institute. Working with several state rural health offices, CHEC project director Gary Wingrove, a former president of the National EMS Management Association and the chair of the International Roundtable on Community Paramedicine, and his colleagues have created a community paramedicine curriculum that can be used by any accredited college in the world to help train community paramedics.

“In March, we're starting a class in six different states, and will be testing distance learning for the first time,” said Mr. Wingrove. “We're filing an application on behalf of 16 different places to the Innovation Challenge program, and hoping to set up a technical assistance center.”

The curriculum, now in its third incarnation, cost about $150,000 to develop, and has been used by dozens of colleges and the U.S. military. The group also developed the “Community Paramedic Program Manual,” a step-by-step guide for communities interested in developing their own program. The manual has been downloaded more than 650 times, and it's available free. (See FastLinks.) “The appetite for community paramedics is huge all over the world, not just in the U.S.,” Mr. Wingrove said.

Mr. Tangherlini, for one, said he hopes the Innovation Challenge comes through. After five years of a very successful community paramedicine program in San Francisco, the HOME Team was shut down when funding ran out. “I've heard that several of my former clients died terrible deaths since then,” he said. “One froze to death on Market Street, and another drowned in Golden Gate Park. I can't help wondering if I could have saved them.”

With those thoughts haunting him, it's little wonder that he's still pursuing his mission on the side. While wrapping up his call to Emergency Medicine News, Mr. Tangherlini answered the other line. It was one of the many police officers he'd worked with through the HOME Team. “He's where? You need what?” he asked. “I'll be right there.”

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