How community paramedics in Oregon fill gaps in care and reduce visits to emergency departments

The Hermiston Herald recently profiled Jessica Marcum, a community paramedic at Umatilla County Fire District #1, about her job helping patients in the region. Unlike paramedics who respond to emergencies, community paramedics work to keep patients out of emergency rooms by providing in-home health services, from medication management after a hospital stay to making referrals for mental health services. Although community paramedics are found throughout Oregon, their impact is especially felt in rural areas. A recent study by researchers at Oregon Health & Science University found that community paramedics in Central Oregon reduced visits to the emergency department by nearly 14%. We hear from Jessica Marcum and Sabrina Ballew, the Mobile Integrated Healthcare Manager at Mercy Flights in Medford, about the role community paramedics are playing to bridge gaps in care and improve health outcomes in Southern and Eastern Oregon.

Note: This transcript was computer generated and edited by a volunteer.

Dave Miller: This is Think Out Loud on OPB. I’m Dave Miller. We end this week with community paramedics. Unlike paramedics who respond to emergencies, community paramedics work to keep patients out of emergency rooms by providing in-home health services. These programs can be found throughout Oregon, but their impact is especially strong in rural areas where there are fewer health care options. A recent study by researchers at OHSU found that community paramedics in rural Central Oregon reduced avoidable emergency department visits by 39%. I’m joined now by two community paramedics.

Sabrina Ballew is the mobile integrated healthcare manager at Mercy Flights in Medford. Jessica Marcum who was recently profiled in the Hermiston Herald is at Umatilla County Fire District #1. Jessica and Sabrina, welcome.

Sabrina Ballew: Thanks to you.

Jessica Marcum: Glad to be here.

Miller: It’s great to have both of you on. Jessica first, how do you describe this work for people who have never heard of it?

Marcum: So, for community paramedics, it’s a little bit of an expanded role for paramedics. At least for my program, we do a lot of the same 911 response, but also we have an opportunity to intervene in patients’ lives where we normally wouldn’t. Sometimes the best care for people isn’t at the emergency room and we’re able to coordinate with a lot of different services to provide that care at home.

Miller: Sabrina, I saw you say in a presentation that’s online that the one service you don’t provide is transportation, which is a little ironic given the way that a lot of us have been trained to think about paramedics. What do you mean by that? What services do you provide?

Ballew: So, the unique thing about the mobile integrated healthcare and community paramedicine is, we bring patient care back to the patients. And just like Jessica said, patient care isn’t always best at the ER and our ER’s are overwhelmed and burdened. And sometimes we can take patients to and connect them to resources such as their primary care provider or urgent care, or we can even link into telehealth or work on behalf of their primary care and provide that care for them in their home. So I always think it’s really, really unique as an air and ground provider of services in Southern Oregon, our department is the only department that doesn’t transport currently.

Miller: Sabrina, what might a community paramedic do over the course of any given day?

Ballew: Our program is very unique. So one of the statements I hear quite often is if you see one mobile integrated health or community paramedic program, you’ve seen one community paramedic program. Our program provides quite a few services. So our team will visit the hospital. They have boots on the ground targeted outreach for our homeless population. We have a mobile crisis response program. So it could vary every day. So we could spend part of our morning in the hospital working with our social work and discharge planners, ensuring patients have a safe discharge home, or we could spend three or four hours out on our local greenway providing services to our homeless population, which looks like providing connections to substance use treatment or a mental health evaluation or housing resources or point of care treatment. It could look like a home visit anywhere in our 2,600 square miles service area. Or it could be an instant right now crisis call to where we go out with a mental health provider and our medical team providing a de-escalation for a crisis call.

Miller: So in a team of people, every individual in the program has to be able to do all of those different jobs?

Ballew: Yes, we are. We have a team on. So we split that day up and we are all cross-trained or trained in multiple different disciplines. So we receive additional training in chronic disease education, mental health de-escalation, mobile crisis response, point-of-care treatment. And we work with our supervising physician to ensure that we have that extra education along with our local hospital systems.

Miller: That does not sound boring.

Ballew: It does not.

Miller: Jessica Marcum, is there a story of a client or a patient that comes to mind that you think illustrates the way this program can work at its best?

Marcum: So at its best, I’ll have to pick a story from when I first started the program. We originally designed our program to deal with or to help work with our high utilizers for 911 and we had a couple who had a lot of falls. So one big part of our program we focused on over the last few years has been full risk assessments. And I’m so we went to this individual who didn’t seem to have anything really wrong with them. We’d lift them up, put them in their chairs and kind of go on about our day until maybe another few days would pass by and they would call again.

