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Case Study: Transporting Behavioral Health Patients to an Alternate Destination

Richard Murdock BS, MICP(R)

Stanislaus County Community Paramedics

Introduction

The term “community paramedic” refers to the use of a traditional paramedic who has received training with an expanded role in primary care. Community paramedicine is a rapidly evolving concept that breaches the circles of healthcare communities across the U.S. The community paramedic can provide a variety of services to their local community focusing on public health, vaccine administration, prevention and wellness, medication compliance, chronic disease monitoring, and minor treatments within the patient’s home.1

Because the services a community paramedicine program provides depend on the needs of local residents, each community paramedicine program is different. This makes it difficult to obtain a comprehensive understanding or establish best practices guidelines.

This article provides a case study of the Stanislaus County (Calif.) community paramedic (CP), which is one of 12 programs in a statewide community paramedicine pilot study. It evaluates the history of the CP concept and the types of challenges unique to metropolitan and rural communities.

History

EMS integrating into the overall healthcare system is a model adopted, researched and delivered across the U.S.2 As the concept evolved, the following locations and organizations started community paramedic programs:

  • Long and Brier Island Community Paramedicine Project in Nova Scotia;
  • Alaska Community Health Aide Program in Sitka, Alaska;
  • SPHERE program in Seattle/King County; MedStar Mobile Health Program in Fort Worth, Texas;
  • Wake County EMS Advanced Practice Paramedics in North Carolina, and
  • The collaborative community paramedicine program in Eagle County, Colo.
  • Minnesota’s 2011 community paramedicine certificate legislation.3

These agencies, cooperatives and state laws built programs in the early developmental years that provided templates for other counties, states, and agencies to follow when building a community paramedic program. They have used paramedics in capacities or settings outside their traditional emergency response and transport roles. They have done their due diligence to ensure the of their programs, therefore providing “best practices” for other EMS agencies to model.4

California Pilot Study

Using a community paramedic (CP) to perform a safe medical screening examination on patients with behavioral health (BH) emergencies is gaining ground in California. The concept is to determine if a patient presenting with behavioral health issues is eligible for transport to a behavioral health center instead of transport to a hospital emergency department.

The alternate transport model is part of a California Statewide Community Paramedic Pilot Study that began early in 2014. The Emergency Medical Services Authority (EMSA) received approval on Nov. 14, 2014, from the Office of Statewide Health Planning and Development (OSHPD) to begin the Community Paramedicine Pilot Project. The alternate transport model is just one of the 12 pilot studies in the Community Paramedicine Pilot Project being performed in California under the auspices of EMSA to capture data to prove the efficacy of using a paramedic in a “non-traditional” way by expanding their role.

Conceptualizing the idea a CP focuses on the Institute for Healthcare Improvement (IHI) Triple Aim, which is a framework developed to optimize health-system performance. IHI believes new designs must be developed to simultaneously pursue the following three dimensions of the Triple Aim:

  • Better care: Improve the quality and experience of care,
  • Better health: Improve the health of populations, and
  • Lower costs: Reduce per capita cost.5

At the writing of this article, the concept of community paramedicine was still new to California. The pilot study was a means to collect data to determine whether paramedics could be trained with an expanded role to provide safe and effective assessment, treatment, and transport of patients within the prehospital setting. California law prohibited paramedics from transporting patients to alternate facilities and places limitations on a paramedic’s scope of practice. To make CP work in the state, Health & Safety Code Division 2.5 and the California Code of Regulations, Title 22, Division 9: Prehospital Emergency Medical Services would need to be amended. This amendment could be accomplished through the Community Paramedic Pilot Study, which has the following goals:

  • Address the needs of frequent 9-1-1 callers and emergency department (ED) users by helping them access primary care services;
  • Transport patients with specified conditions to locations other than the emergency department, such as urgent care facilities or general medical clinics;
  • Reduce recidivism by providing short-term, in-home follow-up care for people recently discharged from the hospital;
  • Provide short-term, in-home support for people with chronic conditions, such as diabetes, asthma, and congestive heart failure;
  • Use physician referral, medical oversight and protocols; and
  • Partner with public health, community health and primary care providers in medically underserved areas to provide preventive care.6

As a result of the comprehensive models across the country, the Affordable Care Act, and the increase in hospital ED census, EMSA decided to implement the statewide pilot study. A letter of intent was sent to each Local Emergency Medical Services Agency (LEMSA) requesting proposals, which were required to contain the following elements:

  • Goals and objectives,
  • Description of proposed concept,
  • Need for the project, and
  • Program management.

