As coordinator of Ashe Community Paramedics in western North Carolina, Cody Darnell spends his days calling on at-risk patients in their homes, seeing what can be done to help them manage their medical and social needs.
A trained paramedic, he’ll check their prescriptions, take their blood pressure and listen to their heart and lungs. He’ll make sure nutritious food is in the pantry, and no tripping hazards are in the hallway.
Community paramedicine is fairly new in the United States, but more counties – especially in rural areas – are seeing the benefits.
In North Carolina, 25 of 100 counties have community paramedic programs; 15 other counties are in the planning stages. Five programs are active in South Carolina; five others are being developed. The Duke Endowment has funded seven projects, including Ashe, since 2013.
“With growing concerns about health care costs and overcrowded emergency departments, community paramedicine is proving to be a promising way to connect vulnerable patients to the support and care that can keep them healthier,” says Lin Hollowell, director of the Endowment’s Health Care program area.
In Ashe County, local leaders launched the program to address issues that exacerbate health challenges. The patient to primary care physician ratio in the county is 1,920 to 1, and there are fewer physicians, dentists, nurses, and PAs than the North Carolina average. Sixteen percent of the population is uninsured, compared with 12 percent across the state. It’s among the state’s fastest-aging counties and most economically distressed.
Ashe Community Paramedics began with a pilot in 2018 after an organizational review found that about 45 percent of the 3,000 calls to their EMS each year were non-emergent, but many of those patients were still transported to the emergency department. Sixty patients were found to be frequent users of EMS.
The program is a partnership with Ashe Memorial Hospital, Ashe Medics and Wilkes Community College. The hospital provides program oversight. The community college provides training and certification. Ashe Medics provides onsite supervision and office space.
Cody jumped at the chance to be involved. He and his wife, an RN at Ashe Memorial’s emergency department, have lived in the area all their lives. A paramedic for four years, he saw it as a chance to work with health care and social service providers to help his neighbors.
He spent the first months visiting town halls, fire departments, senior centers and local events. Cody says that community buy-in – “everyone coming together for the common good” – was strong.
‘The Best We Can’
Cody connects with patients through referrals from primary care partners or service organizations. During home visits, he’ll assess their needs and plan for ongoing disease management. He may focus on discharge follow-up and care coordination with new providers. He’ll make sure patients understand their prescriptions and have transportation to check-ups. He walks through homes to look for loose rugs or dim lighting that could lead to a serious fall.
Last winter, he shoveled an elderly woman’s driveway to help her finally get out to the doctor. This summer, he has been helping a cancer patient move out of a trailer that lacks running water. Community paramedics see first-hand that to truly change someone’s health status, you must also address food insecurity, stable and safe housing, literacy, transportation, and interpersonal relationships and supports.
On a recent morning, he looks in on Alfred, a 75-year-old widower with diabetes who lost his balance during a dizzy spell.
“Can you show me where you were when you fell?” Cody asks after checking the man’s blood pressure. By the end of the one-hour visit, he has discussed antibiotics prescribed for an infection, watched Alfred take his insulin, and reviewed healthful food options for breakfast.
As he drives along a steep mountain road to his next call, Cody explains that many of the people he visits live alone in homes that are hard-to-reach and in disrepair, socially isolated because of limited mobility or poor health. Some have recently been in the hospital after a set-back, or they’ve returned from rehabilitation after a fall. Most struggle daily with myriad health and social service needs.
In this rural area, Cody’s visits can strengthen feelings of connectedness and community – which, in turn, can improve health.
After a quick lunch, he checks-in on a woman who suffers from COPD. For the rest of the day, he’ll work the phones, following-up on applications for benefits such as Medicaid or food stamps.
“Thanks to this program, we’re able to put the patient first and do the best we can for them,” Cody says. “It’s all about bridging gaps to keep our neighbors safer and healthier.”
A 2019 evaluation by the University of California, San Francisco, analyzed six community paramedicine projects in California and found improved coordination among providers of medical, behavioral health and social services, as well as reduced preventable ambulance transports, emergency department visits and hospital readmissions.
“The projects have been so successful that other jurisdictions have stepped up to get approval for their own sites,” the evaluator writes.
The Ashe Community Paramedic program is in its infancy, but local leaders are already reporting accomplishments. They’ve purchased and outfitted a special SUV and medical equipment for mobile patient care; the community college has trained two people. Using insights from the pilot, they’re adjusting training procedures to attract more staff for the roster.
Between October 2018 and July 1, 2019:
• 40 patients were referred to the program
• hospital readmission rates fell nearly 41 percent
• emergency room visits and 911 calls dropped 17 percent
• 88 percent of patients were compliant with their medications
• 6 of the 7 referred hypertensive patients were reaching optimal range for blood pressure
The program will continue to track a reduction in admission rates for ambulatory care sensitive conditions and readmission rates for patients referred to the program. They’ll also document improved compliance with prescribed treatment plans and clinical indicators for common chronic conditions such as diabetes, hypertension and heart disease.
Currently in North Carolina, these services are not reimbursable by private or public payers. The Ashe program, and others funded by The Duke Endowment, will use data to show positive outcomes and money saved. Program leaders believe this may boost to payment reform efforts – but for now, they’re hoping to make the case for future financial support from hospital systems and EMS agencies.
Lin B. Hollowell III
Director of Health Care