The Efficacy of Community Paramedicine:

A National Review of 1st Responder Attitudes,

Misconceptions, and Advocacy for CP Programs

Thomas Beers, MPA, NHDP, EMT-P

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TABLE OF CONTENTS

CHAPTER ONE BACKGROUND OF THE PROJECT

Abstract p. 3
Definitions p. 3-4
Purpose of the Research p. 4-5
Limitations p. 5-6
Summary p. 6-7

CHAPTER TWO REVIEW OF RELATED LITERATURE

Literature Review p. 8
Overview of Established Programs p. 9-12

CHAPTER THREE DESIGN OF THE RESEARCH

Introduction to the Research p. 13

Research Limitations p. 13-14
Research Methodology p. 14-16

CHAPTER FOUR FINDINGS AND DISCUSSION

Analysis of Survey Results p. 17-20

Analysis of Efficacy in Current Models p. 20-21
Money Often Costs Too Much p. 21
Putting People First p. 22
When Surveys and Facts Collide p. 22-24
When Money and People Collide p. 24-28

CHAPTER FIVE CONCLUSIONS, IMPLICATIONS AND FUTURE

RECOMMENDATIONS

Conclusions p. 29
Implications p. 29-31
Future Recommendations p. 32-33

Appendix A:
Opinions and Perspectives on Community Paramedic
Programs in the United States p. 34-37

References p. 38-40

Dedication p. 41
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The Efficacy of Community Paramedicine

Abstract

In the 1970’s fire departments found themselves in a difficult position. Improvements in civil

engineering and code enforcement were leading to a decrease in the occurrences of fire in the

United States. In search of a mission, fire departments adopted the role of 911 medical response

known today as Emergency Medical Services (EMS). Since then, EMS has become a financial

behemoth to the nation and a catch all for medical issues, many of which are not emergencies.

This burden on frontline healthcare is draining the limited resources of EMS services across the

nation. With the advent of the Affordable Care Act, EMS is now seen as an essential component

of the medical community. Under the regulations set forth in the Affordable Care Act, EMS is

mandated to adopt new systems of delivery which have universally been referred to as

Community Paramedicine. However, public safety agencies involved in the delivery of EMS

have been slow to adopt Community Paramedicine. This paper will examine the barriers to

adopting Community Paramedicine and the long term efficacy of Community Paramedicine as

an answer to fixing what many consider to be a fragmented and broken EMS delivery care

system.

Definitions

Throughout this paper, there are terms that may be unfamiliar to the reader. In order to

assist in understanding the scope of this project, key terminology must be understood.

The terms, “EMS” and “Pre-hospital medicine” are used interchangeably in order to

break up the monotony that often occurs while reading research papers of this magnitude. Both

terms refer to what many would consider the local systems in which paramedics and EMT’s are
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permitted and compelled to render aid to citizens. These brave men and women are usually

members of a local fire department, municipal ambulance (EMS) authority, hospital based

ambulance service, or a for-profit ambulance company that is contracted with a local 911

jurisdiction or region.

This paper examines a new type of professional rescuer called a “community paramedic”.

These individuals practice “community paramedicine” which is aimed at reducing health care

expenditures to the local government while rendering non-traditional calls for medical assistance.

Purpose of the Research

The research hopes to remedy the question “Can Community Paramedicine address the

needs of EMS agencies by reducing local healthcare system costs while bridging the gap of

healthcare access for society’s fringe populations and if so, what are the current barriers and

misconceptions to establishing community paramedic programs?”

From a financial outlook, this research question examines the burden of unmet medical

needs that are not addressed by the current and pervasive “you call, we haul” EMS systems

which are unsustainable in many parts of the nation (WPXI, 2019). Medicare alone is drained of

nearly $5 billion annually for EMS services, many of which the calls for EMS service do not

meet the criteria and threshold of an “emergency” (Pettypiece, 2014). In addition to Medicare

expenditures, Medicaid and private health insurance costs have not been studied or added to this

factor.

On an ethical level the research question is even more important to survey. Case in point:

Despite some of the best healthcare in the world within walking distance, life expectancy hovers

at just 70 years of age in some of Cleveland's most impoverished neighborhoods. Meanwhile,

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just 10 miles away life expectancy rises above 82 years (Ross, 2016). The disparity arises from

multiple socioeconomic factors to include access to healthy choices in food, gyms, and even

school systems that can produce populations who are more medically literate. In this

environment of disproportionate access to the full spectrum of healthcare needs, EMS has

become the emergency safety net it was never designed to be nor intended to occupy.

Emergency departments are often overrun with EMS patients who are not exhibiting

emergencies and could be treated on-scene by EMS at their residence, by midlevel practitioners

at urgent cares, or transported to more appropriate facilities (addiction centers, mental health

facilities, etc.) by utilizing community paramedic practices. This model is of even more

importance given the current trends in rising costs of healthcare and EMS transports for geriatric

patients. The healthcare field is experiencing what has been termed the “silver tsunami”

(Barishansky, 2016). This phenomenon is a result of the 1940’s Baby boom which has produced

a sudden surge in the US population that is medically categorized as of being (defined as ≥ 65

years of age). The growing geriatric population and their unique socioeconomic factors adds an

additional burden on EMS agencies who could benefit from utilizing community paramedic

programs to address this added pressure to the healthcare system.

Limitations

A complicating factor in relation to community paramedic programming is that

each jurisdictions community paramedic program is unique in order to meet the needs of that

specific community. This makes researching the concepts of community paramedicine difficult

when attempting to locate a broad based analytical study of their efficacy. This project has

produced a singular resource for local EMS leaders in which they are able to establish a
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knowledge base to launch their own community paramedic programs from reviewing best

practices from around the country.

