What Makes Paramedics Unique?
As first responders, paramedics hold a unique position. Before the patient arrives at the doors of the ED, paramedics have seen and assessed them in their home. Entering into the patient’s living space can provide vital insight into issues that aren’t always obvious once the patient arrives at the hospital, but can lead to chronic ED visits and hospital re-admissions.
Is there food in the fridge? Who does the patient call for help? Are there several medications present? Even a limited time in a patient’s home can provide important clues about these social drivers of health. In turn, these point to larger issues including a lack of access to primary care, a lack of social network, and confusion over multiple medications.
Why Community Paramedicine?
Community paramedicine programs were created to address a number of issues that are familiar to many health care professionals. One of these is the high rate of re-admission for older patients, especially those with chronic conditions.
In rural settings, community paramedicine began because of a lack of access to health care. Instead of making long trips to the ED, patients are able to receive medical care from physicians through telehealth programs, in their own homes. In urban settings, these programs work to reduce chronic re-admission. They also address substance use disorders and work in multidisciplinary teams that include social workers, collaborating to improve community health.
Community paramedicine is remarkably efficient: It uses people who already have medical training to meet the complex needs of patients in their own homes.
Geriatric Assessments and Training For Paramedics
Megan Corry is the paramedic program director at City College of San Francisco. She’s also involved in education and curriculum development, and accreditation of training for paramedicine programs. She recognized a gap in traditional paramedic training at the initial levels, which required a robust list of life-saving skills and clinical rotations, but seldom included the care of non-acute geriatric patients. Triggered by discussions with a colleague, she and her team mapped and developed a geriatric specialty rotation for paramedics that teaches a bio-psycho-social approach at the basic levels of training. For her, this is vital to incorporating the skills and tools needed for the care of older patients.
Her program teaches assessment based on the 4Ms framework of geriatric care: What Matters, Medication, Mentation and Mobility. Putting these 4Ms into context at a patient’s home provides important information through observation of the environment. Paramedics are also taught scripting that could uncover issues patients may be reluctant to divulge, such as financial hardship.
Standardized assessment tools are also included in the rotation, such as the Delirium Triage Screen, ADEPT (Confusion/Agitation in the Elderly) and TUG (Timed Up & Go). These tools give paramedics a quick way to assess the patient’s mental state and mobility, but also provide a standardized language where results can be compared. These same tools are used by physicians in the ED, facilitating communication throughout the patient’s care.
The Benefits of Community Paramedicine
Community paramedicine improves patient wellness and care, starting in their own home. The ED is no longer the patient’s first or only point of care. This leads to a reduction in the number of non-emergency visits to the ED, freeing resources and decreasing wait times.
Leveraging the unique position of paramedics is an efficient way to utilize their training. Their ability to observe a patient’s living environment with a medically trained eye is invaluable. Having channels to communicate these issues contributes to multidisciplinary collaboration, providing holistic care for entire communities. The shared use of assessment tools, language and scripting allows for consistency in patient care, from the ambulance to the ED.
All of this has significant impact on the use of hospital resources. The reduction of chronic visits and re-admissions results in financial savings and overall less stress on the strained healthcare system.
Where is the Field Going?
It is estimated that by 2030, 50% of EMS arrivals to the ED will be geriatric patients. The need for training in the assessment and care of older adults is urgent. For Megan, providing training in geriatric care at the basic EMT level allows it to become instinctive to first responders.
She views paramedics as contributors to a multidisciplinary approach that is the future of community care. Channels for communication and collaboration between paramedics, clinical teams and social workers are essential to unburdening overloaded EDs. She also strongly believes that philosophizing and education need to lead to translational science. Data that drives funding and provides understanding on resource investment is the key to creating functional healthcare systems.