This article is part of State of Health, a series examining integrated care and its potential to improve Michiganders' health. It is made possible with funding from the Michigan Health Endowment Fund.

Paramedics traditionally handle emergency medical situations. But through an increasingly popular new model called community integrated paramedicine (CIP), Michigan paramedics are using their downtime to proactively promote good health and nip emergency room trips in the bud.

Nine agencies in eight Michigan counties are already using CIP to reduce costs and improve outcomes for Michiganders, using two separate models. The first model, known as mobile integrated health (MIH), involves sending paramedics on planned visits to educate and assist populations who may be at risk of a medical emergency. Under the second model, known as community paramedicine (CP), paramedics may also interface with the 911 system to respond to low-priority 911 calls with the goal of reducing ER visits.

Ryan Chadderton sees himself as a pioneer in CIP. A lead instructor in Emergent Health Partners' community paramedic education program and an active participant in the state of Michigan's CIP work group, Chadderton has worked as a community paramedic in both Washtenaw and Jackson counties. He notes that he and Michigan’s other community paramedics are creating the guidelines for CIP as they go. He believes the approach not only cuts costs but also improves outcomes, builds community relationships, and reduces health care disparities.

Emergent Health Partners community integrated paramedics and their community paramedicine vehicle.

"In Jackson, for example, I will see a patient weekly or biweekly. I get to build this relationship with the patient. Whereas an ambulance or transport paramedic may spend 20 to 25 minutes tops, we are spending hours every week. We get to know their families, and we like to include families in the treatment plan," Chadderton says. "While I run my tests and am waiting, we have those conversations where we can pick up on little things."

Chadderton relates the story of a patient who ate a can of SpaghettiOs for supper every night. Through CIP visits, Chadderton and his crew suggested that the patient eat something healthier. Once he began eating a healthier supper, the paramedics encouraged him to change up his lunch as well. This is how Chadderton and other community paramedics help patients make better health choices one small step at a time.

"Patients get excited about being healthy. That helps you get the ball rolling." Chadderton says. "Whoever needs us, that’s who we’re there for. Yes, we want to reduce ER utilization. But the biggest thing is connecting people to health care. ... We can bring health care to them."

Putting out fires and preventing heart failure

One of Michigan's first and most robust CIP programs is the Remote Specialist Visiting Providers program (RSVP), developed by St. Joseph Mercy Oakland Hospital, Bloomfield Township Fire Department, and Star EMS. Operating by the MIH model, paramedics follow up with patients after they get home from hospitalization to make sure they are taking medications correctly and understanding all of their discharge instructions. During the visits, a physician speaks with the patients via secure video chat to address any other concerns. Records from the visit are shared with the patients’ primary care providers.

Lt. Kevin Bailey of the Bloomfield Township Fire Department conducts a community integrated paramedicine visit.

According to Brian Long, Star EMS' director of risk and safety/driving/operational health, this program has greatly reduced readmission rates among the high-risk patients it serves. Patient surveys about the program indicate a 100% satisfaction rate.

"The goal is to help patients transition to home recovery and decrease avoidable readmission," Long says. "We help them transition to recover at home."

Visiting high-risk patients recovering from conditions like congestive heart failure, diabetes, COPD, sepsis, or pneumonia, the community paramedics take vitals and may check weight gain, listen to lung sounds, or run an electrocardiogram (EKG).

"Patients love that they can sit in the comfort of their own home and talk to their physician or advanced practice provider," says Jeri Whitehead, St. Joseph’s RSVP transition specialist. "They retain information because it is a casual environment. Patients frequently have questions when they get home that they didn’t ask their doctors when they were here. This allows them that opportunity."

Capt. Matt DeRousse, EMS coordinator for the Bloomfield Township Fire Department, says paramedics also go through a home safety checklist with patients.

Capt. Matt DeRousse, EMS coordinator for the Bloomfield Township Fire Department.

"Do they have smoke detectors? A carbon monoxide detector? How may rugs cause trip hazards? Are there handrails on the stairs?" he says. "We have a whole checklist of things to help them prevent falls and other potential injuries from happening. That’s the benefit of the fire department being there."

The community paramedics address other social determinants of health while visiting patients — and connect patients and their families with community and social services.

"The benefit of the community outreach is great," Whitehead says. "We find the social barriers and help the patient deal with those, not just medically but with transportation, housing, and food. ... That community outreach is hard to measure."

Community integrated paramedics Kim Whalen and Lt. Kevin Bailey of the Bloomfield Township Fire Department conduct a patient visit with Jeri Whitehead (on tablet screen)..

Chadderton and other paramedics working under the CP model administer point of care testing to identify potential issues like urinary tract infections, give first-dose antibiotics, draw blood to perform basic metabolic panels, and run EKGs to rule out heart problems. In addition, they can provide IV fluids to treat dehydration, replace Foley catheters, change ostomy bags and dressings, and provide wound care.

"Paramedics are used to the outpatient setting and very comfortable treating patients in their homes," says Chadderton’s colleague Valerie Mitchell, Emergent Health Partners' central operations QA/QI supervisor. "There are several illnesses, complaints, and issues that can be treated in a non-emergency setting. [This] reduces workload on hospital staff and physicians. There is an overall savings to the providers and less reimbursement penalties for hospitals for readmissions and ER visits."

Developing a framework

CIP is currently under special study status in Michigan as the state works to develop statewide standards and infrastructure for CIP programs. The state’s goal for CIP is to build infrastructure that moves the modality into the Michigan Emergency Medical Services System’s standardized structure. The Michigan Health Endowment Fund has provided grant funding for the state to carry out that process.

According to MDHHS' community paramedic coordinator, Kristine Kuhl, CIP programs and providers have grown rapidly in the state. She expects that another 18 CIP programs will be launched soon.

"[In 2018], we had 110 to 120 providers – 28 trained as community paramedics and 85 MIH providers," Kuhl says. "... Now, through our grant process, we have sent [56] individuals through training, and a couple of agencies have sent individuals on their own dime."

Stakeholders include licensed EMS agencies, health care plans, hospitals and health care systems, and physician groups. Kuhl notes that many of the programs are self-funded by the cost reductions for their own systems. Emily Bergquist, Medical Control Authority coordinator at MDHHS, notes that RSVP has resulted in a 70% reduction in hospital readmissions among RSVP patients.

"That program started very small and has grown," Bergquist says. "They keep reinvesting because they have saved so much, so quickly."

A 2016-2018 Washtenaw County study of Emergent Health Partners' CIP pilot program found that out of 2,000 patients seen, 53% were treated in place and could stay home. That resulted in savings of $2 to $2.5 million, approximately $500 each for hospital transport and $1,500 to $2,000 each in emergency room charges. 94% of patients surveyed gave the program a positive rating.

Emergent Health Partners community integrated paramedics and their community paramedicine vehicle.

"This is where EMS is heading," Chadderton says. "Our goal is not to take over any services or replicate any services. We meet those unmet needs and get patients what they need to stay home. We can also find what social services to connect them with and, by doing that, we can reduce disparities using a model we already have. We can be at their door very quickly to help them."

A freelance writer and editor, Estelle Slootmaker is happiest writing about social justice, wellness, and the arts. She is development news editor for Rapid Growth Media, communications manager for Our Kitchen Table, and chairs The Tree Amigos, City of Wyoming Tree Commission. Her finest accomplishment is her five amazing adult children. You can contact Estelle at [email protected] or www.constellations.biz.

Photos by Nick Hagen, except Emergent Health Partners photos courtesy of Emergent Health Partners.