Can Community Paramedicine Improve Health Outcomes in Rural America?

The article is part of a partnership between the Commonwealth Fund and the Bassett Research Institute in Cooperstown, N.Y., to explore innovative approaches to the health care challenges facing rural communities across the United States.

Introduction

Medical emergencies are often rooted in missed opportunities: car trouble leads to a missed appointment; new symptoms aren’t noticed; or a patient leaves a clinic without fully understanding their doctor’s instructions.

These kinds of problems happen everywhere. But the odds are higher in rural communities — where patients tend to be older and sicker than their urban and suburban counterparts, and may be more geographically isolated — so there may be fewer people around to notice if they develop a problem. Rural residents must also travel longer distances to reach hospitals and clinics.

In some rural communities, community paramedicine programs are being used to extend the reach of health care providers. They send paramedics and other staff to peoples’ homes with the goal of stabilizing their health and avoiding the need for 911 calls down the line. Instead of responding to emergencies, community paramedics might visit people after an emergency department (ED) visit or hospitalization to make sure they understand their treatment regimen or to assess safety risks in their homes. Some programs train paramedics to offer disease management tips or link people with social supports. “It's a real change in focus for paramedics,” says Gary Wingrove, president of The Paramedic Foundation. “Typically, they are thinking about how to take care of a patient's emergency in the next 30 minutes. As a community paramedic, they're thinking about the next 30 days and they’re working very closely with primary care and specialist physicians and others to develop care plans.”

Community paramedicine programs date to the 1990s and have grown in number over the past decade. A 2017 survey found there are at least 129 programs in the United States, more than 40 percent of them serving rural areas. In this feature, we profile three community paramedicine programs that serve rural communities. The programs are supported by grants or subsidized by large health systems. They won’t solve workforce challenges in rural communities or the fragile financing of rural health care systems, but they are beginning to demonstrate success in helping people manage their conditions and avoid ED and hospital use. Advocates hope they may attract the interest of payers and providers engaged in value-based contracts that hold providers accountable for the quality and total costs of care.

Helping People Manage Chronic Conditions

In 2019, Rozalina G. McCoy, M.D., M.S., medical director of Mayo Clinic Ambulance’s Community Paramedic Service, had a question. She knew that many people with diabetes call 911 when their blood sugar drops to an unsafe level (hypoglycemia), and about half wind up being taken to the hospital. But what happens to the other half? McCoy partnered with paramedics to find out. “We found that people who are not transported have a nearly twofold higher rate of having a recurrent hypoglycemic event within 30 days,” she says. “They call the ambulance, paramedics come and reverse the hypoglycemia with oral or intravenous glucose, but then they leave because the patient is better and doesn’t want to go into the ED. But then nothing happens to their treatment regimen. So they keep having the same problem, even though it can be prevented.”

To disrupt this cycle, McCoy and her colleagues applied for a grant to create a community paramedicine program for patients with diabetes. Mayo Clinic is known for its destination medical center in Rochester, Minn., but the health system also serves rural communities in southern Minnesota, western Wisconsin, and northern Iowa. Back in 2016, one of Mayo’s critical access hospitals in northwestern Wisconsin had begun testing whether home visits from paramedics could benefit patients who were high utilizers of emergency and acute services in its home county. The paramedics followed physicians’ orders to perform tests, review medications, and provide other services. Over a six-month period, the program was associated with a 59 percent reduction in ED visits, and it received positive ratings from clinicians.

Armed with these promising results, McCoy and her team launched a trial in 2020 to test whether support from community paramedics could improve outcomes for rural patients with diabetes who have high blood glucose levels and visit the ED or hospital for any reason. Then, in 2021, they started another trial, this time focused on patients who become hypoglycemic and call 911 or seek medical care for it in the ED or hospital.

In both studies, Mayo Clinic community paramedics visit patients at their homes to identify the reasons for their low and high blood sugars. With support from McCoy, the paramedics then partner with the patient, their care partners, and their clinical teams to optimize patients’ insulin doses, reconcile their medications, promote good nutrition and physical activity, and improve adherence to glucose monitoring and medication. They also help people find food banks or other community assistance programs as well as programs that can reduce the costs of their diabetes medications and supplies.

Over time, Mayo Clinic’s community paramedicine service has grown to support patients with heart failure, cancer, and a range of other chronic conditions, as well as those needing wound care. Community paramedics have been trained to use ultrasound to identify and diagnose patients with pneumonia or heart failure and can perform urgent lab tests at the point of care. “EMS clinicians have an incredibly wide skill set,” says McCoy. “They learn quickly and adapt to new situations and clinical needs.” Mayo Clinic’s community paramedics need at least two years’ experience as a paramedic and must complete specialized training to become proficient in the services offered. Most will also hold academic positions in the Mayo Clinic College of Medicine. “It’s not just more work and more responsibility for the community paramedics compared to being a paramedic,” says McCoy. “This role affords them more autonomy, respect, and ability to contribute to the health care system and to the health of our patients.”

McCoy says the costs of community paramedicine are modest: they include the salaries of community paramedics and the cost of supervision, vehicles, and gas. Thus far, services have been available to patients who need them at no cost and without going through insurance, in part because of limited reimbursement for community paramedic services by different insurance plans. However, as the community paramedic model grows and evolves, McCoy is hopeful that insurance plans will recognize the immense value they bring to patient care and begin reimbursing these services.

Piloting Local Approaches

Maine — one of the most rural states with one of the oldest populations in the country — has also experimented with community paramedicine programs.

