1. Dana Sechler, NREMT-P
Michael D. Curtis, MD
Chief / EMS Director
Medical Director Emeritus
Baraboo District EMS
Ministry Health Care
1

2. 2
Changes in Mindset
 All EMS agencies will not be able to do it
 Could possibly decrease call volume—by
which we have measured success in the past
 Keeping perspective

When you are up to your butt in alligators, it’s
difficult to remind yourself that your initial
objective was to drain the swamp

3. 3
Public Health Goals
 Prevent injury / disability
 Prevent illness
 Prevent death
 Promote births of healthy babies
 Promote a healthy lifestyle
 Assure health services where otherwise
not provided

4. 4
Health Care Problems
 Decreased access to primary care
 Growing number of uninsured/underinsured
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Uninsured are less likely to seek out preventive
care services and defer care
Increased ED visits/emergency care
High readmission rates
Lack of consistently coordinated, high quality care
All of these lead to high costs of care

5. 5
Rural America
 25% of Americans live in Rural America
 10% of America’s doctors practice in
Rural America

6. 6
Rural Training Track Program
 Program created to attract more Primary Care
Providers to the rural communities
 Programs like the Rural Resident Program exist
because typically physicians do not want to practice
in a rural setting due to the special challenges faced
such as:
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Poor usage of primary care providers
Poor use of preventive health measures
Patients typically seek treatment for severe cases of
acute or chronic health issues
Poor means for follow-up care, such as home visits

7. 7
Rural Residents
 Rural residents:
 receive fewer regular medical check-ups
 are more likely to report fair to poor health status than
urban residents
 more likely to have experienced a limitation of activity
caused by chronic conditions than urban residents
 devote more of their income to health care costs
 are more likely to engage in risky behaviors

8. 8
Emergency Departments
 Not being utilized the way they were designed
 Overloaded with non-essential visits
 Recent growth of ED visits has helped increase the
cost of health insurance

9. 9
Medicare
 Spends $12 - $15 billion a year on hospital readmissions
 1 in 5 (20%) of Medicare patients are readmitted into the
hospital within 30 days of discharge

In the case of 50.2% of the patients who were rehospitalized within
30 days after being discharged, there was no follow up with a
physician's office between the time of discharge and
rehospitalization
 1 in 3 (33%) of Medicare patients are readmitted into the
hospital within 90 days of discharge

10. 10
Readmission Diagnoses
 30-day readmissions for the most common
initial diagnoses in rural hospitals are:
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Pneumonia
Congestive Heart Failure (CHF)
Chronic Obstructive Pulmonary Disease (COPD)
Arrhythmia
Kidney/Urinary Tract Infection (UTI)

11. 11
Follow-up Care

Who will provide the follow-up care for these patients?

Doctors?
 Chronic shortage
 Lack of time for out-of-clinic activities

Nurses?
 Chronic shortage
 Too many other opportunities for career development

Home Health?
 Prepared to service “homebound” and “hospice” patients only

12. 12
Possible Solution

Community Paramedics
 Trained specifically for field medicine and home visitation
 Mobility and flexibility are hallmarks of EMS orientation
 Scope of practice includes many advanced medical skills
complimentary to clinical nursing
 Advanced communication methods allow for “telemedicine” type
of patient care management with close supervision by primary
care providers

13. 13
Emergency Medical Services
EMS ≠ Prehospital
EMS = Healthcare
EMS Services will need to address the needs
of all patients who present with a Healthcare
condition or need, throughout the continuum
of the Healthcare system
i.e.: prevention — rehabilitation

14. 14
Solution
 Non-competitive program that is designed to fill in
healthcare gaps
 Provide primary healthcare, improve emergency
response capabilities, and strengthen community
healthcare collaborations in our community
 A Community Paramedic is part public health, part
disease management, part prevention, part social
worker, part patient educator, and part treatment

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Advantages
 Eliminating health disparities to rural areas
 Decreasing overall healthcare costs
 Proper referrals to primary care physicians
 Decreasing misuse of emergency departments
 Proactive EMS care verses reactive EMS care

