Paramedics without the ambulance: Missouri tries to reach patients at home, avoid hospital visits

ST. PETERS — When paramedics respond to a crisis, they might be able to spend 10 minutes with a patient.

The visit ends with two options: “We can take you to the hospital, or you can stay here,” said Kimberlyn Tihen, battalion chief of St. Charles County’s Mobile Integrated Health division.

“Then you’re done, and you’re left with all these questions, and you’re making the story up in your mind,” she said. “How did they get to that point? And where did they go after?”

In an effort to smooth out barriers to health care and keep people from getting sick enough to need 911 in the first place, more and more agencies are creating a new class of paramedic, one that regularly visits people’s homes. The house calls bring routine care to patients, connect them with services and prevent emergencies before they hit.

It’s growing in Missouri, and a New York-based company has plans to expand into the state later this year.

“The goals are simple: Make patients better. Keep them out of the hospital,” said Justin Duncan, chief of the Washington County Ambulance District and president of the Missouri EMS Association.

The trend, called community paramedicine, poses an opportunity to get patients care that is more medically and financially efficient than emergency rooms, said Chris Prener, a social scientist and author of the forthcoming book “Medicine at the Margins.” Prener worked as an EMT in New York state from 2004 to 2008.

“You have this connective tissue between where patients are and the health care system,” Prener said. “Let’s use it for more than just bringing patients to the hospital.”

Gaps in health care

St. Charles County was an early adopter in 2016, modeling its program after one in Denver. It launched with a group of 50 patients who, in the previous year, had logged 148 ambulance trips and 100 hospitalizations.

In the year following the program, the numbers dropped to 57 ambulance trips and 53 hospitalizations.

The district estimated that the community paramedics prevented upward of $42,000 in ambulance trips, nearly $6,000 in emergency department visits and $746,000 in hospitalizations, based on the rates Medicare typically pays for those services.

St. Charles County has been growing the program steadily ever since and today has 35 community paramedics.

Early on, some saw community paramedics as a threat to home health businesses. But Assistant Chief David Lewis, of the St. Charles County Ambulance District, said his staff do different things.

“We’re not here to replace or duplicate home health,” Lewis said. “The overarching goal is to fill gaps, not to replace current care.”

In some cases, community paramedics have seen patients who had been judged ineligible for home health and uncovered additional risk factors that allowed them to qualify.

As it stands, community paramedicine is over and above the regular paramedic training. But within five years, Lewis thinks, it could become a part of normal curriculum for all paramedics.

The Washington County Ambulance District started its program after the pandemic hit in 2020. People were avoiding the hospital because of the coronavirus, so the workload for Duncan’s paramedics had slowed down.

The district enrolled 21 patients who were struggling with diabetes. For some, the issue was transportation. Others were reluctant to visit a medical facility because diabetes is a risk factor for COVID-19.

Duncan said all 21 patients’ blood sugar levels improved, and they had zero emergency department visits.

Last year, the program — known as mobile integrated health — logged over 7,000 patient encounters. Duncan eventually wants to expand into maternal and prenatal health.

On a recent morning, Washington County’s first — and so far, only — full-time community paramedic set out into Potosi, a quiet community in the rocky, green hills of eastern Missouri’s mining country. Washington County is located about 70 miles southwest of St. Louis, with a population of just under 24,000.

Bryan “Buck” Buckley’s first appointment of the day brought him to a home a few miles from headquarters, where he was greeted at the porch by a pug named Molly and a Yorkshire terrier named Isaih.

His patient, 69-year-old Reynold Eugene Neff, was waiting at the kitchen table. Buckley greeted Neff and his wife, Judy, and opened his medical case. He started working through Neff’s vitals: a scale to measure his weight, a pulse oximeter clip to gauge his blood oxygen level and then a blood pressure cuff.

Neff, a retired Chevrolet mechanic, had a stroke in July and spent 11 days in the hospital. He’s still struggling with weakness in his legs, but it’s getting better — he can walk up and down the back stairs of the house now. He’s also managing diabetes.

Buckley visits patients on regular schedules. For Neff, he comes by once every few weeks. The Neffs say the program saves them the costs and travel to medical appointments in Festus, more than 30 miles away.

Buckley put a mobile hotspot — a flat, black box with two antennas — on top of a Folgers tub on the kitchen counter and set up a secure video call on a tablet. A community health worker from a local clinic showed up on the screen, and Buckley read off Neff’s vitals to her.

Then they waited for the doctor.

They cracked jokes and talked about Neff’s prescriptions and church. Buckley and Neff sat at the table. Judy Neff leaned against the kitchen counter. The Yorkshire terrier napped at Neff’s feet. The TV chattered in the background.