Aside from the wide swath of differing community paramedic programs from one

location to another, other certain limitations proved to be quite difficult to address but

countermeasures were deployed to minimize their effects. One of the main sets of data used for

this research was on online survey (Appendix A). Rather than conduct the survey at a local

level, which would not address the questions pertaining to community paramedicine programs in

the United States as a whole, the survey was proliferated via social media sites such as Twitter

and Facebook using open source software created by Google. The final survey produced the

desired effect of an appropriate sampling from across the United States as well as taking other

factors into consideration such as EMS agency type, title/position of the respondent, and other

personal and organizational demographic data points.

What has been produced is a concise review of the current financial indicators and

modeling in relation to community paramedicine programs, the primary barriers to community

paramedic programs, and the social implications to consider for the argument towards adopting

community paramedic principles.

Summary

Pre-hospital emergency medicine is at an exciting crossroads where integration into the

overall health space is merging with the traditional 911 response system. The goal of these

programs are to primarily reduce the expenditures and burdens placed on local first responders.

However, and more importantly, community paramedic programs are set to address the needs of

citizens through full integration into the healthcare system by determining medical needs and,
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when suitable, linking them to the appropriate resources other than the emergency department at

a local hospital. This is of vital importance as community paramedic programs are uniquely

designed to address disparity between sectors of the community who have limited access to

healthcare resources. Much of this disparity is linked to aging in a society and socio-economic

status.
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Literature Review

Over the past decade, there has been a growing amount of literature on the topic of

Community Paramedicine. One of the major issues in the immediate research is how one defines

Community Paramedicine. The notion behind the concept is to allow EMS agencies (fire-based,

third service, or private ambulance) to build community paramedic models that attend to the

needs of their specific community, how those needs effect the overall costs to their portion of the

medical system, and adopt programs that reduce the overall cost to the nation’s crisis of

ballooning healthcare costs. For research purposes, a universally accepted construct of what

defines Community Paramedicine is required for this project. Therefore, for this research,

Community Paramedicine is defined as pre-hospital programs that reduce the burden of

unnecessary transport by a 911 responder and reduces the disparity of healthcare resources in the

vulnerable populations of a community. Leading research in this burgeoning field can be found

in federal documents from the US Department of Health and Human Services, leading and

progressive EMS agencies such as the Houston Fire Department, Wake County EMS in North

Carolina, and nationally recognized medical institutions such as the Cleveland Clinic.

Since there is no singular “correct” methodology to constructing a successful community

paramedic program, the literature review attempts to gather examples of successful community

paramedic programs throughout the United States. This also serves for the reader to digest the

full spectrum of deployment strategies in relation to community paramedicine programs and how

these critical services can accomplish much more for vulnerable populations in any community.

As represented by this list of programs, it becomes obvious that some community

paramedic programs adopt strategies that are simple while others have taken a more complex

route to address difficult socioeconomic issues such as mental health and homelessness.
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Blood Pressure Screening/Blood Glucose Screening, Ohio. This program authorizes

paramedics to meet with citizens in a non-emergent environment and assist them with

monitoring their blood pressure, pulse, and blood sugar levels. This simple program is critical in

that while the focus may appear to be “just taking vital signs”, community paramedics are also

discussing nutritional choices, salt intake, exercise, and can actually do “health care” rather than

“medical care”. The medic may be able to detect the onsets of hypertension and diabetes. This

is similar to getting an annual physical from a primary care physician PCP, which many people

in blighted neighborhoods do not have access to. Now they have access to the health care system

and the community paramedic will be able to help guide them to PCP’s.

Medication/Prescription Assessment & Reconciliation, Colorado. The MPAR allows the

paramedic to assist the citizen with managing prescriptions and ensuring they are current,

supplied, and compliant. This allows the medic to help the patient grow in their medical literacy

and understand the importance of compliance with their prescriptions. It also allows the medic

to reconcile medications that come from different hospital systems and ensure there are no

medications that do not work well with each other. This also allows the medic to look for

patterns of prescription narcotic abuse and “fishing” from the patient. “Fishing” is the term used

for patients who go from one hospital system to another gathering the same mediations in which

they abuse.

Field Initiated Scripts and Triage (FIST), Arizona. This program allows medics to write

prescriptions to patients for antibiotics as well as pain medication, usually over the counter

(OTC) medications. Having a script in hand for an OTC allows the patient to “access” the

pharmacy for common medications. Antibiotics can be used for patients with UTI’s, STD’s, and

other minor infections, alleviating ED congestion with low acuity patients

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Congestive Heart Assessment and Management Program (CHAMP), Ohio. This program

allows the paramedic to access and assess patients on behalf of the local hospital systems post-

discharge for CHF exacerbations. This paper discussed at large the program already. The aim

would be to reduce the volume of readmitted patients by assisting them in managing their CHF

and other medical conditions.

Trauma in Residence Avoidance Program (TRAP) Texas. The fire service adopted EMS in

the 1970’s because there was a decrease in fires due to fire prevention and education, to include

home fire safety programs. This programs aim is to reduce the number of accidental injuries and

mortality due to in-home traumatic events. This includes smoke and CO detection devices, trip

hazard identification, electrical hazard identification, bathrooms assistance devices assessment,

navigation of social services and other needs (i.e.: “Meals on Wheels”), and evaluation of

ingress/egress for EMS emergencies.

Suturing in Place (SIP), California. This program is self-explanatory. Medics with the

appropriate training can successfully suture wounds in the field, negating the need for ED

transport thus reducing congestion and saving healthcare system dollars. The program also

includes injections of tetanus vaccine for those who need to update their immunizations after a

laceration that could develop into a tetanus infection.

Alternative Transport of Mental and Substance Abuse Patients (ATOMS), North Carolina.

A County wide EMS agency has been very successful in managing the needs of patients with

mental health diseases by taking them directly to in-patient mental health facilities reducing

healthcare costs and transportation costs. This program allows the paramedic to transport

patients non-emergently in a vehicle to the direct admit mental health facility. The program also

works for the thousands of patients who call 911 in order to begin sobriety from drugs and
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alcohol, but their only access is the 911 system and the current system only allows EMS units to

transport to the ED, thus creating overcrowding and increased healthcare system expenditures.

