As hospitals continue to experience overcapacity challenges due to the COVID-19 emergency, 911 ambulance crews and community paramedics have found themselves treating more patients at home.
Historically, ambulance crews and community paramedics — both of which operate in the emergency medical services (EMS) space — have always provided some degree of care in the home setting. To do so, they’ve often worked alongside traditional home health and home care agencies, too.
“There’s been a certain amount of care [or treatment] in the home for many years,” Hanan Cohen, paramedic and director of corporate development at Empress EMS, told Home Health Care News. “On the 911 system, it’s not at all uncommon for an EMS crew to respond to a multitude of emergencies. After assessing and, sometimes, treating the person, … they may decide not to go to the hospital.”
New York-based Empress EMS is a partner of PatientCare EMS Solutions, which provides emergency ambulance and other critical health care logistics services.
Typically, if patients or family members decide to forgo a hospital visit, paramedics can speak to the medical control physician and explain that treatment has been given. Patients can then sign a release stating they are willing to stay home, avoiding a costly hospitalization, according to Cohen.
It’s not uncommon for ambulance crews and community paramedics to respond to asthma attacks, diabetic episodes, minor wounds, chronic seizures, cardiac arrests and more.
“All of this is in-conference with a physician,” Cohen said. “We’re always using established protocols, including state and national standards of care when we treat them. It’s not an ad hoc [process].”
The public health emergency has amplified care in the home from ambulance crews and community paramedics in both volume and service level, according to Cohen.
“Many states and regions have enacted protocols to try to decompress the hospitals and prevent surges from becoming completely overwhelming,” he said. “Patients with more minor but standardized COVID-19 symptoms — respiratory complaints, chest pains, mild difficulty breathing, loss of taste — would be treated in the home unless there were other comorbidities or an instability.”
Despite providing care in the home, ambulance crews are not compensated for this work by the Centers for Medicare & Medicaid Services (CMS).
And that lack of compensation causes a sort of ripple effect among other payers, according to Cohen.
“CMS is the guiding force in health care reimbursement on the EMS side. They are the largest payer, they provide oversight, and they guide a lot of public policy,” he said. “In having Medicare not pay for treatment in place, then, certainly, it’s very easy for most other payers to agree with that. There’s this position from the large federal payer and this view [from other payers] of, ‘If they don’t feel the need to pay, why should we?’”
For now, Cohen’s agency, Empress EMS, has applied to CMS’s Emergency Triage, Treat and Transport (ET3) Model. ET3 is a five-year payment model pilot program that will grant ambulance crews more flexibility, including reimbursement, around providing care for Medicare Fee-for-Service beneficiaries.
The pilot program will begin in Fall 2020.
EMS and in-home care providers
Overall, the U.S. emergency medical services products market is anticipated to reach $15.09 billion by 2025, data from ResearchAndMarkets.com suggests.
With EMS crews delivering more care in the home, some traditional in-home care providers worry their services may be overlooked.
Generally, the theory is that if ambulance crews and community paramedics eventually begin receiving reimbursement under Medicare for treating patients in place, this may create more competition for the home-based care providers that may have otherwise been called in.
But experts are quick to dismiss this line of thought.
“We don’t feel like there would be any competition,” Kathie Smith, vice president of state relations for home- and community-based care at the Association for Home & Hospice Care of North Carolina (AHHC), told HHCN. “We feel like it would be a collaborative approach. The goal is to keep people in their homes as long as possible if it’s safe. It’s going to take a village of different types of providers so to speak — EMS workers, community resources and caregivers.”
AHHC is a nonprofit trade organization that represents roughly 800 home health, hospice, palliative care, personal care and private-duty nursing providers in North Carolina.
While there may be overlap between ambulance crews treating patients in the home and in-home care providers, there are many different requirements surrounding both groups.
“Home health is totally different,” Smith said. “If anybody wanted to get into home care or home health, they would have to go through the proper channels of licensing and certification. There are many complex rules for actually providing home health around physician orders, face-to-face encounters, plans of care, certain types of documentation. It is a different approach than what may be being provided through a community-paramedicine program.”
Despite the differences, there is room for potential partnerships between community paramedics and in-home care providers.
“We always like to work in partnership with different types of community resources,” Smith said. “For example, if a person in the community had frequent falls and had diabetes, community paramedics may be involved to provide education and resources within their scope, but at some point they may need to make a referral to a home health agency for ongoing skilled care with a plan of care and physician certification for treatment involving a nurse or therapists.”
Likewise, Cohen believes that future partnerships are possible — and necessary — in order to fill care gaps.
Empress EMS already works closely with half a dozen home health and Visiting Nurse Service (VNS) agencies.
“Certainly, there are a wealth of interagency relationships between 911 and home health, or paramedics and home health,” he said. “Being involved very heavily in the national stage with this there are perceptions that there is competition. When you look at the actual working relationships, whether it’s in Texas or New York or other states, they seem to complement each other well.”