I had the opportunity to go out to the home, really do a lot of different assessments and our assessments have grown over the years. Right now, it’s a program of one. So Sabrina’s really leading the way for the state. They’ve got a great team going. I’ve tried to kind of figure things out with a little bit of her guidance along the way and tried to figure out some sort of reason for this because most people don’t fall and then need an EMS provider to pick them up more than a few times a year or really, even more than once a year. So through, a lot of investigation, looking at their medications and their health conditions and working with their doctor and talking with their EMS crews. For this specific couple, it ended up being talking with some of their family because their family would call when I was there and the family wanted them involved or the patient wanted them involved to kind of figure out what’s going on and why.

And so through a lot of conversation and a lot of care coordination, we’re able to identify some health problems but also a lot of medication errors. And when we ran numbers a while back. We had about 40% of our patients that were not taking their medications correctly, that could result in falls. So with all of that, we were able to get them a lot of care, in the home. Eventually they ended up progressing with some of their health processes and moved into assisted living by choice and ended up very much enjoying it. And when they moved out of state to go live with family, they invited me to their going away party so that’s kind of a little near and dear to my heart.

Miller: It’s an interesting example because it’s complicated and my assumption is that most of the calls or clients that you’re dealing with, we’re not talking about simple situations. But it does make me wonder if a lot of what you’re doing, collectively, is filling in the gaps that exist in our sometimes siloed, always complicated health care system.

Marcum: And that is exactly how my chief has described it over the years as we’re kind of another spoke in the wheel, just figuring out what the gaps are and how we can meet them. So for our program, we started with trying to figure out kind of what was going on so now we have four pages of social needs assessments to figure out what medical devices do people have. Do they have walkers, wheelchairs? Are they getting any social services with transportation? Mental health? Do they get food stamps? Do they have transportation? Do they need those things? Are they getting home health? And then how to get those services to people so that we can prevent their additional 911 usage or re-admit to the hospital. That sort of thing.

Miller: Sabrina, what about you? Is there a story that comes to mind that illustrates the way these programs can work?

Ballew: Yeah. So I have a couple or many, but one of the most recent ones we had was an elderly female, she was in her 60s and recently had lost her husband, unfortunately. And we received a referral for her from a couple different agencies, one from one of our departments in our southern area and then one from our ambulance service for Mercy Flights. And she was having frequent falls and diabetic issues. And unfortunately, she had lost her husband and from what I understood was kind of hiding the fact of how far she wasn’t able to take care of herself over the last few months.

On about the third or fourth call they received, we went out to visit her, we visited her in the hospital so she knew who we were before we visited her. And because she lived in our rural area where there really wasn’t a great cell phone signal. And through our work with her, we brought point-of-care assessments and treatment to her for her diabetes. And we actually brought our mental health team out to her instead of her having to come into town to get an assessment. We brought that to her. So we were able to assess exactly where she was at and the services that she needed. We brought in supportive care for her medical needs or durable medical equipment just as Jessica mentioned. And brought in food because she had significant food insecurities. Then we brought in connection to grief support, the loss of her husband, her high school sweetheart was so impactful to her. She just really did not know what to do.

In the end, she ended up being able to manage her diabetes and her mental health. She lived with a friend that was in the same area for a few months until we were able to find her a place to live locally and she is doing great. She is connected to the grief support, her mental health support, her diabetes is under control. She still sees her friend once a week and it’s not a care facility but it’s more like a retirement home that she’s in. She’s able to have friends and that support around her.

MilIer: I think it’s impossible to answer fully because it’s conjecture. But, what do you imagine might have happened if the kind of coordinated at-home care that you were able to provide didn’t exist?

Ballew: Oh, that would almost all break my heart because of where she’s at. If her cell phone had died or she didn’t have access to her, her outcome probably could have been pretty detrimental if someone didn’t find her or her blood sugar got too low. She may have passed. We may not have gotten to her in time.

Miller: Jessica, how much of what you do could be done remotely by phone or on a computer?

Marcum: Oh, honestly, not much. You lose so much in translation and that’s kind of what I love about integrating paramedics into this part of healthcare. On a 911 call, there is so much chaos going on, you have people under stress, you have family members in stress bystanders. It’s just a lot of chaos and trying to control that and deal with the big emergency is a whole different scenario than coming into someone’s home, say after a hospital discharge. And kind of saying, OK, what’s going on? How can we help you? What were you admitted for? Do you understand your conditions? Do you have your medications and being able to bridge those two? For our system this is huge because you need both of those, you need to see what family members show up on a 911 call when things are really, really bad and also knowing what support system they have. Seeing in the home, some programs do very well with nurses and that sort of thing of making phone calls in the hospitals, do a great job of doing everything they can to set people up for success in the home by making phone calls and doing follow ups.

But I found very often in my career that it’s not the same as when you go into the home. When you have the opportunity to go into the home, and they say, yeah, I have my medications but then you look at them and you go, you have three bottles of each medication and they’re all full. Do you have an opportunity to use a pill box? Do you have anyone to explain what these medications are for? Until you have eyes on the situation, a lot of the times it’s not as it seems when you, when you do that remotely. So being in the home and being able to address some of those needs right away has been probably one of the biggest impacts that we’ve had as well as medical equipment.