In 2012, state policymakers authorized emergency medical service (EMS) agencies in 12 regions (nine of them rural) to launch community paramedicine pilots that allow paramedics to evaluate patients (for example, checking their vital signs and weight as well as assessing home safety), offer basic care (such as checking wounds or performing blood tests), and provide education to those referred by their primary care physician, hospital staff, or home health agency staff. All the EMS providers involved in the pilots completed training, either through local mentorship or external programs, to offer such services. The state didn’t provide any funding for the pilots; the goal was to let communities identify their own needs and see what value the model could provide.

“Maybe a patient is not eligible for home health after a hospitalization,” says Karen Pearson, M.L.I.S., M.A., a policy associate at the University of Southern Maine. “The community paramedic on referral from the physician or the hospital can go check up on that patient, make sure they understand their instructions, get eyes on what their home environment is, and try to mitigate all those factors that would put them back into the hospital. That's a huge benefit in rural communities.”

A review of three community paramedicine providers in Lincoln County conducted by the University of Southern Maine and LincolnHealth, a local health system, found that paramedics provided 1,158 visits to 318 patients over three years (2016–18). More than half had diabetes, congestive heart failure, and/or chronic obstructive pulmonary disease, and most were elderly. The analysis, based on LincolnHealth’s medical record data, found that ED visits and hospitalizations declined in the month after patients’ first community paramedicine visit, compared with the month prior.

There are now 17 community paramedicine programs in Maine, and EMS agencies can apply to expand or create additional programs. Pearson is overseeing an evaluation of the programs, with the goal of documenting the costs and benefits of delivering a core set of community paramedicine services. “What payers are looking for is not only a reduction in hospital admissions and readmissions but also greater engagement in primary care,” she says. The results may encourage Maine lawmakers to approve a policy that would pay for community paramedicine services through Medicaid.

Serving Frequent ED Users

In 2016, Allegheny Health Network, a large health system serving the western third of Pennsylvania, developed a mobile integrated health (MIH) program led by community paramedics to serve patients who frequently call 911 for care.¹ The MIH team includes 12 community paramedics, a clinical psychologist (who is also a community paramedic), a pharmacist, a medical director, and a data analyst. The team receives referrals from primary care and specialty care providers, social workers, and EMS agencies that work with the health system. Their annual budget is paid for by the health system.

At the initial visit in patients’ homes, MIH team members try to identify issues that prevent people from managing their health. “Is there a literacy issue? Is there a transportation problem? Are you struggling with mental health issues? Do you have an issue trusting your clinician?” says Jonah Thompson, CP-C, director of Prehospital Integration, who leads the MIH program.

Patients are typically followed over two to three months, during which the lead MIH team member might meet with them weekly to identify and try to solve problems. “Paramedics are uniquely trained and have the experience needed to walk into uncontrolled environments and look around and go, ‘Well, that’s a problem and that’s a problem and that’s a problem,’” he says.

Thompson says the program has been shown to increase patients’ use of primary care, specialty care, and prescribed medications. It also has reduced spending on hospitalizations and ED use, generating savings for the health system that offset its costs.

Spreading Community Paramedicine to Other Rural Communities

These three programs suggest that community paramedicine can help fill gaps in care in rural communities and improve health outcomes for chronically ill and other high-need patients. But spreading them will require new payment approaches and the cultivation of a paramedic workforce.

The most obvious hurdle is payment. While community paramedics seek to keep patients healthy in their homes, EMS reimbursement has historically been linked to transport, with payment contingent on patients being driven to hospitals or other facilities. But that is starting to change. In 2018, in 14 states, Anthem BlueCross BlueShield began offering reimbursement for EMS calls that don’t end in patients being transported to EDs, opening the doors to community paramedicine programs. Fourteen Medicaid programs also reimburse some types of EMS services beyond transportation; in five states, Medicaid programs explicitly reimburse community paramedicine services. And in 2020, the Centers for Medicare and Medicaid Services launched a new payment model that allows EMS providers to bill for providing some treatment in place, either in partnership with another health care provider or via telehealth.

To build the business case for community paramedicine services, studies such as the trial at Mayo are needed to explore which services help patients stay healthy and avoid the need for ED or hospital use. State rural health offices and state EMS agencies also could partner with health care providers and insurance companies to develop pilot programs and sustainable reimbursement mechanisms to support community paramedicine programs. The National Rural Health Association offered several policy recommendations to strengthen EMS services generally, including guidance for private insurers on how to structure and pay for community paramedicine programs.

Funding for community paramedicine could also come from opioid settlement funds, crisis stabilization services, or other initiatives designed to curb addiction and mental health crises that often drive use of emergency services. In North Carolina, for example, several rural counties have deployed community paramedics to visit people after drug overdoses to provide support, offer naloxone and other harm reduction tools, and link them to treatment. The program has been credited with reducing drug overdoses as well as reducing the costs of emergency services.

Another challenge is that paramedics can be hard to find in rural areas, where EMS providers are typically emergency medical technicians, who have less training than paramedics and are often volunteers. If community paramedicine programs were adequately funded, they’d be better equipped to offer competitive pay and opportunities for advancement, and more people might be encouraged to enter the field.

Of course, some EMS providers may not wish to become community paramedics, preferring the tempo of emergency calls. But for those interested in community paramedicine, the field offers an opportunity to make a difference in people’s lives. “They become a trusted provider,” says Pearson.