Hospice Revocation Avoidance Program, Texas. Community Paramedicine is about

navigation of the healthcare system to include all parts. Several community paramedic programs

have included reducing the calls for service of hospice patients when death is imminent and the

family wishes to revoke palliative care against the patient’s interests. The program consists of

hospice identifying which families are at risk of revoking palliative care and once identified

having the community medic meet with the family and address their concerns as well as explain

the role of 911 responses in these situations. Successful programs have shown a reduction in

revocation by 10%, saving the healthcare system dollars while advocating for the patients best

interests.

Care of the Transient and Those in Extreme Need (COTTIN) Program, California. The

community paramedic must know not only the abilities of the local emergency departments but

all facets of the healthcare and ancillary human services in the immediate area. This includes

assessing the needs of those in extreme poverty and the transient/homeless populations.

Community Paramedics would need to know social services, faith based groups, warming

centers, homeless shelter capabilities, soup kitchens, crisis intervention, veteran’s assistance

programs, pro bono dental services, and how to gain access to them for this special population

thus reducing homelessness and improving the quality of the local community.

While the literature review shows that community paramedic programs have a legitimate

usefulness, what remains uncertain is why there is a lack of instituting or replicating these many

successful programs in communities throughout the United States. The second part of this

research paper will illustrate the apprehension that many key stakeholders in EMS agencies have
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when it comes to this type of resource deployment. The research shows that there are two major

issues with community paramedic programs in the United States. The first are the gaps in

understanding and adopting Community Paramedicine programs based on the current

reimbursement models. The second is the prevailing attitudes towards community paramedic

programs. This includes differing opinions on their usefulness and power to change or even fix a

system that is often described as “broken” (Beers, 2019).

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Introduction to the Research

Community Paramedicine programs are a relatively novel concept in pre-hospital

medicine and have caused a great amount of confusion as well as ambiguity. Many EMS

agencies struggle to understand how community paramedicine can be beneficial financially,

medically, and socially to their local jurisdiction. The opacity of community paramedic

programs further prevents widespread adoption and implementation of these programs into

emergency response capabilities. An appraisal of the current attitudes on the efficacy of

community paramedic programs reveals a multitude of prevailing opinions. Their value is not

universally accepted and the general opinion of current EMS provider’s attitudes concerning

community paramedicine as a whole reveals interesting results. This complicates the

proliferation of community paramedic programs. When EMS professionals cannot understand

how community paramedicine is structured, it becomes even less likely that EMS leaders can

bridge the gap in the healthcare needs for society’s vulnerable populations.

Research Limitations

This section of the research is composed of a survey of the current perceptions and biases

towards community paramedic models. This research focuses on much of the confusion as to the

validity of transitioning EMS programs from more traditional 911 services to more community

focused paramedicine programs. Surveys were conducted with EMS practitioners across the

United States to gather insight into the pitfalls and current status of programs from a multitude of

jurisdictions. The research was limited to survey respondents in the United States only. This is

because other nations such as Canada and the United Kingdom have nationalized EMS programs

that are very different in their funding models than in the United States. In the US, EMS
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agencies are funded from local tax dollars where as in the other aforementioned nations, EMS is

a federally funded safety program.

Survey Methodology

To better understand the aforementioned issues, a national survey was conducted for the

explicit collection of data on opinions and knowledge for this capstone research project. The

survey was designed using open and universally accessible formats and forms through Google.

This generated an open link to the survey. The survey link was distributed using social media,

primarily Twitter, and sent out using a network of nationally recognized authors and subject

matter experts in the public safety sphere. Within the 72 hours, a satisfactory number of survey

responses (n = 286) were collected with a sampling that was evenly distributed across the four

geographical regions of the United States. The full survey is located in Appendix A.

Using commercially available software, the data was reviewed. Respondents were

stratified based on their position within their agency to gain a greater understanding for the

purposes of this research as to the general consensus and opinions of community paramedic

programming and crossed with their rank. The survey looked at demographical data, such as

position within their agency, the type of agency, and other critical factors such as overall

impressions about EMS in general when compared to community paramedic programming. The

questions were carefully considered in order to highlight veiled biases as well as ensure an

appropriate sampling from across the country. This last part was of particular importance as

some areas of the country are more apt to develop community paramedic programming than

other geographical regions. The results of the distribution are seen in figure 2.
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Fig. 2

Additional biases were also considered such as position within the agency and type of

agency. Those results are as below in figures 3 and 4.

Fig. 3
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Fig. 4
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Analysis of Survey Results

The raw data was analyzed to look for and cross reference a multitude of data points in

regards to the attitudes towards community paramedic programs. Of the 286 respondents, 201

identified as frontline (non-supervisor) EMS providers, 45 as frontline supervisors, and 34 as

chief or administrative chief officers. The remaining six respondents were removed due to

ambiguity in their roles.

Keeping these three positions within the various organizations in mind, we focused on

two questions universally and regardless of location or EMS agency type or other factors. Those

two questions were, “Regardless of whether you have or do not have a community paramedic

program, how do you feel towards the idea of these types of programs?” and “Based upon what

you know about community paramedic programs, do you find the concept confusing or

understandable?” Both questions were rated on a scale of 1 through 10. The results showed that

frontline EMS providers, universally and regardless of the type of agency, felt more favorably

towards community paramedic programs than chiefs and supervisors/officer. It also appeared

that the higher rank one was within an EMS agency, the less favorable one felt towards

community paramedic programs and the more confusing they were to the individual (figure 5).