The one-year pilot study began with 12 sites in Sept. 1, 2015. One of those sites is Mountain-Valley EMS Agency, which started the Stanislaus County CP Pilot Study program.

Stanislaus County Pilot

There is broad consensus within EMS that CP programs are not one-size-fits-all because they should be developed to meet the specific needs of the community, which vary from location to location.7 However, despite the local nature of these programs, the Stanislaus County CP Pilot Study program found the following four steps to be best practices that would help any agency get started with such a program:

  • Acquire partners who are critical to the success of the program;
  • Acquire an active medical director;
  • Focus on the patient’s well-being, and
  • Collect and analyze program data.

The right partners: The best path to meeting the needs of the community’s residents is through collaboration with other healthcare stakeholders. It is one of the most important steps in starting a CP program.

In the early stages of the Stanislaus County CP pilot project, one of the first tasks was to develop a steering committee that included subject matter experts who were pertinent to the pilot program. The program dealt with assessing behavioral patients and determining whether those patients were eligible for transport to a location other than a hospital, it required buy-in and expertise from the following groups:

  • Public health;
  • Behavioral health;
  • Office of emergency services;
  • Hospital(s);
  • Ambulance provider(s);
  • LEMSAs, and
  • Law enforcement.

The responsibilities outlined for the steering committee were multiple and involved brainstorming meetings to build the program from scratch. The committee collaborated to provide feedback on the development of policies, implementing and developing a local curriculum specific to behavioral health, feedback to the medical director on a well-person treatment algorithm and mental health clearance algorithm, and data collection and evaluation strategies.

An active medical director: An involved active medical director can make the program successful. The role of a medical director for an EMS system is to ensure quality patient care. The medical director’s responsibilities include involvement with the design, operation, evaluation and quality improvement of the EMS system. Medical directors oversee patient care, and develop and implement medical protocols, policies, and procedures.7 The role of a medical director for a community paramedic program is similar. A large percentage of their time will be devoted to protocol development. However, due to the nature of community paramedicine and involvement from stakeholders outside the EMS agency, the medical director will often collaborate with primary care or other healthcare providers outside of the responsibilities of EMS.

Mountain-Valley EMS Agency and Stanislaus County CP Pilot Study Medical Director Kevin Mackey, MD, FACEP, contributed more than protocol development and stakeholder collaboration. He was also intimately involved with selecting the CP candidates and establishing an interview process during which he met one-on-one with each of them. Mackey also actively participated as an instructor for the core curriculum, which was developed and provided by UCLA Center for Prehospital Care, as well as the local curriculum, which was developed by members of the steering committee.

In addition to the above training, the CP students were required to attend crisis intervention training (CIT), log clinical time shadowing a psychiatrist or credentialed behavioral health specialist, and shadow an ED physician.

Mackey developed two protocol algorithms to be used by the emergent ambulance crew and the community paramedic:

  • Well-person algorithm: The well-person algorithm provides a flow chart of “yes” and “no” answers to questions provided by the 9-1-1 paramedic on scene when they assess the patient to determine whether a non-emergent BH issue exists. If the patient is eligible for a medical screening examination a community paramedic is dispatched to the scene.
  • Mental health clearance algorithm: When the community paramedic arrives on scene, they will complete a medical screening examination. The mental health clearance algorithm provides a flow chart of “yes” and “no” answers asked by the CP to determine whether the behavioral health patient qualifies for transport to the BH center.

Focus on the patient: One of the main reasons for implementing a program of the magnitude of the Stanislaus County CP program is to provide better care to the patient. Keeping the patient at the center of the program design helped the stakeholders and participants complete the mission at hand. The repetitious communication with the stakeholders involved in the Stanislaus County CP program was, “patient first, community second, and organization third.” The focus on patient safety was maintained by eliminating unnecessary transports to an emergency department. Other obvious benefits birthed out of the mission included reduced ED bed use and financial costs.

