Beyond 911: Expanding the Primary Care Role of First Responders through Community Paramedicine

6/29/2022

Paramedic photo

The lack of access to providers and services, particularly in rural areas, may lead to higher emergency department and emergency medical services (EMS) utilization, which can be costly to individuals, hospitals, and the state. Research estimates that between 23% and 39% of 911 calls in eight cities in 2020 were low priority or nonurgent—meaning they were related to quality-of-life or other low-priority incidents that may not require a time-sensitive response. To reduce 911 calls, emergency room crowding and hospital readmissions, state policymakers are seeking opportunities to increase access to appropriate, cost-effective care for patients with nonemergency or nonurgent health needs. Community paramedicine is one potential option for connecting such patients to primary care and other support services

What is Community Paramedicine?

Community paramedicine, as a form of mobile integrated care, is one potential option for connecting patients to with nonemergency or nonurgent needs to primary care and other support services. Whereas the primary responsibility of EMS providers is to stabilize patients in crisis and transport them to emergency health care services for treatment, community paramedicine enhances the role of EMS providers as partners in public health and community health delivery.

The International Roundtable on Community Paramedicine defines community paramedicine as “a model of care whereby paramedics apply their training and skills in ‘non-traditional’ community-based environments, often outside the traditional emergency response and transportation model.” A community paramedic is typically a licensed EMS professional—such as a paramedic or emergency medical technician—who completed an appropriate educational program and has demonstrated competence in the provision of health education, monitoring and services beyond the roles of traditional emergency care and transport.

To improve access to care and coordinate community services, community paramedicine addresses four main priorities:

  1. Emergency medical response.
  2. Multiagency collaboration.
  3. Patient-centered prevention.
  4. Education programs.

Community paramedics 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 Community Paramedicine Laws

To better address the health care needs of residents and reduce health spending, states are exploring strategies to implement community paramedicine and expand the roles of EMS professionals. Strategies include examining scope of practice, reimbursement for community paramedicine services and allowing alternative destinations for transport.

Scope of Practice

A practitioner’s scope of practice is the defined parameters of duties or services that a credentialed individual may provide, typically determined by state statutes or rules. Several federal agencies and organizations—such as the National Highway and Transportation Services Administration, the National Consensus Conference on Community Paramedicine and American College of Emergency Physicians—suggest that not every EMS professional action needs to be clearly defined in scope of practice. Community paramedicine is an expanded role for EMS professionals but aligns with their training and does not present new procedures or medications. Even so, at least 45 states have a statewide community paramedicine scope of practice defined in statute, rules or protocols.

United States and Terriorities of Community Paramedic Scope of Practice

State examples of community paramedicine scope of practice legislation include:

Arkansas (2015 Ark. Acts, Act 685) established a licensure program for community paramedics with a defined scope of practice. Community paramedics must complete two years full time as a paramedic, complete a community paramedic training program from an accredited college or university and meet certain clinical training requirements. Community paramedics may coordinate community services, monitor chronic disease, assess health status, conduct hospital discharge follow-up care, collect laboratory specimens and manage medication compliance.

Maine (Me. Rev. Stat. Ann. tit. 32 §84.4) allowed the board of emergency medical services to pilot 12 community paramedicine programs in 2012 to provide patient evaluation, advice and treatment to prevent or improve a medical condition within the scope of practice of the emergency medical services provider. Following the success of pilot programs to integrate and coordinate care for patients with chronic conditions who are at high risk for unnecessary emergency department visits or re-hospitalization, the program was made permanent in 2017 (HB 981).

To learn more about community paramedics’ scope of practice, visit NCSL’s Scope of Practice Policy Legislative Database.

Reimbursement

There is increased interest from private and public payers in community paramedicine models as an opportunity to reduce costs, improve care quality and improve population health. States may provide reimbursement for community paramedicine services through pilot or grant funding, Medicaid reimbursement, commercial reimbursement or provider partnerships.

At least seven state Medicaid agencies—including Arizona, Georgia, Hawaii, Minnesota, Nevada, Oregon (during the COVID-19 emergency) and Wyoming—reimburse for community paramedicine services. At least 14 states provide reimbursement for EMS treatment of patients without transport to an emergency department.

As of 2022, at least 21 states required reimbursement across public or private payers for community paramedicine, and the number of community paramedicine programs across the country continues to grow.

United States and Terriorities of Reimbursement for Community Paramedicine

Alternate Destinations

Community paramedicine programs may help decrease demand on emergency department resources by triaging patients in the field and transporting the patient, with consent, to an alternative destination. At least seven states—Arizona, California, Delaware, Illinois, Louisiana, New Mexico and Ohio—allow patients to be transported by EMS services to alternate destinations, such as primary care clinics, general medical clinics, urgent care centers or other social or psychological services.

Concerns exist regarding the under-triage and transport of patients requiring emergency care to alternative destinations. Proponents suggest additional training—such as community paramedicine certification—and medical director supervision may ensure patients are accurately triaged and assessed for transport to primary care, urgent care or other social or psychological facilities.

Arizona’s Treat and Refer Recognition Program, created through a Medicaid state plan amendment in 2016, allows emergency care providers to determine the appropriate destination to transfer a patient, provides reimbursement for ambulatory services without transportation to a hospital or other health facility, and creates community paramedicine training for providers.

Louisiana (La. Rev. Stat. Ann. 40:1131(4)(a)) allows an ambulance provider to transport an individual to an alternative destination with the individual’s permission and only if their conditions does not meet the definition of an emergency medical condition.

Federal Action

At the federal level, the Centers for Medicare and Medicaid Services (CMS) created the Emergency Triage, Treat and Transport (ET3) program in 2019 and selected its first round of 205 applicants in 2020. ET3 is a voluntary, five-year payment model that provides greater flexibility to ambulance care teams to transport a Medicare Fee-for-Service beneficiary to a hospital emergency department or other covered partner, such as a primary care office, urgent care clinic or community mental health center. In addition, ambulance care teams will be able to initiate and facilitate treatment either at the scene of a 911 emergency response or via telehealth.

During the COVID-19 public health emergency, CMS allowed EMS to be reimbursed for transporting patients to any destination that is able to provide treatment consistent with EMS protocols, including any alternative site part of a hospital, critical access hospitals, community mental health centers, urgent care facilities, ambulatory surgery centers or any location providing dialysis services

NCSL Resources