Fire-Based EMS: The Shift Toward Community Integrated Paramedicine

Firefighters are called upon to do many things. Similarly, each fire department and fire district has to function as an all-hazards response agency, and will be expected to handle whatever emergency comes its way.

For us, the only constant seems to be change. So we have two options: Either fight changing times and go the way of the dinosaur, or adapt and embrace the opportunities that change brings us.

That being said, change is hard. When I hired onto the Tucson, AZ, Fire Department in 1979, I remember one captain in particular who complained about having to wear “worthless turnout bunker pants.” He was an old-school “fireman,” and also constantly expressed dismay that the “nurses”—certified emergency paramedics—were taking over his profession. He has since retired, and I don’t think he would even recognize the fire service as it is in 2016, and all that modern firefighters are asked to do.

Current and coming changes

Those of us lucky enough to have served in the fire service over the past 35 years have seen firsthand how an entire profession can change—and why our already-diverse industry must evolve once again. But for us, change doesn’t just mean “doing things differently.” Often, it means that our profession needs to re-evaluate and expand its very mission in order to serve a community that is itself rapidly changing.

For years, retired Chief Dennis Compton, who served with the cutting-edge Phoenix Fire Department and with the Phoenix-area Mesa Fire Department, has spoken about the change that our profession has seen, and adapted to, from our very beginning. We started out simply fighting fires but then expanded into the fields of EMS, hazmat response and technical rescue. In the past 20 years, the fire service has also moved into drowning and injury prevention, as well as domestic terrorism preparedness. Most fire service organizations also push the use of seatbelts and child car safety seats. These changes all met, and continue to meet, the changing needs of the communities we serve.

New social changes and demographics tell us that we in the fire service must evolve yet again. Healthcare costs are out of control. Government-mandated programs have changed the way people acquire and use health insurance. And the Patient Protection and Affordable Care Act (PPACA, aka Affordable Care Act) is looking at the value-based payments—the soon-to-be-famous “triple aim” of health care: improving the experience of care, improving the health of populations, and reducing per-capita costs of healthcare.

According to the U.S. Census Bureau (2014), there are 76.4 million Baby Boomers—those born between 1946 and 1964—who are, or soon will be, an age that will require more frequent and specialized medical care. So now we have the impetus to change how we deliver our service.

Over the years, the three E’s of fire prevention—Education, Engineering and Enforcement—have helped reduce the actual working-fire response to 4.6 percent nationally (NFPA 2012). Now the U.S. branch of the Institution of Fire Engineers, partnering with the NFPA, has started another new and innovative program: Vision 20/20. The effort focuses on prevention and Community Risk Reduction (CRR).

CRR is another visionary program that supports prevention activities at all levels in the communities we serve. CRR asks us all to look at our overall community to identify what we can do to reduce the impact of fire, perhaps by placing smoke alarms in homes, educating communities about fuels reduction or even examining how we reduce emergency calls in our communities. I applaud Vision 20/20 project manager Jim Crawford and the many others who have made CRR a viable and relevant national program.

Introducing CIP

The new wave that the fire service must get comfortable riding is Community-Integrated Paramedicine (CIP), or as some call it, Mobile Integrated Healthcare (MIH). We have hit the tipping point, and there is now nationwide interest in the role the U.S. fire service plays as the “gatekeeper” to EMS.

When I became interested in this concept in 2010, the phrase commonly used was “community paramedic”—a term that has been trademarked by the North Central EMS Institute. So when the Rio Rico Medical & Fire District (RRMFD) in Arizona applied for a grant from U.S. Health and Human Services, we used the phrase “Community Healthcare Paramedicine” (CHP).

In 2014, the Arizona Department of Health Services put together a steering group referencing “Community Integrated Paramedicine.” This is a term I support because, for an approach to be successful, it must be truly integrated into the overall resources of each community. The term “integrated” has gained traction throughout Arizona and, fortunately, integration is one of the things the fire service does best.