When the doctor showed up on the screen, Buckley propped up the tablet on the kitchen table. He leaned it against a decorative pumpkin with a proverb written on it: “Trust in the Lord with all your heart.”

‘If I can fix this ...’

Because the community paramedic programs are relatively new, they face a significant financial roadblock: In Missouri, there isn’t a universal system for them to bill insurers.

Washington County’s program is entirely funded through grants, Duncan said, which is financially unsustainable.

“If we can get a reimbursable model, it’ll be in every community across the state, and arguably across the country,” Duncan said.

The Washington and St. Charles County programs are run by local ambulance districts. A New York-based company called MedArrive, which dispatches community paramedics based on referrals from insurers, hospitals and doctors, plans to expand to the Kansas City area this year. It already has programs in New Jersey, North Carolina and Florida.

Some states are beginning to build out their payment models for community paramedicine, said Bryant Hutson, MedArrive’s vice president of business development, but there is still “a lot of work to do.”

The St. Charles County Ambulance District funds its community paramedicine programs through multiple sources. One of its programs, Lewis said, is part of a pilot that allows it to receive the same Medicare reimbursement it would get for a patient transport, minus mileage. For another program, which is geared toward preventing hospital readmissions, it receives fees from hospitals.

“We’ve developed several funding mechanisms,” Lewis said. “When we started, there was no money for any of this.”

Community paramedics’ work often starts with the patient’s nonmedical needs. To treat a patient’s diabetes, for example, it’s important to know if they have access to fresh, healthy food. If a patient has a wound that is healing, they need to have clean, running water.

Tihen, the St. Charles County medic, said now she gets to hear the patient’s whole story, and figure out how problems built up over time. She looks in pantries and medicine cabinets. She meets patients’ family members. She learns what they eat for dinner and at what time.

“It’s like, ‘Oh, that’s why they keep calling 911. That’s why they’ve called us three times at 1 o’clock in the morning,” she said. “So if I can fix this, they won’t call again.”

Tihen recalled one patient she visited, who lived in an independent living community. Paramedics were called because he was wandering the grounds. He didn’t want to go to the hospital, but everyone thought he needed help, so he was referred to the community paramedics.

When Tihen arrived, she looked in his fridge. Inside she found a QT cup and some rotten food.

“We started asking those questions, like a detective: When’s the last time you had a meal? How did you get that meal? Does someone take you grocery shopping?” she said. “You wouldn’t believe the number of patients that fly under the radar, where they’re just well enough that nobody catches it.”

Sometimes the medics realize that the patients don’t have a support system. They don’t have someone to drive them to buy food or pick up prescriptions — and the community paramedics can see those things more easily than someone could at a doctor’s office.

“When you go to the doctor, don’t you get cleaned up, wear a nice outfit? You put your best foot forward, like when you go to church,” Tihen said. “And they’re going to say what the doctor wants to hear.”

Not just health care

Before his second patient visit of the day, Buckley stopped by the garage at Great Mines Health Center. From among the stacks of medical supplies, he retrieved a pump sprayer and packed it in the back of the SUV.

He drove to the apartment of a patient who, he’d noticed during a previous visit, was struggling with an insect infestation. The woman let him inside, and he sprayed insecticide around the doorway and behind the refrigerator and around the windows.

Buckley returned the sprayer to the car and brought back his medical kit. He sat next to the patient and drew a blood sample that her doctor had ordered.

Buckley began working as a paramedic in 1994. He became a community paramedic in December.

“I’m not going to lie, I was burnt out, riding on the truck 28 years,” said Buckley, who is also a pastor at Bates Creek Missionary Baptist Church. “We’ve all sat back and said, ‘If they’d only do this.’ Well, guess what? I’m in a position now where I can do it.”

“My job isn’t just health care,” he said.

His point was well-illustrated during his fourth visit of the day.

A home health agency had declined to go to a patient’s house, because of a large hornet’s nest hanging from the roof by the front door.

“I don’t blame them,” Buckley said. “I don’t know if their workers are allergic. Nobody wants to get stung. So if this is the obstacle to her getting help in her home, I kind of feel like it’s my obligation to do what I can.”

Once he was sure the patient was safely inside the house, Buckley pulled the SUV close, and rolled his window down halfway. He held out a container of wasp and hornet killer and sprayed it at the nest, emptying two cans of white foam.

When Buckley got back to headquarters later, he parked the SUV in the ambulance bay and hung his stethoscope on the rear view mirror.

“Another day at the office,” he said.