Favorability towards CP Understandability of CP

(10 = greatest favorablity) (10 = more easily understandable)
Frontline EMS Personnel 8.2 7.4
Supervisors/Officers 7.9 7.1
Chiefs/Admin 7.8 7.6

Fig. 5
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What is interesting of these results is that despite the growing literature on the efficacy of

community paramedic programs, chief officers felt that they had the greatest understanding with

the least favorability. Frontline providers were the most favorable to community paramedic

programs but also felt they were easier to understand than their officers. This may be a result of

the changing tide in EMS initial education standards. Supervisors have established careers

already in EMS and community paramedic concepts were not taught in their initial paramedic

training. Thus they found the concepts more confusing when compared to both their

subordinates and their chief officers who may be more aware of these types of programs given

their administrative positions.

One of the most interesting aspects of the data set was the perceived financial benefits of

community paramedic programs based upon agency position. When chief officers were isolated

within the data set, 73.5% (25 of 34) indicated that they agreed community paramedic programs

save healthcare dollars and generate a new revenue stream for EMS agencies. Given that fire-

based EMS is the most prevalent form of EMS delivery in the United States, the data was further

evaluated and found that 71.4% (15 out of 21) chief officers of fire-based EMS programs

indicated that community paramedic programs were financially beneficial to EMS. However,

the survey asked respondents to indicate barriers to establishing community paramedic programs

in their jurisdiction. Focusing again on chief officers who have the authority to establish these

types of programs and who also indicated that they were most comfortable with understanding

community paramedic programs (figure 5), overwhelmingly, 88.2% (30 of 34) of chief officers

stated the number one reason was that “current reimbursement models are prohibitive”.

The prevailing attitudes towards community paramedic programs based on geography

were also examined. States located in the southern region of the United States were less likely to
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indicate that they were not interested in community paramedic programs (8.9%) and also had the

highest reported count of a combination of “interested”, “have” and “currently developing”

community paramedic programs (76.9%). The Midwest portion of the United States was on the

opposite side of the data with 29.7% of respondents indicating that their agency was not

interested and only 66.6% indicating that their agency was “interested”, “have” and “currently

developing” community paramedic principles and practices. See figure 6.

Row Labels Count of For Validation, please place your initials below
Midwest (IL, IN, IA, KS, MI, MO, MN, NE, ND, OH, SD, WI) 84
We are currently working toward a community paramedic program 4
We are not interested in community paramedic programs 25
We currently have a community paramedic program 20
We do not have a community paramedic program but are interested 32
We had a community paramedic program but abandoned it 3
Northeast (CT, DE, ME, NH, MA, NJ, NY, PA, RI, VT) 54
We are currently working toward a community paramedic program 12
We are not interested in community paramedic programs 12
We currently have a community paramedic program 10
We do not have a community paramedic program but are interested 18
We had a community paramedic program but abandoned it 2
South (AL, AR, FL, GA, KY, LA, MD, MS, OK, NC, SC, TN, TX, VA, WV) 78
We are currently working toward a community paramedic program 9
We are not interested in community paramedic programs 17
We currently have a community paramedic program 26
We do not have a community paramedic program but are interested 25
We had a community paramedic program but abandoned it 1
West (AK, AZ, CA, CO, HI, ID, MT, NV, NM, OR, UT, WA, WY) 70
We are currently working toward a community paramedic program 8
We are not interested in community paramedic programs 15
We currently have a community paramedic program 16
We do not have a community paramedic program but are interested 23
We had a community paramedic program but abandoned it 8
Grand Total 286

Fig. 6

When using cross referenced data points within the survey, the research also indicated

that, nationally, hospital based EMS services were the most likely to adopt community

paramedic principles, followed by fire-based and municipal third service EMS agencies.

Private/for profit ambulance companies were the least likely to adopt community paramedic
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programs. This is most likely attributed to the uncertainty of payment plans for community

paramedic programs and the inherent nature of for profit/private ambulance services. The results

can be found in figure 7 below.

Current State of CP Programs in EMS Agecnies (by agency type) Fire based EMS Hospital Based Private Ambulance (for profit company) Third Service (municipal based but does not do fire) Grand Total
We are currently working toward a community paramedic program 12 6 10 5 33
We are not interested in community paramedic programs 25 8 22 14 69
We currently have a community paramedic program 24 19 8 21 72
We do not have a community paramedic program but are interested 45 12 18 23 98
We had a community paramedic program but abandoned it 7 3 2 2 14
Grand Total 113 48 60 65 286

Fig. 7

Analysis of Efficacy in Current Models

Traditional public safety occupations have clear cut roles and descriptions that can

universally describe their place in the world. Firefighters put out fire, paramedics save lives and

police officers prevent crime. Community Paramedics are not so fortunate. At its broadest

definition, community paramedicine aims to “encourage paramedics to refer patients in need to

community based support services (O’Meara, Stirling, Ruest, & Martin 2016). This broad

definition does not give appropriate guidance to decision makers and stakeholders on how to

create community paramedic programs. It is not a clearly defined position as the aforementioned

public safety roles. Two recent surveys address this very critical piece concerning community

paramedicine programming. In 2015, a survey examining community paramedicine revealed

that frontline paramedics expressed role confusion and undefined accountability as a major

barriers to establishing community paramedicine programs (Brydges, Spearen, Birze, & Tavares,

2015). More recently, for the purposes of this project, a national survey was conducted and

found that approximately only one-third of EMS practitioners agreed that community

paramedicine was “very understandable” (Beers, 2019).

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The inability to understand community paramedicine and its role is the primary hindrance

to its widespread adoption across EMS agencies as a whole. Without the requisite knowledge,

public safety executive officers cannot begin to justify expenditures and funding for community

paramedic programs which leads to the second issue surrounding community paramedic

programs: money.

Money Often Costs Too Much

Money is really at the root of the many of the issues surrounding community

paramedicine and there is a credible amount of research to support this including the survey

conducted for this research project. Many chief officers have indicated that they believe that

transporting patients, regardless of the low level of patient acuity, is the most financially

successful model for their jurisdictions. It is a reimbursement model that has been prevalent for

almost 30 years. A moderate sized city of 50,000 can accrue nearly $1,000,000 annually is EMS

billing fees at the established Medicare reimbursement rates. These fees are structured by the

Department of Health and Human Services and establish rates for basic and advanced life

support EMS calls.