Collect and use data: Collecting data relevant to patient outcomes and patient costs is vital to any program. Interpreting and sharing data provides the evidence needed to drive changes and improve systems. Data collection, analysis, and reporting is the most powerful case for convincing healthcare partners that the CP program has achieved the Triple Aim of improved patient experience of care, improved population health and reduced per capita cost of care.7

Metropolitan Challenges

Due to the size of a metropolis, a metropolitan healthcare community most often offers EMS agencies a large group of stakeholders to partner with in developing a community paramedic program. These agencies are apt to have available resources to provide for establishing a collaborative workforce when tackling such issues as behavioral health and substance abuse.

In a metropolitan community, opportunity exists to expand and incorporate several CP models within the prehospital setting. As mentioned throughout this article, transportation to an alternate facility is a model that is often used in metropolitan areas. Transport to an alternate facility doesn’t just pertain to the transport of a behavioral health patient to a psychiatric facility instead of the ED. Many locations across the nation are using CPs for transporting patients to a sobering center instead of a hospital or jail, transporting a homeless patient to a shelter, or transporting a non-urgent medical patient to a clinic.

In addition, the CP assesses, treats, and refers or releases the patient on scene. This model is cost efficient and response ready. In other words, when a patient is treated and released on scene, the ambulance and its crew go back into the 9-1-1 system faster, providing an opportunity for that ambulance to respond to a higher acuity call.

Frequent 9-1-1 callers are an issue often seen in a metropolitan area. CPs can be used to address the needs of frequent 9-1-1 callers by transporting these patients to a non-ED destination, coordinating the patient’s care with a social service provider, or deciding to not transport the patient at all. The CP use in a metropolitan area provides several benefits to the community healthcare system.

Rural Challenges

In 1966, the National Academy of Sciences developed a white paper called “Accidental Death and Disability: The Neglected Disease of Modern Society” which addressed the need for education on first aid across the nation and a coordinated transportation and communication system to increase survival on the nation’s highways, many of which were rural in nature.

Many things have changed since the release of the white paper. Specific changes relate to reduction rather than increase. For example, fewer physicians are practicing rural medicine now than in 1966.8 In addition, volunteer rural EMS and fire agencies have seen a drastic decline in participation and volunteers, and rural areas have patients who use EDs more often and follow up post-discharge less often.9,10

A recent survey conducted by the National Association of EMTs identified 49% of community paramedic programs as serving rural areas filling a large gap in healthcare.7

Rural settings can expand the reach of primary care and public health services by using CPs, thus “filling the gaps” in the local delivery system due to shortages or primary care physicians and long travel times to the nearest hospital or clinic.11

However, financial support for community paramedic services in a rural setting is a significant challenge. Collaboration with local and regional hospitals, primary care providers, and insurance companies to develop incentive structures and reimbursement mechanisms that would allow CPs to assess and treat patients in their homes is a must. Securing Medicaid reimbursement for services provided by the CP may require changes to state legislation or regulations.11 Data collection and evaluation strategies are crucial elements to be considered during the development of a community paramedic program and necessary to document the value of the service to the local delivery systems as well as for policymakers, funders, and third-party payers.11

Senior Citizens

Baby boomers are now transitioning into the age of senior citizens. This stage of life often introduces new medical concerns. Recent data indicates that an estimated 20.4% of adults aged 65 and older met criteria for a mental disorder, including dementia, during the previous 12 months.12 More than 50% of residents have some form of cognitive impairment, and many nursing home patients have personality disorders exacerbated by chronic health problems.13

Researchers confirm that older adults with evidence of mental disorder are less likely than younger and middle-aged adults to receive mental health services and that, when they do, they are less likely to receive care from a mental health specialist.12

The senior citizen community is an area of great need in regard to behavioral health issues. In the past year, the Stanislaus County CP program has been contacted by long-term care facilities and skilled-nursing facilities asking for assistance transporting their patients with behavioral health issues to a mental health facility for the patient to receive appropriate mental health treatment. Unfortunately, due to the parameters of the local study, the age group exceeds the maximum age cut off.

