Brief State Definitions and Coverage of Community Paramedicine

Community paramedicine is a form of mobile integrated health care service that uses the medical expertise and specialized training of EMS clinicians to connect patients with non-urgent needs to primary and preventative care. Ambulatory transport, emergency department visits, acute care and hospitalizations and hospital readmissions are often costly to individuals and to states under Medicaid coverage. Research has shown community paramedicine may reduce costs to the health care system, and some states are pursuing this strategy to ensure residents have access to the services necessary to manage their health conditions.

Inadequate access to primary care services is often due to long travel times, limited medical providers and limited appointment availability. These challenges can lead to an overuse of emergency department services. Research suggests that crowding in emergency departments may lead to delayed service delivery and poor quality care, while overuse and overreliance on emergency departments may lead to unnecessarily high costs and gaps in care coordination.

The primary responsibility of EMS providers is to stabilize patients in crisis and transport them to emergency health care services for treatment. Community paramedicine reinforces the role of EMS clinicians as partners in public health and community health delivery. Community paramedics may provide a variety of services, including:

• Providing and connecting patients to primary care services.
• Completing post-hospital follow-up care.
• Integrating health care services and data collection with local public health agencies, home health agencies, health systems and other providers.
• Providing education and health promotion programs.
• Providing services not available elsewhere in the community.

State Definitions of Community Paramedicine

States often frame community paramedicine differently, either through the definitions they set in statute, or by the parameters set on community paramedicine programs. Some states include components of community paramedicine within their state statute regarding EMS. Examples of components include:

• Alternative destination: States define an alternative destination as a lower-acuity facility that provides medical services, including, but not limited to, health centers, physician offices and behavioral health care facilities. Alternative destinations often exclude critical care hospitals and emergency departments. States may use community paramedicine programs to allow EMS clinicians to transport a patient to an alternate destination, ensuring they receive the appropriate level of care.
• Treatment without transport: States define "treatment without transport" as a service provided by emergency medical services where the patient does not require ambulance transportation. In these cases, the guidelines for triage are noted in the code, and authority lies with the paramedic. States may leverage community paramedicine programs to allow EMS clinicians to treat a patient without transporting them to another facility and be reimbursed for the care they provide on-site.
• Telehealth: States define telehealth as a virtual mechanism of connecting providers with patients. Some states use community paramedicine programs to facilitate telehealth for older adult patients.

The definition of community paramedicine varies from state to state. Several states use the term "community paramedicine" or "community paramedic services" to define the program within their state code. Definitions often include providing care to patients who "do not require ambulance transportation," patients who require "episodic care," providing access to preventative treatments and post-discharge follow-up treatments. Definitions also include requirements and parameters for community paramedic education, training, licensure, certification and scope of practice.

• Alabama defines community paramedicine as the "provision of episodic care, patient evaluation, advice and treatment directed at preventing or improving a particular medical condition, within the scope of practice of the emergency medical services personnel."
• California sets standards for community paramedicine programs, including providing short-term post-discharge follow-up care for patients recently discharged from a hospital.
• Utah defines community paramedicine as medical care provided to a patient who is not "in need of ambulance transportation or located in a health care facility."

Other common themes include providing patients with evaluation and "medical advice" while also connecting patients with primary care providers for further treatment. Some states also incorporate elements of telehealth into their community paramedicine programs.

• Hawaii required the department of health to establish and administer a community paramedicine program, including guidelines, partnerships and the employment of telehealth to enhance access and improve patient experience.
• Tennessee defines its community paramedicine program as a service that provides patients with "evaluation, advice, treatment directed at preventing or improving medical conditions." The program also facilitates referrals to other community resources.

States also use the term "mobile-integrated health care" when establishing community paramedicine programs. Mobile-integrated health care is defined as patient-centered health care services often utilizing mobile resources in an out-of-hospital environment provided by a wide array of health care entities and practitioners by the NAEMT. Mobile integrated health care (MIH) is commonly associated with community paramedicine with many programs referred to as MIH-CP programs. Since MIH programs employ other health care professionals besides EMTs and paramedics, some states have overarching chapters addressing MIH in their statutes. Details regarding community paramedicine programs can be found in those chapters.

• Massachusetts defines the state's community EMS program under the chapter regarding mobile integrated health care as a program developed to use EMS providers to provide community outreach and assistance to residents.
• Connecticut uses mobile integrated health care to develop a program to provide medical evaluations, treatment, transport or referrals under non-emergency conditions by a paramedic.
• Missouri includes elements of MIH, including establishing protocols and supervision standards regarding collaboration between community paramedics and other health care professionals. Community paramedics are allowed to provide mobile care according to the health care plan developed by the patient's physician or nurse.

States may also refer to community paramedicine programs by other names, including community health aide programs. Some community health aide programs provide health care access in tribal communities. These programs operate similarly to community paramedicine programs; however, like MIH programs, they employ different professionals, such as nurses or physician assistants, as the aides. Some states also operate a community EMS program where EMS clinicians work within their scope of practice to provide community outreach and assistance to residents and work towards injury and illness prevention within the community.

• Alaska implemented a community health aide program to provide primary care, behavioral health care and dental care to rural and native communities.
• Washington defines a community health aide program as a program that trains and certifies a tribal health provider who can perform a wide range of services within their scope of practice for the community.

Coverage and Payment

Coverage and payment for community paramedicine programs vary from state to state. Services provided by community paramedics are eligible for coverage by both Medicaid and private insurance.

Minnesota reimburses certified community paramedics and community EMTS through Medicaid for certain services. For example, services for patients who were seen at the emergency department three times within a four-month period or for patients who were identified by a primary care provider to prevent readmission. Maine sets different reimbursement rates for services provided by community paramedicine programs in rural communities, and the state allows reimbursement of treatment without ambulance transport. Georgia, among other states, allows commercial insurers to reimburse for community paramedicine billed under the code for ambulance response and treatment without transport.

Similar to how states use components of community paramedicine programs to define their services, states also provide coverage of specific components of the program. Some states, such as Arkansas, Kentucky, and Virginia, reimburse ambulance providers for additional components of community paramedicine that were previously not reimbursed. These services include telehealth, treatment without ambulance transport, and transport to "non-hospital" destinations.

As the number of community paramedicine programs continues to grow across the country, states continue refining the definition and scope of such programs and implement strategies to reimburse for services provided by them.