The Evolution of EMS: Community Paramedicine & Mobile Integrated Health

Over the past few years, EMS providers have likely heard the more frequent use of terms such as mobile integrated health (MIH), community paramedicine (CP), and community health paramedicine (CHP).  These topics have also gained the interest of EMS leaders, as the nation attempts to slowly move from fee-for-service to a value-based care health care system.  The Centers for Medicare and Medicaid Services (CMS) has already made a huge leap forward with the creation of the Emergency Triage, Treat, and Transport (ET3) model.

TEMSA recently sat down with Corey Naranjo of Harris County Emergency Corps (HCEC) to discuss the organization’s community paramedicine work. Corey Naranjo is a community health paramedic and registered nurse with Harris County Emergency Corps (HCEC).

TEMSA: What do the terms MIH, CHP, and CP mean?

Corey Naranjo:

  • Mobile Integrated Healthcare (MIH) is a broad term that involves using patient-centered, mobile resources in the out-of-hospital environment. These components can include:
    • Traditional EMS response.
    • Community paramedics.
    • Advanced practice provider (PA-C, NP) responders.
    • 911 nurse triage lines.
    • Alternate destination/ER diversion.
  • Community paramedicine (CP), also called community health paramedicine (CHP), falls under the umbrella of MIH. CP involves the utilization of specially trained paramedics to provide individualized care to patients who are at risk for preventable hospital admission or readmission.
  • CP programs might focus on patient navigation, referral to resources, and/or out-of-hospital programs.
  • Some CP programs are specialized or patient-specific:
    • High utilizers.
    • Hospice revocation avoidance.
    • Admission/readmission prevention.
    • Home health partnerships.
    • Primary care.
  • Many CP programs are designed to align with key reimbursement areas for CMS, which are important to hospital partners:
    • Acute myocardial infarction (MI).
    • Chronic obstructive pulmonary disease (COPD).
    • Heart failure (HF).
    • Coronary artery bypass graft (CABG) surgery.
    • Elective primary total hip arthroplasty/total knee arthroplasty (THA/TKA).

TEMSA: How did HCEC first get involved in mobile health? 

Corey Naranjo: Despite the fact that Houston is a large area with several adjoining communities with accompanying EMS agencies, the implementation of community health initiatives in our area has been somewhat slow.  Harris County Emergency Corps (HCEC) began its CHP program in 2014, initially looking at high system utilizers.  The program consisted of a mix of home and telephone visits with a small, targeted group of patients.

TEMSA: What does HCEC’s community paramedicine involve today? 

Corey Naranjo: Our current program is centered around patient navigation, resource assistance and referral, and overall implementation of mobile integrated health care services.  Referrals are primarily made by field paramedics via electronic patient care records.  Upon receipt of the referral, the community health paramedic (CHP) reviews previous 911 utilization along with previous medical information in order to get a more comprehensive view of the situation.

A telephone or in-person intake assessment is performed that is specific to community paramedicine.  Based on the gaps identified, the CHP provides the necessary referrals, education, and safety interventions.  Additionally, we consult with the patient’s primary care provider, as he or she is often unaware of either the unmet need and/or the frequent emergency services utilization.

As an extra layer of support, the patient is flagged within the computer aided dispatch (CAD) system.  If a 911 call is initiated from that location, a CHP is automatically added to the call and notified via text message.  Pending availability, the CHP can then co-respond with the 911 unit and assess to see if alternative options exist to manage the patient.

Finally, our program collaborates with partners to provide community-based interventions to improve population health, prevent acute-on-chronic conditions, and improve appropriate response to medical situations and emergencies.  These efforts include free courses for the community: Stop the Bleed, Hands-Only CPR, Diabetes Self-Management, Chronic Disease Self-Management, Management of Chronic Pain, Tai Chi, and A Matter of Balance.  Additionally, program staff regularly participate in health fairs, community events, and school functions to perform screenings, answer health-related questions, and provide education on health and the appropriate utilization of 911 and other emergency services.

TEMSA: What kind of results are you all seeing? 

Corey Naranjo: In the 2019 calendar year, 79 patients have been referred to the CHP Program at HCEC, and the results have been outstanding!  We have seen a reduction in the frequency of 911 calls from high utilizers, as well as an improved quality of life and health empowerment as evidenced by pre-established patient surveys.

  • HCEC’s CHPs have collaborated with or referred to:
    • Meals on Wheels.
    • Primary care providers.
    • Sliding scale primary care clinics.
    • Physician specialists.
    • Social isolation reduction programs.
    • Evidence-based fall reduction courses.
    • Mental health adult protective services.
    • Child Protective Service (CPS).
    • House-call practitioner services.
    • Harris County Public Health
    • In-patient rehabilitation hospitals.
    • Skilled nursing facilities.
    • Personal care homes.
    • Dementia social workers.
    • County-supported health plans.
    • School districts.

TEMSA: What recommendations do you have for other EMS agencies that might be thinking about community paramedicine?

Corey Naranjo: Establishing a new MIH or CP program can seem daunting, and there is a great deal of preparation involved to improve success.  There are both online and in-person courses for MIH Providers, which I highly recommend.  The entire approach of community paramedicine is vastly different from traditional EMS assessment and treatment.  It is more holistic, in-depth, and has a different overall goal than that of field medics.  I also encourage program administrators to contact other administrators in your area.  Managing an MIH-CP Program has its own unique challenges.  One lesson I learned was: establish your program completely before taking on patients; otherwise, you will still be developing when you should be seeing patients.  Get the groundwork complete before implementation.

Things to consider are budget, vehicle, protocols, response plans, any specialty programs, referral process, loop closure process, and charting.  I suggest several brainstorming and planning sessions, utilizing SMART aim statements and goals.  Set up a timeline, and celebrate the “small” achievements.  If you get overwhelmed, look back at your overall program goal/aim statement to get you back on track.

When I took over the CHP Program at HCEC, I felt very alone.  I knew of a few agencies that had working programs, but I was unsure of how to connect.  Within SETRAC (Southeast Texas Regional Advisory Council), I connected with current CHPs, as well as those agencies still in the planning or development stages.  We now have an official MIH-CP workgroup, and we meet regularly and share ideas and tools.  Collaboration is much more effective than working in silos!

TEMSA: What are the next steps for HCEC’s community paramedicine program?

Corey Naranjo: One of our largest unmet goals is to establish a partnership with a hospital or hospital system.  MIH is so new to the Houston area, that most facilities have not even heard of such an endeavor.  A colleague at a neighboring agency just completed a pilot study with post-MI patients from a community hospital, which is part of a large system.  I am hopeful that the data from the pilot will help serve as a springboard for other hospitals to link with local MIH-CP Programs across the Houston area.

TEMSA: Why should agencies consider looking at MIH/CP Programs?

Corey Naranjo:

  • Aligns with the EMS Agenda for the Future.
  • Aligns with the Institute for Healthcare Improvement (IHI)’s Triple Aim:
    • Improving the experience of patient care.
    • Improving the health of populations.
    • Reducing the per capita cost of health care.
  • The U.S. health care system moving toward value-based care.
  • Health care resource stewardship.
  • Cost reduction.
  • Patient health empowerment.

I highly recommend looking at EMS 3.0: Explaining the Value to Payers from NAEMT.  It is extremely simple and effective in showing how different agencies can benefit from aligned care such as MIH-CP.