In this month’s installment of the Innovation of the Month series, we explore Gainesville, Fla.’s Community Resource Paramedic program, which aims to address the social determinants of health and resolve the underlying issue of misutilization of the emergency system.
MetroLab’s Ben Levine and Stefania Di Mauro-Nava spoke with Ariella Bak, program coordinator at Gainesville Fire Rescue, and Dr. Lisa Chacko, associate medical director at Gainesville Fire Rescue and assistant professor at the University of Florida College of Medicine, to learn more.
Stefania Di Mauro-Nava: Could you please describe what the data-driven approach to community paramedicine project is? Who is involved in this effort?
Ariella Bak: As communities have searched for innovative strategies to break the cycle of poor health and high demand on community services, the community paramedicine model has emerged nationwide as a promising evidence-based approach. In this model, fire and EMS departments utilize frontline paramedics in collaboration with interdisciplinary partners such as physicians and social workers to address the needs of high-volume users and other need-based cases all in the patients’ homes.
The Community Resource Paramedic (CRP) program was created by Gainesville Fire Rescue, in partnership with the University of Florida and UF Health, in search of a new paradigm for delivering emergency medical services. In this model, a paramedic and resource coordinator utilize a non-fire vehicle and visit patients in their homes. The focus of the program is to address social determinants of health and resolve the underlying issue of misutilization of the emergency system. CRP personnel communicate with health-care providers in real time to ensure patients are adhering to their medication and treatment plans, and convey details of their complete social picture, while also conducting detailed wellness checks on patients of particular high risk.
The data-driven approach to community paramedicine lends itself to creating an effective and efficient process to improve patient health outcomes. By tracking metrics at patient intake (quality of life score, patient acuity score, number of 911 calls, number of emergency room visits within X time period, etc. ) and discharge, CRP is able to evaluate the effectiveness of the intervention. This project is aimed at creating a cohesive data network between emergency medical services and the hospital-based system. This allows for coordinated patient-centered care to occur and ultimately yield improved health outcomes with appropriate utilization of the health system.
The CRP Team partners with a local nonprofit called Rebuilding Together to address issues of fall prevention and mobility. Mobility and issues surrounding access are a top-three need for CRP patients. Following an amputation procedure, it is not uncommon for patients to remain in a health-care facility until the ramp has been built. Remaining under care even unnecessarily can cost the patient thousands of dollars. Courtesy of the city of Gainesville.
Di Mauro-Nava: Can you describe what motivated the city and university to address this particular challenge?
Bak: “Super-utilizers” or recurrent users represent a small fraction of the individuals who use emergency services, but account for the majority of the costs. In the U.S. in 2012, super-utilizers made up 5 percent of total patients, but were responsible for 50 percent of health-care expenditures. The top 1 percent of users accounted for 23 percent of health-care costs, averaging about $98,000 per patient annually. This creates a strain on limited health-care resources and results in longer emergency room wait times and consequently a lower quality of care. Many of these individuals suffer from preventable health issues that could be resolved through early intervention and health education.
In 2017, over 189 Gainesville residents called 911 more than five times in one year, and 39 of those patients called 911 more than 10 times in one calendar year. Avoidable hospital readmissions and repeat EMS responses burden limited health-care resources, and the demands on the 911 system cannot be met with available transport units. Access to services lies at the core of this challenge. The current paradigm of treating medical symptoms in the hospital setting leaves underlying social needs unmet and this imbalance increases overall health-care costs.
Estimates suggest that issues associated with access and missed appointments cost the nation nearly $150 billion annually. In 2017, 18 percent of Medicare patients who sought treatment at the hospital were readmitted within 30 days, costing $26 billion ($17 billion of which is attributed to avoidable readmissions). Local governments and universities are looking for new ways to leverage technological and social science innovation within community health-care service and bring meaningful solutions to their communities.
The CRP Program attributes success to all community-based partners. These partners, such as Bread of the Mighty food bank, improve patients’ quality of life by proving fundamental needs including food, clothing and durable medical equipment. Courtesy of the city of Gainesville.
Ben Levine: What have been some of your initial findings and is this changing how you view the issue?
Bak: In 2017, health-care partners, including Gainesville Fire Rescue (GFR), received seed funding to launch a preliminary "community resource paramedic" (CRP) program. This pilot demonstrated considerable success and has gained attention from community health professionals across the U.S. In this early effort, within a sample of 17 participants, there was a 50 percent reduction in visits to the emergency room, a 44 percent reduction in missed or cancelled primary care visits, and a 58 percent reduction in hospital admissions. Limitations include variability in enrollment periods, lack of access to outside hospital data and lack of a control group. Addressing limitations moving forward, our plan is to form a robust partnership with UF Health Shands Hospital to allow for closer data monitoring for a shared cohort of patients with defined intervals for follow up. An expanded partnership with academic faculty will allow CRP to increase the rigor of data collection and analysis including preparing results for publication.
CRP is committed to taking the initiative to become a voice for citizens. Coordinating efforts with each social and medical organization is critical to making services in Alachua County more dynamic and accessible. During the initial stage of launching CRP, relationships were formed with community stakeholders to effectively advocate on behalf of patients’ needs. This process pushed health-care providers to analyze collaboration in a different facet.