A lot of times we have someone who’s having falls. The other day, actually, for example, I worked with our local fire department in a neighboring town and they said this person’s having falls and we think we kind of know the problem but we’d like you to do an evaluation. So, we did a little bit of the physical evaluation, found some things we could maybe address with some home health services or additional ones. And they took a look at her walker and found she had a broken brake wire and the fire department there took it apart, went and got a replacement for her brake wires and got that repaired right away.

Miller: That’s obviously not gonna happen on Zoom, not the diagnosis of, of the walker problem and certainly not the fix.

Sabrina, we’ve been talking mostly so far about physical health conditions, but you did mention substance use disorder at the very beginning. How often do you and the other members of your team deal with substance use disorder or mental illness?

Ballew: So I did pull just a quick number before this meeting and in the last year, we served 3963 members and they were patients that we reached out to and about 44% of them–and this is what they report to us in our social determinants assessment–had a substance use disorder either currently or within the last six months. And 52% of them reported some sort of mental health disorder. And of that population, we try to connect many of them to mental health or substance use disorder treatment, if they’re willing to or wanting to. Again, it’s about consistency and showing up because they may not be ready for it at that time. But it continues to get worse recently. And then the other struggle is being connected to primary care. So, in between trying to find primary care, we’ve been working through that in our community.

Miller: Well, that’s one gigantic statewide gap in the availability of services. How often, Jessica, do you run into that where you’re trying to coordinate care for people and keep them at home, keep them away from the emergency room, but the best way to do that is to get them connected to care that doesn’t actually exist?

Marcum: Oh, and that it’s going to be different for every program in a very rural area. We do the best that we can. I’ve spent the last six years figuring out what local resources we have, how to access them, who would qualify and so most of the time before I go on a visit, I’ll have a decent idea of what services are getting, what they’ll qualify for and when I get there identifying if they need them, or if we need to try and pull in some kind of nontraditional things. Maybe the local fire department in a very rural area has some more resources. They could help rebuild a walker or find some family or friends or a local church. There are some things that we just can’t do for people, unfortunately, and they don’t qualify for services, but knowing our local resources has been helpful in some of those areas.

Miller: Sabrina, how is your funding or reimbursement model different from the way ambulances normally work?

Ballew: So our funding model is primarily through grants and some contracts with our local CCO and our county for our mobile crisis response. But for ambulance response, normally if 911 is called, the reimbursement model for that is the transportation to the hospital. So ours is more of a proactive outreach and by referrals.

Miller: Would any policy changes–and I’m thinking about Medicaid in particular since you mentioned CCOs are the coordinated care organizations that are the regional providers of Medicaid services in Oregon–make your model more financially viable and more broadly used?

Ballew: So we’re very lucky to have CCOs in Oregon that are supportive of this program and they are looking at ways to expand it. There could be more that jumped on board and looked at the model for it for Oregon, but that limits the services that we provide to just Medicaid populations. So if they don’t have that or they’re underinsured or uninsured, there’s that, or even our Medicare population, those patients, it’s really hard to get them to qualify for services. So we are really looking at how we can address that population or have a change in policies there. And I think Jess can probably talk a little bit more about that, but working with our elderly population, the Medicare hurdle is pretty large.

Miller: Well, Jessica, what’s the financial, society-wide financial argument just in terms of dollars and cents for providing this kind of at-home care as opposed to using the emergency department?

Marcum: So I think, again, just kind of going back to, the best care for people is typically in their homes and it’s usually a little bit cheaper. I think seeing people in their homes and identifying problems early before they become big issues would be cost savings. And we actually got information from a chart that Prosser Memorial Hospital uses over in Washington for their estimated cost savings. And for our program, we’ve ranged between, depending on the amount of patients that we’ve seen, about $200,000 to $400,000 a year of estimated avoided health care savings because of the interventions we’re able to provide in the home.

Miller: My understanding is that - we have just about a minute left - but Jessica, that you lost a part time community paramedic because of funding. What’s that meant for the services you provide? You mentioned earlier, you’re now at a program of one.

Marcum: It just means a little bit of delayed response sometimes to see patients. We do a lot of meetings, care coordination because of our contract with our local CCO, it’s opened up a lot of opportunities and it also takes a little bit of time away from some of the field time but being able to coordinate care for people on another level, it’s really opened some doors. So we’ve had a very generous hospital that’s been very supportive of our program. We’ve had a local hospital district, our CCO. So we’re hoping to grow and expand back again through our continued work. And people are starting to know more about these programs and that’s been incredibly helpful.

Miller: Jessica and Sabrina, thanks very much.

Ballew: Thank you,

Marcum: Thank you.

Miller: Jessica Marcum is the community paramedic, part of the Umatilla County Fire District #1. Sabrina Ballew is the Mobile Integrated Healthcare Manager at Mercy Flights.

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