Rio Rico’s program

Started in 2014, Rio Rico’s pilot project focuses on helping participants manage their medical conditions so that they don’t have to return to the hospital or call 9-1-1 often. Our CIP teams consist of a firefighter emergency paramedic and a firefighter EMT. Under this model, we first identify high-utilization users from within our 9-1-1 system. Then our CIP teams schedule non-emergency home visits in a proactive attempt to help patients manage their disease or chronic health issues. This seems like common sense, and indeed it is more time- and cost-effective to send a two-person CIP team on a prescheduled visit at 2 p.m. than to dispatch two units of four to six firefighters to a frantic emergency scene at 2 a.m.

During our home visits, we help guide and engage participants in an overall understanding of their health and disease process. We also try to identify the reason for frequent 9-1-1 calls, help the individual identify other healthcare resources that exist, and show them how to access them. In some cases, it may include referring them to mental health services. Connecting patients with healthcare resources is the key.

While at a patient’s home, the CIP team will establish baseline vital signs and conduct a health survey. Working with the well-respected University of Arizona Poison and Drug Information Center, the team also does a “medication reconciliation” to ensure that patients are taking their medications properly and not taking medications that counteract each other.

In the home, the CIP team can do what a doctor cannot (unless he or she makes house calls). Team members gather all the medications in the home, create a comprehensive list and do a pill count, and send in a report to the Arizona Poison and Drug Information Center, which, if necessary, can do a peer-to-peer consult with the patient’s primary care physician. Having the CIP team partner with a professional pharmacist (available via a phone 24/7/365) is priceless.

Our teams also conduct a Home Environmental Survey and Safety Survey. This identifies and mitigates trip/fall hazards, as well as mold infestations or other environmental issues that can adversely impact health. If we suspect mold inside the home, for example, we can work with community resources to make the affected dwelling safe.

Our CIP program is also ideal for follow-up home visits of post-discharge patients from the hospital. In addition to helping patients, it also helps strengthen a hospital’s bottom-line financials, as the PPACA levies penalties against facilities that have patients readmitted within a 30-day period.

According to a study in the American Journal of Managed Care, post-discharge phone calls by a case manager to certain high-risk patients were associated with fewer readmissions. The intent-to-treat 60-day readmission rate for the treatment group was 7.4 percent, compared with 9.6 percent for the control group, which represents a 22 percent “relative reduction in all-cause readmissions,” according to the study.

The intervention group did have more physician visits and prescription drug fills after discharge, which may also account for the reduced readmissions, according to the study.(1)

Golder Ranch Fire District, which serves the Tucson suburb of Oro Valley and its surrounding area, started its own CIP pilot program in July 2014. As part of it, they are examining the rates of patient readmission. Their study is still under way, but first reports are very positive, and I am excited to see what the data reveals.

Rio Rico challenges

When Rio Rico Fire started its CIP program in January 2014, it was the first in Arizona, and one of only a handful of fire-service-based programs in the nation. (Mesa Fire and Medical Department also has some outstanding pilot projects, but they are not using firefighters exclusively, and are not calling their service providers CIPs. The Mesa project, which is quite progressive and highly successful in its own right, uses certified physician assistants.)

Rio Rico is a beautiful place to live and work, but there are challenges. We are located about one hour south of Arizona’s second-largest city of Tucson, and less than 15 miles from the U.S.-Mexico border. Our district serves a population of about 11,000 in a 42-mile-square service area. Thousands of other Rio Rico residents live in our primary mutual-aid area, which encompasses an additional 119 square miles.

We are located at the start of the CANAMEX trade corridor, which transports up to 85 percent of produce imported into the United States and Canada each year. As such, RRMFD protects more than 55 large produce warehouses, but the vast majority of our service area is in a rural setting, where residents are woefully under-resourced in regard to healthcare.

Rio Rico has 22,000 residents, and the ratio of PCPs to population is less than 50 percent of the state average. Moreover, a lack of public transportation means that it is challenging for patients to get to those scarce medical resources. Rio Rico has no public bus system, or specialized transport services to help our aging population get to doctors’ appointments. Additionally, higher-level specialized medical patients must be transported 60 miles north to Tucson.