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Advantages
 Decreasing nonessential ambulance transports
 Decreases workload and increases quality and
efficiency of managing patients in a primary care
setting by utilizing EMS personnel through nontraditional methods
 EMS personnel currently have a good basis of
training, expertise and scope of practice to provide
essential primary care services

17. Role:
Physician-Ordered
Initial & Follow-up Care
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Case Study – Mrs. Jones
 Mrs. Jones is in her mid-70’s, and lives alone
 Has new onset of symptoms to a chronic condition

Physician debating sending pt to floor for observation
 The PCP requests a Community Paramedic visit and
evaluate the patient once a day for a week
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CP writes a report in patient’s chart after each visit

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Case Study – Mrs. Payne

66-year-old female recovering from abdominal
surgery for small bowel obstruction
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Discharged to her residence after 2 days of post
surgical observation
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Developed complications due to internal leakage of
intestinal contents into her abdominal cavity
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Patient had one phone call 3 days after discharge
with her surgeon and was assured that pain was
normal

20. 20
Case Study – Mrs. Payne

911 called after 5 days at home due to fever and pain

Patient and surgeon were unaware that she was febrile
and septic or that the appearance of her suture site was
not “normal”
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Transferred to UW where she underwent emergency
surgery but died 3 days later
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Could a Community Paramedic follow-up to augment
written discharge orders have saved this person’s life?

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Readmissions Reduction Program
 The Affordable Care Act of 2010 requires
HHS to establish a readmission reduction
program.
Effective October 1, 2012
 Designed to provide incentives for hospitals to
implement strategies to reduce the number of
costly and unnecessary hospital readmissions.
 Readmission = “an admission to a hospital
within 30 days of a discharge from the same
or another hospital.”


22. 22
Readmissions Reduction Program
 20% of Medicare patients are readmitted to a
hospital within one month of discharge
 CMS considers this number excessive and
believes that readmissions are an indicator of
quality of care, or lack thereof
 Provides an incentive for hospitals to
decrease readmissions by coordinating
transitions of care and increasing the quality
of care provided to Medicare beneficiaries

23. 23
Readmissions Reduction Program
 Part of CMS’ goal to transition to value based
purchasing

paying for care based on quality and not just
quantity
 These incentives are escalating penalties that
decrease a hospital’s payments from all of its
Medicare cases

Purpose is to improve quality and lower costs for
Medicare patients

Ensure that hospitals discharge patients when they are
fully prepared and safe for continued care at home or
at a lower acuity setting

24. 24
Predicted Costs to Hospitals
Total number of discharge patients at local hospital:
2,792 (patients)
Percentage of annual admissions at local hospital that are
Medicare insured: 42%
1,173 (patients)
Percentage that are readmitted within 30 days:
20%
Total patients that are non-reimbursable by Medicare:
235
Average amount charged (non-reimbursed) per patient:
$15,318
Annual projected non-reimbursable funds:
$ 3,599,730
(patients)

25. 25
Community Paramedic Programs
 International:
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Programs in Australia, New Zealand, the United Kingdom,
and Nova Scotia
 Several across the U.S.
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Red River project – New Mexico (1990’s)
Colorado
Minnesota
Huge explosion of others attempting some type of program
across the U.S.
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Already starting to diversify
 inner city EMS agencies are adopting CP concepts
 applying them to 9-1-1 calls

26. 26
Community Paramedic Programs
 The Community Healthcare and Emergency Cooperative (CHEC)
formed in July 2007

addressed critical health care shortages in rural and remote areas—
specifically by developing a new community health provider model
 From this partnership, the Community Paramedic Program emerged
 CHEC members based the Community Paramedic model on the best
practices of similar initiatives around the world, including the Alaska
Community Health Aide, the Nova Scotia Community Paramedic model
and the Australia Rural and Remote Paramedic Program
 CHEC has a standardized training curriculum that is consistent
internationally, yet can be modified and customized for each
community, province and nation

27. 27
Value to the Local Hospital
 Patients can be discharged earlier with proper
continuation of care and no decrease in Medicare
compensation
 Better patient retention due to higher patient satisfaction
as hands-on care follows through home recovery period
 Positive publicity of participating in this unique program
 Overall community health improvement as care plans
include prescheduled home follow-ups