However, with healthcare as a whole focusing on results and value based programming,

as prescribed by the Affordable Care Act, EMS is under the same pressures as hospitals and

other healthcare agencies. Some programs, like the City of Houston Fire Departments ETHAN

Program (Emergency Telehealth and Navigation), adopting principles outside of the standard call

and haul model have substantial savings to and an EMS agencies coffers (Alqusairi, 2015).

Backing this claim is the prestigious New England Journal of Medicine which has cited that

community paramedic programs could save millions of healthcare dollars to regional systems

when operated at the municipal EMS level (Iezzoni & Mongan, 2016).
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Putting People First

The most important aspect of community paramedic programs are the ability to bridge

the gap between vulnerable patients and their inability to receive adequate access to healthcare

needs. For many, EMS becomes the primary route in which to seek medical care that could be

addressed by resources outside of the emergency department. One of the leading reasons for the

overuse of EMS is “healthcare literacy”. The US Department of Health and Human Services

studies have shown that ethnic minorities and those who struggle financially are more likely to

drain healthcare dollars for a multitude of reasons (US HHS, 2008). This would include

municipal EMS systems and the burden it places on them as well.

The literature review cited here brings together many already established academic

proceedings into one singular and culminating fact that Community Paramedic programs can

address the divide between those most in need of adequate healthcare access and the needs of

local communities. Later, this report will examine how both financial and cultural shifts are

needed in order to bring community paramedic programs to fruition and assist in bridging that

gap.

When Surveys and Facts Collide

Understandably there is no universal definition of what a community paramedic program

entails as it is tailored to the needs of any one specific community. Therefore it is important to

look at community paramedic programs that are scalable in scope so that they can be adaptable

to agencies regardless of size. Major community paramedic programs that have garnered the

most coverage and acceptable practices are being examined for the purposes of this paper. The

goal is to examine the experiences of others and make them understandable and applicable to any
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other singular agency that is considering adopting community paramedicine principles in their

mission capabilities. This portion of the research also examines the cost savings those successful

programs have experienced and will extrapolate factual data on the cost saving of community

paramedic programs.

Because the research question is not singularly focused on financial incentives but also

emphasizes how community paramedic programs meet the needs of the disenfranchised within a

community, current trends in hospital admissions and the healthcare needs of the largest user of

EMS services, the Baby Boomer generation, is also analyzed. An audit of EMS transport data to

a major hospital system was also conducted and is currently being analyzed to show that there is

a major shift in more EMS transports for the elderly who have complex social and medical needs

that can benefit from community paramedic programs. This data will be published in the final

project.

Additionally, a local hospital system in Greater Cleveland was able to share readmit rates

and the overall costs to the healthcare system that this imposes. The financial implications of not

adopting community paramedic programming is overwhelmingly large. The research will tie

this overall and unnecessary healthcare expenditure/burden to address how public and private

enterprises can collaborate to reduce healthcare spending through collaborative approaches to

community paramedic programs.

The research findings as presented are aimed at expressing the efficacy of community

paramedic programs in the United States. The research examined community paramedic

programs from two distinct approaches. The initial construct of this project was more analogous

with an overall review of the current literature in order to prove the efficacy of established

community paramedic programming based upon financial incentives at the local government
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level. In addition, the research looked to find data that showed a community need or benefit for

community paramedic programming based on vulnerable populations who could benefit the most

from community paramedic programs. This project also incorporated survey data to establish

not just current programs but also examine how biases and misunderstandings towards

community paramedic programs effect the ability or inability of a local jurisdiction to establish

community paramedic programs of their own.

When Money and People Collide

Each community has specific needs that must be addressed differently. As unique as

each community is, so too should be a municipalities community paramedic program. These can

be based on disease processes that effect one race more predominantly than another, therefore

one community having different needs over another based on diversity. Poorer communities

may have more of a need to access healthcare than others and this could be based on

socioeconomic factors. They are and should be as unique as the communities themselves. This

creates an issue for researchers who examine community paramedic programs. In order to

examine community paramedic programs in this research, community paramedicine was defined

as any pre-hospital programs that reduced the burden of unnecessary transport by a 911

responder and reduces the disparity of healthcare resources in a communities vulnerable

populations.

One program examined was the Houston Fire Department’s (HFD) ETHAN program.

ETHAN is an acronym for Emergency Tele-Health and Navigation. The aim of the ETHAN

program is to reduce unnecessary transports to emergency departments by EMS and 911 services

provided by the HFD while at the same time achieve cost savings results to the HFD and the
 25

overall healthcare system. The program allows EMS units to refer patients to medical care other

than an emergency department for low acuity and non-emergency 911 calls.

The results of the ETHAN program showed a reduction in unnecessary EMS transports

by almost 81%. Additionally, crews were able to return to service in an average time of 27

minutes. When compared to the return to service time of 83 minutes for a more traditional

model of “you call, we haul”, this reduced the out of service time for non-emergency calls by 56

minutes (Jackson, et al, 2015).

More concrete evidence of healthcare cost savings to the system through the ETHAN

program was also observed. HFD found that low acuity 911 patients who are transported in the

current models cost the overall healthcare system about $2,400 per 911 encounter. This

estimated cost includes transportation and emergency department visit. Patients who participated

in the ETHAN program cost the overall healthcare system approximately $450 per 911

encounter (Alqusairi, 2015).

Community paramedic programs do not just benefit the local EMS jurisdiction. More

robust community paramedic programs can include home-health visits from fire and EMS

practitioners for patients who are chronic users of the 911 system. Many of these “frequent

flyers” have complex medical issues that can be handled outside of the emergency department

but due to issues of medical literacy, transportation issues and health access disparity, 911 is

often the access point, however inappropriate, for many senior citizens with chronic yet not

emergent health issues.

