Interview with Ron Quaranto, COO of Cataldo Ambulance Service, Inc. and Vice President of the Massachusetts Ambulance Association
What is community paramedicine?
The initiative behind community paramedicine is to provide quality care to high-risk patient populations (e.g. congestive heart failure, pneumonia, MI, etc.) at a controlled cost. We want to avoid unnecessary ambulance rides, ER visits, hospital admissions and observation when a patient does not necessarily require all that additional care and expense, and could simply receive some type of intervention and management in the home environment. That is a driving force behind community paramedicine.
How did Cataldo begin its community paramedicine program?
When community paramedicine became a hot topic here in Massachusetts, about half a dozen ambulance services lobbied the state to allow for a special project waiver in order to trial community paramedicine. Massachusetts regulations, the way they are currently written today, do not allow ambulance services to treat and not transport. With community paramedicine, we want to treat patients at home and preferably leave them at home with good treatment. Both Cataldo and Eascare Ambulance Service were successful and were granted a special project waiver. In order to get the waiver we needed to have a partner, and Cataldo chose the Beth Israel Deaconess Medical Center to do our trial with.
Tell us about Cataldo’s community paramedic program.
About three years ago, we began the development of our program, SmartCare. Our approach, unlike other community paramedic programs out there, was not to use our existing ambulance fleet, but to instead use dedicated vehicles and clinicians who are specially trained in providing care for the high-risk, more complex patient populations. The vehicle we use is not an ambulance – it does not have lights or a siren. It is a minivan style vehicle that is fully equipped at the ALS level, so paramedics have everything that an ambulance has (all of their equipment, intubation, IV, medication, etc.) but in a non-emergent vehicle. The vehicle also has advanced technology with teleconferencing and data sharing, and a modem so laptops can connect wirelessly and transmit that data.
While there are other agencies out there, like home care agencies and visiting nurses associations, which are all incredibly valuable and which we work very closely with, our program is slightly different. We do different interventions and have different skill sets. We have identified vehicles and community paramedics who are specially trained to do advanced treatment on these particular patients. When we identify a patient in need (meaning a patient who does not require 911 services but does require some attention), we deploy the community paramedics. They go to the home, evaluate the patient, and in the end make a determination on whether or not the patient can remain at home or should go to another healthcare facility, be it an urgent care center, the ER, or the primary care physician’s office. All treatment and evaluation is done based on pre-established protocols that we’ve collectively developed with the care team so they know what intervention they can do and at what points they need to stop and consult with the care team. There is always a high-end interaction between our community paramedics, the ordering nurses, and the primary care physicians, and the community paramedics are able to do a lot of data sharing, such as the electronic patient care report, test and lab results, etc., right from the patient’s home. We also have the ability to utilize teleconferencing, so we can bring the physician or nurse face-to-face with the patient for follow-up on a specific issue.
Another value of the SmartCare program is that our communication center is available 24 hours a day, 7 days a week. Most healthcare facilities/institutions have systems in place that are available during the day, but are not necessarily available during evenings, nights and weekends. These are the times when there is a demand and the limited availability of care causes people to call an ambulance and go to the hospital when they may not need to. By having SmartCare’s resources available at these times, community paramedics can go directly to the patient, evaluate him or her, and then make the decision on whether or not the ER is the correct destination, or if he or she can remain home and avoid the expense and stress. Patients usually do not want to go out and sit in the ER waiting for what is often a minor diagnosis, and then come home faced with copayments and other bills. Being able to see a healthcare provider in the home setting and get the same results, in many cases, saves patients both time and money and allows for a better quality of life.
Does SmartCare have any patients scheduled for regular visits?
Unfortunately, one of the things that the special project waiver prevented us from doing was that proactive approach. We want to identify patients who are considered high-risk and enroll them in our program for regular evaluations, both in-person with a community paramedic as well as over the phone. While this proactive approach is an integral part of community paramedicine, we’re not allowed to do it yet, though we’ve requested to and I’m confident we will be granted the ability to once regulation is rewritten for community paramedicine here in Massachusetts. Massachusetts has only recently signed Mobile Integrated Health into law and the state, along with the Department of Public Health, created an MIH workgroup to finalize the regulations and protocols under which community paramedics will practice. Once that is complete, we will have the ability to treat patients both proactively, prior to them in need, as well as more urgently should they have a situation that requires immediate attention but not emergency 911 response.
Was it difficult to get the special project waiver? Was it a long process?
It really was quite challenging. It was new and there was a lot of pushback from some of the outside agencies who felt threatened that we were going to take away from their responsibilities – their patients and their transports – which certainly wasn’t the case and has proven not to be the case. We’re looking to work collaboratively with these other services. Even though Cataldo is a transportation provider, we made it clear from the beginning that our intent is not to provide all the transportation, even for the patients who may need it. For a community where Cataldo is not the provider, we call that community’s provider to make sure they maintain the transport. Though the intent behind our program is not to steal transportation volume and revenue, it was a little bit challenging to convince everyone. It took quite a few presentations for the leadership to grasp community paramedicine here in Massachusetts. It’s still a work-in-progress, but we’re confident that in the next six months or so we’ll be fully operational without special project waivers.
As for the timeline of the process, it took about a year of presentations, meetings and development. We submitted our initial request in November 2013, and were issued a special project waiver which ran from October 2014-November 2015, and then were granted an extension until regulations are finalized.
Since the program began, have you received any feedback from those outside agencies that were originally pushing back?
Yes, we’ve had great responses from both the municipalities and the other mobile healthcare agencies. We’re required by the state to report monthly on our interactions, and so far we’ve had great patient outcomes and all indications are that everyone is very pleased with the special project waiver, hence why they are moving forward with more formalized regulation. With ACOs being developed and new regulations that manage hospital readmissions, the SmartCare program has been a good thing for everyone – we can all control costs better while maintaining the quality care that patients deserve.