Rio Rico successes

Rio Rico’s CIP program is just over 21 months old, and we are still gathering data on our patient-satisfaction surveys and call outcomes for 2014. So far, we have had a 100 percent customer-satisfaction response. To us this means that using a non-traditional CIP team is filling a gap in our community, and that we are making a difference in the lives of our citizens.

Our program has already saved the overall response system, and RRMFD, money as well. In just six months, one participant reduced her 9-1-1 calls and emergency room visits by 50 percent. This saved the healthcare system money, and also equates to less fuel used, and less wear-and-tear on our response units and first responders themselves.

In another case, we found local physical-therapy resources for a patient, this after medical providers told her that PT services were only available in Tucson. This saved her hours of driving time, reduced her stress, and kept her at home—off the streets and less likely to be involved in a motor vehicle accident. She hugged our CIP team members when she found out she did not have to travel.

At one particular medication reconciliation, we encountered a patient who was taking several anti-depressants, prescribed by five different physicians. This would likely never have been caught, but because our CIPs visited her at home, it was found, reported and corrected. Sometimes we are the “eyes and ears” of the primary care physician.

One of the more pleasant yields of this effort is that a calm, prescheduled home visit is a very different environment than an emergency response generated by an anxious 9-1-1 call. Our teams have time to get to know the individual, and they have experienced firsthand the positive outcomes of this project. They are seeing individuals and their families starting to engage in their own health, and are making lifestyle changes that promote better health outcomes.

Gaining traction

The concept of using certified emergency paramedics (CEP) for proactive healthcare is not new. The practice has been used in other countries, including Canada, England and Australia, and has slowly gained traction in the United States. We currently see programs in a cross-section of our country, including Colorado, Minnesota and Texas. Unfortunately, many other states have been slow in recognizing the potential positive impact of these programs for fire-service-based EMS providers.

Approximately 16 months ago, when I presented on CIP at the 10^th annual International Roundtable on Community Paramedicine, in Reno, NV, I was the only speaker representing fire-service-based EMS. All other participants hailed from the private sector, including ambulance companies and healthcare providers from across the nation. Word had apparently not gotten out that the fire service should be a major player in filling a healthcare gap in the communities we serve.

Today, in contrast, hardly a day goes by that I don’t get a call or read about another fire agency interested in starting a CIP program. We have hit the tipping point!

Ride the wave

One of the lessons learned during this project is that most people simply do not know the myriad duties that the modern fire service performs. Too many think that the fire department just puts out fires, then sits around and waits for calls.

In setting up any program, we have an opportunity to educate community leaders about today’s modern, all-hazard fires service. We can also point out the distinct advantage the fire service brings to the table, in that our stations are strategically located throughout the jurisdictions we serve—and that in 99 percent of the cases, we already have the trust of community members.

Today’s firefighters must, of course, be proficient in fighting fire. But as data and in-the-field experience repeatedly show, fire calls are only a small percentage of what we do—and that EMS calls make up the vast majority of what our jobs entail.

The U.S. fire service is our nation’s true leader in CRR. Today, firefighters are regularly involved in fire and injury prevention, and so much more. Working proactively to improve the overall health of our communities is another valuable change to our dynamic, constantly evolving profession.

A paradigm shift is upon us. The U.S. fire service has always been good at pulling individuals out of the river—and now, with CIP/MIH, we are now moving upstream to keep them from falling in to begin with.

Our fire-service-based EMS is the all-access gateway into the U.S. healthcare system. We need to accept that reality, and work to make our community partners and professional counterparts aware of the potential to improve patient outcomes.

The need to embrace change and make a positive impact in patient care, to reduce overall healthcare costs and to improve quality of life is the next wave we all need to catch.

1. L. Doug Melton, et. al. "Prioritized Post-Discharge Telephonic Outreach Reduces Hospital Readmissions for Select High-Risk Patients." AJMC.com, 2012. Retrieved from www.ajmc.com/journals/issue/2012/2012-12-vol18-n12/Prioritized-Post-Discharge-Telephonic-Outreach-Reduces-Hospital-Readmissions-for-Select-High-Risk-Patients