In 2015, Michigan’s Washtenaw County and Livingston County were facing a crisis — patients in the area had come to rely heavily on the 911 system and ambulance transportation for non-urgent medical needs. The county had grown by 24 percent over the past 22 years, but 911 medical calls had increased by 98 percent in that same amount of time. Emergency transports increased just 35 percent while non-emergency transports increased a whopping 400 percent.

Key leaders recognized and responded to this trend: Mike Mikhail, M.D., Senior Vice President for Envision Physician Services, Dale Berry, then President and CEO of Huron Valley Ambulance, Michael Baker, M.D., FACEP, Director of Telehealth at Emergency Physicians Medical Group, an Envision Physician Services provider, and Robert Domeier, M.D., emergency physician at St. Joseph Mercy Health System and Emergency Medical Services (EMS) Medical Director for the Washtenaw/Livingston Medical Control Authority (MCA).

Together, these leaders facilitated a partnership between Envision Physician Services, Huron Valley Ambulance and St. Joseph Mercy Health System to create the Washtenaw/Livingston MCA Community Paramedic (CP) program, the first in the state of Michigan to provide care via 911 intercept.

Improving Population Health and Adding Value to Care

According to Dr. Baker, the CP program prevents transfers for nursing home patients and preventable visits to hospitals for low-acuity cases by addressing common issues that would require transport to emergency centers under normal circumstances. “We saw that a lot of the time, nursing homes were calling 911 because a patient was having issues with their feeding tube. In a case like that, the CPs can prevent the patient from potentially losing that tube and having to visit emergency care to have it reinserted,” Dr. Baker said.

The program also creates an opportunity for underinsured and uninsured patients to save on medical costs. Of the 1,200 patients that the program has served, nearly 34 percent were insured by Medicare or Medicaid, and nearly half had no insurance coverage. For these patients, the program has served as a less costly alternative to emergency care.

Maintaining a Commitment to Care Quality

The program prepares experienced paramedics to become CPs by providing 262 hours of additional training in evaluation and treatment according to established care protocols. CPs also receive support from an Envision Physician Services’ TelEmergency physician.

With Envision’s telehealth system, the medical control physician is able to confirm the CP’s evaluation via two-way video and determine a further course of care for the patient, including whether or not the patient is in need of transport to an emergency care facility.

The program also provides state-approved utilization protocols to 911 dispatchers, protocols which Dr. Domeier developed. If a dispatcher determines that a patient meets the protocol requirements, the dispatcher gives the patient the option of receiving care from the community paramedic instead of a standard transporting ambulance.

In addition to Envision Physician Services’ telehealth technology, CP vehicles are equipped with all state-required paramedic equipment plus additional supplies and equipment required for CP protocols, such as kits for blood and urine testing, catheter equipment and medications such as antiemetics and antibiotics.

Moving Forward

“We want to expand this program so that more patients can access the value there,” Dr. Baker said. The program currently operates with just one 24-hour unit and two 12-hour units, and one of those 12-hour units was just added earlier this year. Despite these limited resources, the program has been able to treat more than 1,200 patients since its inception.

The biggest roadblock to the program’s expansion? Funding.

While currently funded under CMS’s Emergency Triage, Treat and Transport (ET3) model, the five-year performance period of this iteration of the model is coming to a close. As such, the program is currently pursuing additional reimbursement models, including private payor reimbursement, CMS’s bundled payments for care improvement initiative (BPCI), and the next iteration of the ET3 program scheduled to begin in the spring of 2020.