28. 28
Goals
 Decrease hospital readmission rates
 Decrease non-essential ED visits
 Improve patient outcomes
 Improve continuum of care
 Decrease overall healthcare costs

29. 29
So, what have we been doing?
Past:
 Baraboo is the 3rd Nationally approved CP Program
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Consortium with the North Central EMS Institute
http://www.communityparamedic.org
 Approved as a pilot program through WI State EMS Office
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Appointed Captain Lori Spencer to administer the CP program
 Began working with Dr. Marv Birnbaum and Jan Beyer
 UW Emergency Education Center
 Goal is to collect data over 3 years to prove the validity of CP

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So, what have we been doing?
“It is important to note that such studies have
not ever been done for evaluation of the
impacts of EMS, especially regarding ALS
—and we do not want the CP programs to
go down the same path.
Current CP efforts around the U.S. are not
collecting data to determine the value of
the program.
This process must be better and must show
its worth.”
~ Dr. Marvin Birnbaum

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So, what have we been doing?
Partnerships:
 Created a Steering Committee with the following entities:
 UW Madison Medical School &
Emergency Education Center
 Sauk County Public Health
 State EMS Office
 Office of Rural Health
 St. Clare Hospital
 Home Health
 Ho Chunk Nation
 Ambulance Commission members
 Others

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So, what have we been doing?
Curriculum:
 Colorado Community Paramedic course
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Dr. Birnbaum sits on the oversight committee
Lori took the course
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Didn’t take the clinical portion, as she is an RN
 Marv, Lori, and Jan took curriculum and ‘Wisconsinized’ it
 The revised curriculum is specific to primary care
 Intent is to be taught by UW Medical School
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around 200 hours with didactic and clinical portions
Other staff are ready to take the course though UW

waiting for…

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So, what have we been doing?
 The intent was to fund the CP Program through grants
 For the first 3 to 5 years
 After that, we believed that Medicare and insurance
companies will reimburse for these services

Based upon perceived cost savings
 Reality:
 Applied for numerous grants
 Scored over 93 points in all the grants
 Denied for numerous reasons

34. 34
So, what have we been doing?
 Grants—
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UW School of Medicine & Public Health grant
Health Resources & Services Administration (HRSA)
Innovation Grant from Center for Medicare & Medicaid Services
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Also applied as a consortium with North Central EMS Institute ($27 million)
No CP programs were granted any funds with the CMS grant
Robert Wood Johnson Foundation
 Reasons for denial
 Physician comment, “EMT’s shouldn’t be doing this in the field.”
 “Great idea(s), but too cutting edge—come back in 3 to 5 years.”

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So, what have we been doing?
Present:
 Minnesota passed law to recognize CP as a practicing
level of EMS

Services can bill, and get reimbursed
 Program administrator took new job as a Hospice nurse
 Still applying for grants
 Changed focus
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CHF
Wound care
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Include partnership with Madison FD


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We’ve come a long way,
but still have a ways to go…

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What’s next?
Future:
 New Name: Mobile Integrated Health Care
 Telemedicine
 Locally, we will continue working with Partners to:
 Finish State curriculum
 Send additional staff to CP training
 Implement actual field program
 Collect data
 Work on Legislative initiatives
 Work on permanent funding

Hospitals?

38. 38
What’s next?
Future:
 National / State perspective will look at Scope of profession
 Similar to RN licensure
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A Paramedic will be credentialed (endorsed) based upon training
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ACLS, PALS, TEMS, Critical Care, Community Paramedic, etc.
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State will regulate the service that provides the level—not necessarily
the individual
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EMS Office will host a Stakeholder meeting at the State the level, to
begin discussions with partner groups
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Appears that there may be support at the National level
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Grassroots effort from the bottom up
National acceptance from the top down

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Questions?
Contact info:
 Dana Sechler, NREMTP
dsechler@bdems.com
Office: 608-356-3455
 Michael D. Curtis, MD
Michael.Curtis@ministryhealth.org
Cell: 715-498-2240