Improper adherence to a prescribed medication regimen is a top cause of unnecessary readmission to the hospital. The CRP Program mitigates this issue by conducting a medication reconciliation on each patient upon enrollment to the program. During this process, an inventory of medication is noted while comparing information to the prescribed medication list. All discrepancies are discussed with the patients’ primary care providers. Courtesy of the city of Gainesville.
Levine: How are your findings being used and implemented by the city and/or community?
Bak: Within the Gainesville community, the CRP program provides significant insight into the value of community-driven health initiatives. Our findings help quantify the social and medical determinants that lead to the high burden on our EMS teams. For example, due to CRP’s experience in connecting patients with their primary care providers, more groups like the police department’s co-responder program are now able to understand the impact of regular physician appointments to improving a patient's quality of life. This helps reduce the number of EMS calls made and overutilization that we see in our emergency departments while adding an emphasis on increased quality of care.
Additionally, CRP allows for a tertiary level of advocacy on behalf of Gainesville citizens. As paramedics enter the residences of CRP clients, they often become the “eyes and ears” for the clinical team. That being said, through the deployment of evidence-based tools, the CRP team is able to collect data on geographical hot spots to then advocate for population health. Thus, CRP has become a voice for the citizens of Gainesville. The fire department no longer merely responds to 911 calls, but proactively fights to improve access and bring resources to the community. To give an example, transportation has been noted as a primary need throughout the pool of CRP patients. Gainesville Fire Rescue and staff within the city of Gainesville have been collaborating on pilot programs to mobilize health and social services. An Uber Health program has launched to assist the elderly community in making it to health appointments. Second, areas within the health system have expressed great interest in adapting some of the tools CRP uses in their own patient care settings to further streamline health education and create a more integrated system.
The CRP program holds patients accountable through implementation of numerous tools including a contract outlining "homework" for patients to complete in between CRP visits. Especially while trust is being formed, the CRP personnel work meticulously to connect patients to primary care. This process is often accompanied by long hold times, learning how to navigate an access center and adequate advocacy skills. Courtesy of the city of Gainesville.
Levine: What was the most surprising thing you learned during this process?
Lisa Chacko: Moving this work forward has required an incredible amount of advocacy and relationship building! What's fun about cross-sector work is that you have to bring together stakeholders that might not traditionally collaborate or even interact. Our experience has been that CRP is a natural catalyst for this kind of collaboration. Through our work advocating for the program, we have been able to see first hand what an incredible and engaged community Gainesville and the University of Florida have created together.
Bak: Empowerment lies at the core of innovative programming, particularly in the health space. Top-down program design, while sometimes effective, does not align with a patient-centric mission. Through implementation of the Gainesville CRP program, the theme of empowerment arose continuously in various tiers in ways unimaginable:
- Patient care
- Interfacing with health-care providers
- Academic collaboration
Unlike working with the patients, interacting with the health system proved daunting as receptionists guarded access to physicians. While this made communication difficult at first, the CRP program began communicating with physicians by sending letters and simply bolding, highlighting and circling necessary next steps for physicians to bring certain resources on board. The result was earth-shattering: Physicians had no idea about some of the circumstances of their patients’ health picture and not only completed the items requested by CRP but offered advice and next steps of their own, thus closing the feedback loop. CRP, with the help of eager students and physicians, was truly becoming a new “care team.”
Community paramedicine in Gainesville is built on a foundation of trust. Patients must often work through traumatic experiences in order to rewrite their narratives and achieve improved health outcomes both mentally and physically. Courtesy of the city of Gainesville.
Di Mauro-Nava: Where will this project go from here?
Bak: The CRP program is looking forward to increasing scope and scalability through implementation of a Mobile Integrated Healthcare (MIH) or a telemedicine component. The MIH movement has great potential to increase access to high-quality care for patients by utilizing telecommunication infrastructure to deliver care to a patient remotely. Increased use of technology (tablets, smartphones, etc.) will allow CRP to better connect our available resources, simplify patient education, and provide quick and easy transmission of data from our triage activities (patient well-being assessments, patient card sort activities, etc.) while expanding the scope of medical care and interventions offered to patients. MIH enables access to additional health-care providers, including specialists, to help patients stay closely connected with an accessible medical network while eliminating barriers of access. Patients will be able to connect with their physicians in the comfort of their own home, leading to an effective, practical means of chronic disease management.
As the CRP program continues to redefine the fire department’s health delivery model, we hope to better target underserved subgroups of the population in Gainesville. By doing so, the unique needs of the diverse communities will be met effectively and yield increased health outcomes. CRP hopes to utilize the MIH technology to assist substance abuse patients with wrap-around services at the vulnerable time frame directly following an overdose episode. The implications of the CRP program are significant and the program will continue to fill a unique niche of care coordination, advocacy and providing the utmost level of patient care.
Chacko: Over the past several years, CRP has managed to establish itself as a reliable community partner. We have solidified our workflows, increased our capacity through new hires and a student internship program, and successfully advocated for funding from our partner health system. Our next steps will include negotiating a sustainable collaboration with the health system, engaging additional academic partners, and continuing to build evidence through data collection and analysis.
To ensure that best practices emerge, we are engaging leaders from the EMS and academic medical community who have successfully built community paramedicine and MIH programs for their own communities. It will also be important for CRP to engage in discussions at both the state and federal level about how best to create a policy context that will foster further implementation of this model. We strongly believe that CRP can serve as a unique model of public-sector innovation for other communities across the country.