An example of this type of community paramedic program that addresses chronic health

issues can be seen when examining current financial issues surrounding Congestive Heart Failure
 26

(CHF). According to the federal governments Healthcare Cost and Utilization Project (HCUP),

the average cost associated with a single hospitalization for CHF is $10,500. If, for example, the

Cleveland Clinic, a large scale hospital system, treated 2500 CHF cases, system-wide per annum,

the total amount of healthcare dollars expended on just these 2500 patients would exceed $26

million annually.

However, according to Medicare, all Cleveland Clinic facilities have an average re-

admittance rate of 22% within 30 days of initial EMS and emergency department contact. Public

and private medical insurance, by law, does not reimburse hospitals or EMS for any readmitted

patient within 30 days of the last hospital contact. This equates to a loss of approximately $5.8

million to just this one disease alone to one hospital system, in one city in the United States.

Community paramedic programs are a key dimension in preventing this multi-million

dollar loss to the local healthcare system. By allowing local city operated community

paramedics to follow up with recently discharged patients who present with chronic illnesses

such as CHF, the results of several large studies show a 20% reduction in remittance within 30

days (Jackson, Shahsahebi, Wedlake, & DuBard, 2015).

Further complicating the intersection of already overburdened EMS systems and

healthcare costs for the chronically ill is the growth of geriatric patients who use 911 EMS

services for healthcare access. This is attributed to the concept of “Silver Tsunami” which is

defined as the oldest members of the Baby Boomer generation having been medically defined as

geriatric. Along with advanced age comes the increasing reliability in 911 services

(Barishansky, 2016).

This research analyzed demographic data for patients transported by municipal EMS

agencies for 24 months from January of 2017 and through December of 2018 to a large primary
 27

healthcare hospital. The data concurs that geriatric patients who enter the emergency department

via local fire based EMS systems have been outpacing non-geriatric patients by the same mode

of arrival at three times the rate of growth. In January of 2016, geriatric patients that required

EMS services and transport were 10.66% greater than the non-geriatric patients. By the end of

the study, in December of 2018, geriatric patients accounted for 27.07% by the same measure

(Gorbett & Beers, 2019). Again, geriatric EMS encounters are outpacing the general public’s

EMS encounters at a rate three times greater than they were two years ago. The data field

included 128,420 EMS treatment and transports from across the EMS healthcare system (Figure

1).

Fig. 1

Given the vulnerability of the geriatric populations and their susceptibility to falls,

medication errors, and chronic health needs, community paramedicine may be a reasonable

solution to address the increase of geriatric patients. Special consideration should be noted that

the geriatric patient volumes will continue to grow as the Baby Boomers continue to add more of

its generation to the roles of the medically defined geriatric population.

 28

Many EMS encounters, geriatric or general population, could be handled by community

paramedics through a variety of programs. To address the Silver Tsunami, community

paramedic programs could be as simple as community blood pressure or diabetes monitoring

programs and community courses on fall hazard prevention programs. Community paramedic

programs could also be more dynamic with public and private partnerships between EMS

agencies and local hospitals. The argument is quite strongly in favor of community paramedic

programs and their ability to curb and divert unnecessary EMS transports through preventative

efforts.
 29

Conclusions

Community Paramedicine is fraught with inconsistency. There is only certainty in that

community paramedic programs do indeed save healthcare dollars within an already fragile

national healthcare economy. Numerous programs across the nation in cities large and small

have shown great success from simple blood pressure monitoring programs to more robust

integrated healthcare models similar to that of transporting patients to alternative destinations for

mental health and substance abuse clinics rather than emergency departments. It is clear that

there is disconnect at many local levels with the idea of how to construct, implement, and

monitor community paramedic programs. Even within EMS organizations, there is discordance

among ranks on the efficacy of community paramedic programs. Until local EMS leaders begin

to realize that healthcare dollars are finite and that value based programming and engaging a

communities most vulnerable populations is the future of EMS, then the only ones who will

suffer are the citizens who need these alternate solutions today.

Implications and Outstanding Issues

Governing bodies at the federal level of government have long been aware of the

misalignment of incentives within the “you call, we haul” EMS model. As previously noted,

Medicare billing reimbursement expenditures for 911 EMS transportation crested $5 billion in

2016. More alarming to the total cost of EMS services is that only 33% of EMS transports were

billed to Medicare. Medicaid bills account for another 20%, while the remainder is a mixture of

private and self-pay insurances (Munjal, Margolis, and Kellermann, 2019). Therefore, more than

50% of the 14.6 million 911 ambulance transports each year are paid for by publicly funded

health insurance.
 30

In April of this year, the Centers for Medicare & Medicaid Services (CMS) Center for

Medicare and Medicaid Innovation (CMMI) announced the Emergency Triage, Treat and

Transport (ET3) Model which is considered an Alternate Payment Model (APM) for 911

medical transports. This new model appropriately moves payment incentives from the “you call,

we haul” model of payment to emphasizing more appropriate triaging of patients in the field and

finding alternate solutions to meet a 911 callers medical needs. While this is truly a major step

towards incentivizing community paramedic programs, it is currently in a trial stage in which a

very limited number of agencies may participate via a federal grant system (Myers, Zavadky, &

Lawrence (2019).

One could easily argue that the federal government is too large and bureaucratic to

Address the needs of local EMS agencies. Given the turning tides of political landscapes as well

as the less than smooth roll-out of the Affordable Care Act and its failure to insure all

Americans, this is an understandable sentiment among some in the healthcare and health

insurance industry.