A need exists to use the CP for BH patients over the age of 65. When the study concludes, Mountain-Valley EMS Agency has plans to broach the subject of behavioral health issues in the elderly with its stakeholders and develop a plan to use CPs for this age group. The CP can be used in many capacities to assist patients over the age of 65. In addition to behavioral health issues, the CP can be used for hospital post-discharge follow -up by making sure the patient is following the discharge instructions, taking their prescribed medications, and ensuring they are following up with necessary appointments.

Best Practices

Because the CP concept is new to California, the site project managers and medical directors have used the IHI’s Triple Aim framework and have adopted “best practices” from other areas of the U.S. to help develop a foundation from which to build.

Improve the quality and experience of care: Stanislaus County’s pilot study concept was developed due to local overcrowding of ED beds, which are often occupied by BH patients with no acute care medical complaint. The issue of behavioral health patients unnecessarily occupying ED beds is a problem across California. It is not isolated to Stanislaus County. In 2009, California cut back on mental health funding by closing outpatient psychiatric units and trimming the number of inpatient psychiatric unit beds.14

When no mental health facility beds are available, the BH patient could remain in the ED bed for many hours or, in some cases, even days. Reductions to county mental health facilities have hit emergency departments hard. In some areas, every BH patient in an ED bed requires one nurse for observation, taking up valuable nursing resources for an extended period of time. However, in many EDs, the patient is observed by a non-registered nurse. These variations are due to local, county or state guidelines, hospital policy, and resources.

A study performed by Arica Nesper, MD, regarding the financial cuts to Sacramento County looked at data from October 2008 until May 2010 (one year before the cuts and eight months after it). The following findings were reported:

  • Psychiatric consults in Sacramento County emergency departments tripled over the 18 months studied, and
  • The length of time spent by psychiatric patients in the ED rose by 55%, from 14.1 to 21.9 hours. Taken together, the study authors found those numbers equated to “a five-fold increase” in daily emergency bed hours for psychiatric patients in the county.15

The study concluded the increase in psychiatric patient time in the emergency departments of Sacramento County was attributable to county cuts to mental health services.7

A psychiatric patient without an emergent medical need can occupy a bed in an acute care facility for hours and even up to several days in some cases. Many EDs do not have the resources to provide psychiatric services to patients. There are too few psychiatrists, psychiatric emergency services, and mental health workers in the ED to perform ED evaluation and treatment. A study by the Schumacher Group found that more than 70% of the EDs surveyed reported having mental health patients boarding for 24 hours or longer, with 10% stating that the patients are boarded a week or more.16

In Sacramento County, and likely in others, hospital EDs are seeing increased numbers of patients with BH emergencies. In fact, data provided by the California Office of Statewide Health Planning and Development (OSHPD) shows Stanislaus County emergency department encounters with patients who have mental disorders rose from 5,184 in 2011 to 8,335 in 2014, which is a 60% increase over three years.17

So how does a system improve the quality and experience of care for the BH patient? The focus, from an EMS standpoint, is to eliminate unnecessary transports of BH patients to an ED by using the CP to perform a mental health evaluation to determine whether the patient is eligible for transport to an alternate facility. It’s not the overall solution to a problem that exists in EDs across the country, but it’s a starting point that transports the right patient to the right location. The effect will reduce stress on the EMS system, the hospital, and most importantly, the patient.

Although the pilot project study is still in progress, patients are providing positive feedback. Patients who are evaluated by the CP report being more satisfied with the outcome of transport to a facility that is best equipped for their crisis. In addition, Behavioral Health staff has developed a new respect and trust in the CP model. This is illustrated when the CP is requested by the crisis emergency response team (CERT) to perform an MSE on patients who have voluntarily walked into the CERT office for evaluation.

