Growing Role of Paramedics in Home Care
September 8, 2014 10:40 AM
NAHC’s National Council on Medicaid Home Care has observed a growing trend of paramedics serving in home care. In some states, paramedics have begun to compete with home care companies for business traditionally provided by agencies, while in Minnesota, Medicaid has begun to pay for paramedics to provide these services. The following is a synopsis of developments of paramedics in home care in Minnesota, Colorado, Texas, Massachusetts, and North Dakota.
While Emergency Medical Technicians (EMTs) and paramedics both work in emergency medical services (EMS), paramedics, while less common, typically have significantly greater course requirements. For more details on the differences, click here.
In Minnesota, paramedics provide certain home care services through the community paramedics program. A community paramedic (EMT-CP) is someone who is certified as an EMT-paramedic (EMT-P), but also meets additional service, educational, and otherrequirements. Minnesota also has certification requirements for EMTs, AEMTs (Advanced Emergency Medical Technicians), and paramedics. For certification requirements specific to community paramedics, see here and here.
Payment. In April 2012, the Minnesota Governor signed into law Minnesota statute 256B.0625 Subd. 60 for Community Paramedic Services, which provided Medicaid reimbursement for such services. In order to receive payment, these services must be provided as part of a primary care provider’s care plan, and must be billed by a Medicaid provider that is contracting with the community paramedic. Further, the community paramedics’ services must be “coordinated with other community health providers and local public health agencies, and the care plan must “not duplicate services already provided to the patient, including home health and waiver services.”
Community paramedic services reimbursable by Medicaid “shall include health assessment, chronic disease monitoring and education, medication compliance, immunizations and vaccinations, laboratory specimen collection, hospital discharge follow-up care, and minor medical procedures approved by the ambulance medical director.” While some of these services, like chronic disease management, seem to indicate services traditionally provided by home care companies, others, like immunizations and vaccinations, do not. Services that are not Medicaid reimbursable include: facility fee, mileage, services related to hospital-acquired conditions or treatments, and travel time.
For specific rates, see Minnesota’s Community Paramedic Services State Plan Amendment, approved February 2013, here.
According to Kathy Messerli, Executive Director of Minnesota HomeCare Association (MHCA), MHCA met with the Minnesota Department of Health in late August, and have asked for clarification regarding what home care services can be provided without a license (for EMTs and home care agencies). MHCA has also heard that there may be some interest in having fire fighters provide services in the homes as well, which raises questions as firefighters don’t report to a physician as EMTs do. Minnesota’s Department of Health is researching the issue and will get back to MHCA with next steps.
The Council spoke with Ellen Caruso, Director of Government Relations for the Home Care Association of Colorado, for her thoughts on the developments of EMTs and paramedics in home care in Colorado. The following is a synopsis of that discussion.
Background. Under Colorado law, any entity that provides home care (medical or non-medical/personal) has to be licensed as a home care agency. EMTs and paramedics had been providing home care services in Eagle County for a long time through companies such as Eagle County Paramedic Services. Currently, a Colorado statute offers a home care license “with conditions” option for such companies. Ms. Caruso stated that 4-5 paramedic companies now have opted for such a license. Eagle County Paramedic Services, after meeting with the Department of Health, became fully licensed as a home care company.
Ms. Caruso has noticed that others perceive the value that EMTs and paramedics could provide in home care. Normally, EMTs transport those frequently admitted to hospitals to the hospital sometimes as often as 2-3 times a week. Ms. Caruso stated that often these people do not need to go to the hospital, but the EMT cannot make this decision. She stated that some people think it makes sense from a policy standpoint to have EMTs providing certain services at home, such as being able to remind high-utilizers of ED and hospital services to take their heart medicine and treat wounds.
The Home Care Association wants all providers of home care, including EMTs and paramedics providing in home care, to be fully licensed as a home care agency in Colorado. Licensure already exists for medical home care (nursing) and non-medical home care (personal care). Ms. Caruso approached the Department of Health, as well as other stakeholders, and suggested a third level of home care licensure that home care agencies could partner with EMTs and paramedics.
Reception to New Licensure Proposal. The Department of Health favored the idea of a third level of home care licensure, as did the 4-5 EMT and paramedic groups mentioned above that had a conditional home care license. In addition, the groups favored a new credential of a community paramedic, which would include educational requirements in nursing and emergency services. The largest opposition to these efforts came from the firemen. Fire stations, who openly say they provide hospice, home health, shots, and wound care, were resistant to these licensure efforts. They wanted to continue to provide such services without the requirements of licensure.