Adding to the federal government’s ability, or inability, to adequately administer

regulations on local EMS agencies, to include the equitable distribution of the ET3 model, is the

argument of states’ rights. Rules and administrative codes for the scope of practice for

paramedics differ from state to state. Emergency advanced airways and other life saving

techniques can, and do, differ from state to state. While some states may allow for some

paramedics to conduct bedside, or point-of-care, testing such as specific blood draws and tests

that are necessary for some community paramedic programs, other states do not allow for any

other EMS delivery system other than, “you call, we haul”. As an example, in Ohio, paramedics

working and engaging with patients in non-emergent settings are still not authorized to act in
 31

such a capacity. This begs the question of what would occur should an Ohio EMS agency apply

and accept a grant under the federal government’s trial of ET3? This is the most obvious

disconnect between state and federal rules governing EMS in the United States.

It was previously mentioned that other western nations, such as the United Kingdom,

EMS is a national program administered by the National Health Service. At the federal level in

the United States, EMS is not even aligned with Health and Human Services but rather is

governed by the National Highway Traffic Safety Administration. If there is any evidence of

disconnect between the federal government and the needs of pre-hospital medicine’s responders

it is this peculiar marriage of the NHTSA and frontline medicine. Even the national philosophies

of how to deliver EMS in the United States is at juxtaposition with our other western nations.

European models are based upon the Franco-German philosophy of bringing the hospital to the

patient whereas the United States typically follows a model of bringing the patient to the hospital

(Dick, 2003).

Finally, in a capitalist society, free enterprise is the rule of the land. Just as private

ambulances routinely attempt to privatize municipal EMS systems for profit, community

paramedic programs will be worth millions of dollars at the local level and private enterprises

will be considering approaching local cities and towns to operate community paramedic

programs for profit. Fire-based EMS systems and third service municipal EMS agencies stand to

lose the competitive advantage and those profits associated with community paramedicine if they

are considering to stay out of the community paramedic business. Both labor and management

need to work together is they wish to keep EMS reimbursement and expansion of fee services as

a supplement to their pre-existing municipal operating budgets.

 32

Future Recommendations

This research shows that there is a disconnect between those few agencies that have

entered community paramedicine and the vast majority of agencies who still feel that this new

deployment capability has no place in EMS or fire-rescue. There is also discord between the

layers of government that would make community paramedicine universal. Rules are not aligned

let alone visions. EMS was the same in its infancy in the 1970’s. Many fire departments felt

EMS had no place in their profession. Those agencies and leaders died a slow and painful death

as EMS became abundant and accepted practice.

Today, EMS and fire leaders who refuse to accept community paramedicine are on the

same path as those who were unwilling to accept change in the past. They have not learned from

the past and are now dooming themselves. The “you call, we haul” incentive package is quickly

disappearing. That money spigot is tapped; the money was always finite and the EMS industry

is moving forward with or without those who wish to not acknowledge these facts. The change

is going on today and it will take collaboration and patience.

Like any worthwhile change in EMS or civil regulation, organized lobbying to enact

change is an apparent first step. Leaders of local EMS agencies should be having discussions

with state authorities to change administrative rules that allow local EMS practitioners to create

programs within their local jurisdiction in order to address the patients at a community level.

State law makers need to be asking for appropriate federal oversight of EMS as a whole, with

national standards of care and reimbursement models that promote community paramedicine.

The research here shows that frontline personnel are more likely to find the notion of

community paramedicine more appealing. The major assumption is that frontline ranks are more

saturated with first responders that are younger than their supervisors and chief officers. This
 33

raises the supposition that initial paramedic training is beginning to address the EMS landscape

and introducing community paramedic concepts to the newest generation of pre-hospital

professionals. Taking it one step forward would be the creation of degree programs that are

focused on community paramedicine and healthcare administration for the pre-hospital

environment. This is not an innovative approach in healthcare as mid-level practitioners for

nursing and physicians is becoming normalized throughout the industry. Perhaps now is the time

to formalize a national curriculum for advanced practicing paramedics who can deploy in the

future to community paramedicine programs.

 34

APPENDIX A

Opinions and Perspectives on Community

Paramedic Programs in the United States
Thank you for participating and helping me with my studies! Results of this survey will be shared towards
the end of the year or early 2020.
* Required

1) What region of the United States do you practice EMS? *

Northeast (CT, DE, ME, NH, MA, NJ, NY, PA, RI, VT)
Midwest (IL, IN, IA, KS, MI, MO, MN, NE, ND, OH, SD, WI)
South (AL, AR, FL, GA, KY, LA, MD, MS, OK, NC, SC, TN, TX, VA, WV)
West (AK, AZ, CA, CO, HI, ID, MT, NV, NM, OR, UT, WA, WY)

2) What type of EMS agency do you primarily work in? *

Fire based EMS
Third Service (municipal based but does not do fire)
Private Ambulance (for profit company)
Hospital Based

3) What is you role in your agency? *

Front line responder
Officer/Supervisory Role (all officer/supervisory ranks outside of administrative roles)
Chief/Assistant Chief/Administrator/Executive (anyone in an administrative role only)
Other:

4) Is your agency volunteer, full-time, part-time, or combination? *

Full Time
Part Time
Volunteer/paid per call
Combination

5) What is the population size your agency serves? *

Under 50,000
50,001 to 200,000
200,001 to 500,000
Over 500,000
 35

6) Does your agency have any form of community paramedicine programs? (can be
called any variety of name such as MIHC, advanced practice medic, alternative transport
programs, etc.) *
We currently have a community paramedic program
We do not have a community paramedic program but are interested
We are currently working toward a community paramedic program
We are not interested in community paramedic programs
We had a community paramedic program but abandoned it

7) Regardless of whether you have or do not have a community paramedic program, how do
you feel towards the idea of these types of programs? *

1 2 3 4 5 6 7 8 9 10

Strongly Unfavorable Strongly Favorable

8) Based upon what you know about community paramedic programs, do you find the concept
confusing or understandable? *