Improving the health of populations: One group of high users of hospital emergency departments includes patients with behavioral health and substance abuse problems. About 12.5% of all ED visits across payers are due to mental health and/or substance abuse treatment needs.18

When mental health services and supports are unavailable or poorly coordinated, patients with unmet mental health needs turn to hospital emergency departments for care.19 In the current healthcare delivery system, hospital EDs are the only institutional providers required by federal law to evaluate anyone seeking care.20 The Emergency Medical Treatment and Active Labor Act (EMTALA) requires that all hospital EDs medically screen all patients seeking care in the ED, including evaluations and stabilization of patients suffering from mental illness.21

A system of delivering non-emergent BH patients to the hospital ED leads to inappropriate and inadequate patient care, issues with patient and staff safety, and overall decreased ED capacity.20

Currently in most locations across the U.S., a behavioral health patient is encountered by fire, law, and EMS through the activation of the 9-1-1 system. The BH patient is typically handed in one of the following two ways:

  • The patient is placed on a hold issued by law enforcement, and the patient is transported to an ED for medical clearance and stabilization, or
  • The patient is transported by ambulance to an ED for observation because the crews are not comfortable leaving the patient unattended on scene due to their unstable mental health crisis. The patient arrives at the ED, where they are met by an admitting clerk and a nurse who take the report from the transporting EMS crew. The patient is asked questions, and then vitals are taken and assessed to determine if the patient has a medical need. Many times, the BH patient has no medical need and waits until a psychiatric counselor arrives to perform an evaluation and a plan for discharge to either home or psychiatric facility.

Typically the care received at the hospital ED on a nonmedical BH patient is poor due to several factors: EDs are typically loud, hectic environments that are poorly suited to deescalating a mental health crisis; ED psychiatric assessments are often inadequate because ER staff members are often untrained in psychiatry and psychiatrists are often unavailable; treatment generally only includes prescriptions for medication.22-24 The fact that a lack of training is often seen in hospital EDs contributes greatly to the longevity of stay for a behavioral health patient. Evidence shows that a less-experienced clinician is more likely than psychiatrists to admit patients, fearing they will be held liable if a patient who is not admitted harms themselves or someone else.25

Transporting a behavioral health patient to a facility that best meets their needs improves the patient’s overall mental health. They are less likely to increase in agitation, which provides a safer environment for the crews and the patient. The training received by the CP is extensive, and the evaluations focused on the single issue of behavioral health crisis. The CP is trained to build a rapport with the patient and to deescalate the crisis the patient may be having. The focus is always on the patient and creating an environment that confirms to the patient their need is being addressed.

Reducing per capita cost: Realized cost savings is an important piece of the implementation of a CP project. Many of the projects across the nation have provided data that supports a cost savings to the ambulance providers and hospital. Ambulance reduction due to the reduced non-emergent transports is an important data element to capture for the ambulance provider. Many projects use a CP to treat and release on scene or redirect the patient to a clinic or assist with scheduling a doctor’s appointment. Reduction in hospital ER admissions for non-emergent conditions is a substantial cost reduction data element collected by CP project pilot sites in California.

For example, data collected by the Stanislaus County Pilot Project shows the average billable charges for a single BH patient in the ED is roughly $7,634. The average reimbursement for this type of expenditure is $153.

The loss in reimbursement for a behavioral health patient with one hospital ED stay is sobering, but the annual loss for all the BH patients in that same hospital is staggering. Partnering with a CP to transport these nonmedical BH patients to an alternate facility can save hospitals money.

 

Table 1: Potential Loss in Reimbursement for Behavioral Health Patient

Scenario

Hospital A's ED accepts 30 non-emergent behavioral health (BH) patients monthly.

BH patients cost the hospital an average of $7,634.

$7,634 X 30 = $229,020/monthly expense to Hospital A
Hospital A collects $153 reimbursement on each of those 30 patients.
$153 X 30 = $4,590/month in reimbursement
Hospital A is not financially benefiting from accepting these patients.
$229,000 - $4,590 = $224,430/month in unrealized revenue

In this scenario, Hospital A fails to collect almost $225,000 revenue monthly.

Conclusion

The community paramedic is a valuable resource used to safely assess the behavioral health patient to determine whether transport to an alternate behavioral health facility is warranted instead of a transport to a hospital emergency department. The behavioral health patient who exhibits a non-emergent crisis is best served where they can be stabilized by staff that specializes in treating behavioral health conditions.

Optimizing health system performances are developed when community paramedic programs implement such strategies as the Triple Aim to conceptualize the idea of better care, better health, and lower costs to a healthcare system.

References

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Published: October 3, 2016
Revised: January 5, 2017