Vulnerable Patients During COVID-19: How Can Community Paramedicine Programs Keep People Safe at Home?

Note, while this narrative is based on a real patient, names have been changed to protect privacy.

“Is it safe?” she asks, “We see the news, my mother is old and frail, what if she catches COVID?” I observe Maria, who smiles despite the obvious discomfort on her face.

Maria’s skin is paper thin, marred with bruises of varying degrees of healing, threatening to tear at the slightest bump. Over the last few days, Maria experienced escalating abdominal pain. I do not find any urgent symptoms during my assessment, but I would prefer for Maria to be further evaluated at the hospital. While voicing my opinion, Maria and her daughter immediately locked eyes, silently communicating their fear.

This is not the first time I have been asked this question as an Emergency Medical Technician (EMT) working on the ambulance, and it will not be the last. Maria is one of many patients who need care but refuse to go the hospital out of fear of contracting SARS-CoV-2 (COVID-19). The fear is legitimate. Approximately 99,000 patients die annually from hospital-acquired infections, who is to say COVID-19 would be any different? Moreover, with increasing evidence showing limited ICU bed capacity corresponds to an increased risk of death, there is reason to be concerned.

While I understand the apprehension, I worry about Maria and all the other patients who have chosen to forgo needed care to avoid possible infection. The COVID-19 pandemic has shown us that we need a new model of caring for people safely at home. Rather than unnecessarily transporting nonurgent cases, we need an intermediary patient-centered service. Fortunately, Community Paramedicine programs exist to fulfill this exact need.

What are Community Paramedicine programs?

Community Paramedicine programs fill gaps in local health care infrastructure to address primary care physician shortages or provide care when a patient is unable to travel to see a provider. Community Paramedicine programs operate under the supervision of a physician and offer a range of services to continue a patient’s care at home without causing unnecessary transport. The most commonly offered services include:

• Medication Reconciliation
• Education
• Fall Risk/Home Safety
• Chronic Illness Management
• Diet and Weight Monitoring
• Lab Collection
• Behavioral Health
• Wound Care
• IV Therapy
• Post-acute Follow-up
• Social Support Services

During a CP home visit, the paramedic evaluates the patient’s medical, social, and mental condition and their ability to remain at home safely.

In our current system, paramedics have no choice but to take patients to the emergency department due to a lack of alternative services and care settings. This leads to unnecessary costs and potentially dangerous exposures for elderly or immunocompromised patients. Moreover, the stress of operating an ambulance during COVID-19 is weighing on EMTs.

Existing Landscape of Community Paramedicine Programs

Over 111 Community Paramedicine programs have been implemented in the United States, and there is evidence of cost savings by diverting unnecessary emergency department visits and ambulance transports. For example, one Texas-based program alone has prevented more than 1,800 ambulance transports and hospital readmissions for 146 patients, saving Medicare an estimated $800 million dollars over 5 years.

Despite these significant positive results, policy barriers remain. Community Paramedicine programs are not widely available as limits of current reimbursement impede expansion. Medicaid, for example, will only reimburse for treatment without transport on 911 calls in six states, meaning patients must activate the 911 system to see a Community Paramedicine professional. This places an additional strain on the emergency response system rather than establishing routine Community Paramedicine services as part of the broader fabric of care delivery.

Opponents argue while there is some promising data from established Community Paramedicine programs, there is little peer-reviewed literature on the effectiveness of these interventions. Most program data are self-reported and therefore open to bias; and the peer-reviewed data consistently come from a select few programs. Opponents also cite the difficulty of establishing reimbursement models to sustain these programs long-term as it remains an open question of who should pay for these services. Still, the findings to date are promising.

The Changing Landscape of Telehealth

Telehealth is one of the largest emerging markets resulting from the COVID-19 pandemic. In 2019, telehealth accounted for approximately 11% of all patient visits. In the midst of the COVID-19 pandemic, telehealth represents 46% of all patient visits. Community Paramedicine programs are complementary to telemedicine. The goals are aligned: keeping people healthy at home and providing services with limited contact outside of congregate settings. This is particularly true for the most vulnerable patients among us—patients like Maria, who have serious illness, chronic conditions, or are immunocompromised.

Such Community Paramedicine programs have been successfully introduced in Massachusetts by the Commonwealth Care Alliance (CCA). This program is dedicated to keeping their patients out of the emergency department and safe at home. Almost 93% of surveyed patients reported a positive experience and preferred the at-home service rather than going to the emergency department. Patients continue to advocate for expansion of these programs citing a sense of autonomy and empowerment, not offered in the emergency department.

The Future of Community Paramedicine

The COVID-19 pandemic provides an opportunity to significantly expand Community Paramedicine programs nationwide. These programs are built on the existing EMS infrastructure and can serve as a bridge between telehealth and in-office visits. Continued research is needed to determine the most effective model and to ensure successful implementation in diverse contexts and settings. Still, we already have enough evidence to show these interventions can work, and COVID-19 reveals the dire need for such a service. If Community Paramedicine programs were adopted as a national standard, patients like Maria could be cared for safely at home.