1 2 3 4 5 6 7 8 9 10

Very Confusing Very Understandable

9) Based upon your understanding of community paramedic programs, either your own or from
other programs, what do you think are some of the advantages to these programs (check all that
apply)? *
Saves healthcare dollars
Connects patients to resources other than the emergency department
Allows crews to have transport options other than "you call, we haul"
Generates new revenue sources for EMS agencies
Relieves the burden on frontline EMS responders
Educates citizens on what is appropriate for 911 services
I do not think community paramedic programs accomplish any of the above
Other:
 36

10) Based upon your experiences or from what you know from others, what are some of the
barriers to establishing a community paramedic program? (check all that apply) *
current reimbursement models are prohibitive
not enough personnel to fill the role
lack of interest within my agency (from staff/crews, not admin)
lack of legal guidance or legal ambiguity on these programs
Uncertainty on the current state of community paramedicine
lack of support/interest from administration, local government, or medical direction
Other:

11) Do you feel that the current state of EMS, simply put as "if someone calls no matter what
the issue, we transport to the emergency room" as a whole, is broken? *
Yes
No
Other:

12) Do you feel that community paramedic programs can fix the EMS system? *
Yes, they can
No, they cannot
No, the system is not broken

12) If your agency has a community paramedic program, what option best describes the
program *
We have dedicated personnel each day that are assigned to the program
We allow our crews to refuse patients that do not need to go to the emergency department via 911
vehicle
We allow crews to perform non-traditional EMS services such as write prescriptions, suture on
scene, or advanced skills
We have a collaborative program with hospital personnel who visit patients that our EMS crews
identify as needing community paramedic intervention
We have none of these options
Other:

13) Do you feel that, no matter what, community paramedic programs are here to stay? *
Yes
No
I do not know
 37

14) If community paramedic programs continue to grow, who should operate them? *
EMS systems (any type)
Hospitals
Private companies (not hospital or private ambulance)

15) Do you feel there is anything else we should know in regards to your thoughts on
community paramedic programs that could answer the following research question: "Can
Community Paramedic programs address the needs of EMS agencies by reducing local
healthcare system costs, reducing the strain on EMS crews, and bridge the gap of healthcare
access for the chronically ill and vulnerable populations we serve?"

Your answer

16) For Validation, please place your initials below *

 38

References

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Achieve Greater Value for EMS . Retrieved from https://www.hfmatxgc.org/wp-

content/uploads/2015/05/1510J4-Diaa-Alqusairi-ETHAN-Project.pdf

Barishansky, R. (2016, June 21). The Silver Tsunami: Are You Ready? Retrieved April 20,

2019, from https://www.emsworld.com/article/12223262/the-silver-tsunami-are-you-

ready

Beers, T. (2019). Online Survey: Opinions and Perspectives on Community Paramedic Programs

in the United States

Brydges, M., Spearen, C., Birze, A., & Tavares, W. (2015). A Culture in Transition: Paramedic

Experiences with Community Referral Programs. CJEM, 17(6), 631-638.

doi:10.1017/cem.2015.6

Dick WF (2003). "Anglo-American vs. Franco-German emergency medical services

system". Prehosp Disaster Med. Volume 18 (1) 29 – 35

Gorbett, T., & Beers, T. (2018, December 04). Cleveland Clinic EMS Transports 2017-2018.

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Iezzoni, L. I., & Mongan Institute for Health Policy. (2016, March 24). Community

Paramedicine - Addressing Questions as Programs Expand: NEJM. Retrieved October

27, 2019, from https://www.nejm.org/doi/pdf/10.1056/NEJMp1516100?articleTools=true

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Evidence-Based Approach for Planning After Hospital Discharge, Ann Fam Med

March/April 2015 13:115-122; doi:10.1370/afm.1753

 39

Jackson, A., Alqusairi, D., Persse, D., Gonzalez, M., Langabeer, J., & Champagne-Langabeer, T.

(2015, November 2). Houston EMS Advances Mobile Integrated Healthcare Through the

ETHAN Program. Retrieved November 9, 2019, from

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through-the-ethan-program/.

Munjal, K., Margolis, G., & Kellermann, A. (2019). Realignment of EMS Reimbursement

Policy. Retrieved November 19, 2019, from

http://www.naemt.org/WhatsNewALLNEWS/2019/06/24/realignment-of-ems-

reimbursement-policy.

Myers, B., Zavadsky, M., & Lawrence, P. (2019, September 6). Thinking About Applying for

CMS' New ET3 Model? Retrieved November 19, 2019, from

https://www.jems.com/2019/04/04/thinking-about-applying-for-cms-new-et3-model/.

O'Meara, P., Stirling, C., Ruest, M., & Martin, A. (2016). Community paramedicine model of

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04-24/medicare-s-5-billion-ambulance-tab-signals-area-of-abuse.

Ross, C. (2016, June 16). In Cleveland area, communities just 10 miles apart have a large gap in

life expectancy, new study says. Retrieved from

https://www.cleveland.com/healthfit/2016/06/in_cleveland_area_communities_just_10_

miles_apart_have_a_large_gap_in_life_expectancy_new_study_says.html.
 40

U.S. Department of Health and Human Services. 2008. America's Health Literacy: Why We

Need Accessible Health Information.

WPXI. (2019, November 14). EMS Patient Debt: Local EMS companies massive debt causing

loss of paramedics, ambulances. Retrieved November 14, 2019, from

https://www.wpxi.com/news/top-stories/local-ems-companies-massive-debt-causing-loss-

of-paramedics-ambulances/1008387089.
 41

Dedication

This academic work is dedicated to my father, Dr. Thomas E. Beers PhD, who always

believed in me even when I did not believe in myself. His life of service to the nation, the

community, and his students made the world a better and safer place. I wish I had just 10 more

seconds with you dad so I could tell you that you were right all along.

And to my wife, Megan Beers, for the support, understanding, love, friendship, and

coffee. You are the best that ever was and ever will be. I’m addicted to you.