Status of Legislation. Following stakeholder meetings, last year, a Colorado legislator wrote a bill that was not introduced. The Home Care Association wanted to include a third level of licensure. As the firemen opposed this legislation, the legislator stated that they would pick up the issue again this year. Ms. Caruso stated that there are plans to submit a new bill in the next legislative session.
Reimbursement. Ms. Caruso stated that while emergency medical services in home care is currently not reimbursed by Medicaid, she stated that Medicaid and hospitals might support such reimbursement as this service would reduce re-admissions to hospitals and improve care coordination with managed care companies.
CMS Innovations Pilot. In order to reduce costs and improve the quality of care for those with cardiovascular disease, The Centers of Medicare and Medicaid Services, through its Innovations Center, granted a three year, $1.7 million grant to southwest Colorado. This grant, beginning in May 2012, provides early-detection telemedicine and remote consultations for this population, which includes using paramedics to provide urgent care transports and follow-up in home visits. The grant calls for the training of 25 paramedics and telehealth clinicians, and is estimated to reduce healthcare costs by $8.1 million. For details, click here and here.
MedStar Emergency Medical Services (MedStar EMS) started its Community Health Program in July 2009, where it identified high needs patients and developed care plans for these patients. One key element of these care plans were “regularly scheduled home visits” by MedStar’s Mobile Healthcare Providers (MHP). The Mobile Healthcare Provider would conduct a medical assessment, and verify that the patient is in compliance with taking her medications and in contact with her primary care provider.
Since then, MedStar EMS has implemented several programs joining EMS and home care services. In its Home Health Partnership, MedStar EMS provides after-hours episodic care for Klarus Home Care’s patients. MedStar EMS’ EMS Loyalty Program provides regular home visits to high emergency department or 9-1-1 utilizers. MedStar EMS’s CHF Readmission Avoidance program provides home visits to those who are a greater risk for re-admission to a hospital for CHF. The MHP in this instance also serves to coordinate the patient with her primary care physician, and to provide education on care management. The MHP also can coordinate in-home diuresis with the primary care physician.
For details, click here.
According to the Boston Globe, EasCare LLC of Massachusetts has developed a pilot program to expand the paramedic role into the home for residents of Eastern Massachusetts. Services include treating acute issues associated with chronic diseases like congestive heart failure and diabetes, as well as those with injuries from falls, infections, and minor wounds. In its pilot, it will partner with Commonwealth Care Alliance (CCA). EasCare will train 10 paramedics in home care, and will rely on referrals from CCA to provide services to 2,000 of CCA’s patients. According to Dr. Toyin Ajayi, hospitalist medical director and director of transitional medicine at Commonwealth Care Alliance, the pilot “fits our need to provide comprehensive, home-based care 24 hours a day.”
While the Boston Globe stated that this pilot program is scheduled to launch on October 1, James Fuccione, the Director of Legislative and Public Affairs from the Home Care Alliance of Massachusetts, stated that the program has only recently been approved. Fuccione states that the Home Care Alliance of Massachusetts is working with the Department of Public Health and still evaluating the pilot, but states that “there is room in the continuum for paramedicine as long as it works alongside home care in a collaborative, team-based approach and not as a substitute for it.”
Payment. While Mr. Fuccione has not seen the actual pilot proposal, to the best of his knowledge, Commonwealth Care Alliance is partially paying for the pilot, and EasCare is claiming the model is being carried out at a loss to them.
For details, click here and here.
To see Commonwealth Care Alliance’s press release, click here.
In April 2013, North Dakota passed a law that directs its Legislative Management department to “study the feasibility and desirability of community paramedics providing additional clinical and public health services,” and also the “ability to receive third-party reimbursement for the cost of these services.”
Home care agencies should lobby their state associations to continue to monitor paramedics encroachment into home care services, and make sure that if they obtain Medicaid reimbursement, it is done in a way to not compete with agencies for these finite resources. Further, the agencies and forums should ensure that all stakeholders are working together to provide high quality services without redundancies. To ensure a qualified and reliable workforce, the Council supports requiring community paramedics that provide non-emergency services in the home to meet regulatory and licensing home care standards. For details, see page 44 of the Council’s 2014 policy blueprint, here.
Home care agencies should continue to keep up to date with developments of paramedics in home care, and to contact the Council with any questions or concerns.