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Community Paramedicine & Chronic Wound Care: Collaborative Potential or Too Many Complicated Questions?

As far as calls to 9-1-1 go, a request for first responders to remove compression stockings may not seem like an emergency situation, but Caroline E. Fife, MD, FAAFP, CWS, FUHM, knows better than to suggest that. When she was informed that one of her wound care patients called 9-1-1 in a panic because her prescribed stockings were “pinching her legs,” Dr. Fife insists that she did not need to be on the scene when the ambulance arrived to know that life-saving care would be needed for what might ordinarily seem like a routine task. 

“[The patient] thought the circulation was being cut off from her foot, and she was probably right,” said Dr. Fife, Medical Director of CHI St. Luke’s Wound Care Clinic in The Woodlands, Texas. “She didn’t have any family there with her, and nobody was living with her. She really was having an emergency because she was not physically able to take the stockings off.”

With arthritis in her hands and knees and a medical history that included back and hip problems, the elderly patient was wearing the stockings as part of her ongoing treatment for a venous ulcer. She was previously discharged from the outpatient clinic as “healed” with post-treatment instructions to wear the stockings.  The woman was able to successfully get into the garments but could not get them off by herself.

“The stockings have butlers that you place your foot in to help you get them on, but the movement that it takes to get them off is different. It takes more strength, and when you have arthritis and can’t bend over, you can’t do it,” Dr. Fife continued.

With nobody else to call, the woman’s options appeared to be quite limited.

“If she hadn’t [called 9-1-1], she might have lost a toe or a foot,” said Dr. Fife. “The stockings began to bind, whichcan actually cut off arterial circulation.”

This patient, a real clinical example, is not an isolated incident. The volume of wound care patients continues to grow in the United States, with more than 6.5 million people living with chronic wounds.1 As the general population lives longer and develops additional comorbid conditions, the problem of nonhealing wounds does not appear to be trending in a positive direction — at least not for those who lack assistance at home.

“It’s a huge problem,” Dr. Fife said. “And the things [these patients] need are relatively straightforward; they can’t get their shoes on, they can’t get their wraps on. They just need someone to check on them, to make sure they haven’t fallen down, and that they are generally safe.”

The real issue is not that most of Dr. Fife’s patients cannot function independently at all. In fact, many of the patients who are discharged home maintain a fairly high level of independence, she said. Therein lies the conundrum, however, as a certain level of independent living disqualifies people from the option of Medicare’s home health benefit because they are not considered to be “homebound.”

“Many of these patients can still drive,” Dr. Fife said, citing an example that precludes them from a visiting nurse coming into their homes on a consistent basis. “So they are falling into this situation where they are too ‘able-bodied’ to have a care provider, but their movement is too restricted to keep them from getting another wound. And it’s such a great example of how patients can become increasingly more restricted in their living situation.”

One alternative for these patients and their wound care clinicians may be community paramedicine. This evolving health care service line model allows paramedics and emergency medical technicians (EMTs) to operate in expanded roles by assisting with public health, primary health care, and preventive services to underserved populations at lower costs.2,3 As of 2015, more than 100 emergency medical services (EMS) agencies in 33 states, plus the District of Columbia, have launched community paramedicine programs or mobile integrated health care models that utilize patient-centered mobile resources in the out-of-hospital environment.4 The goal of these programs is to improve access to care and avoid duplicating existing services with visits in the home and other nonurgent settings conducted by first responders.5 

The adoption of this service line for patients with chronic wounds, however, does not seem to be a linear equation. For wound care, community paramedicine programs (which strive to reduce hospital admissions and readmissions like outpatient centers) currently may raise more questions than offer answers for patients and providers. Questions reach all areas of care, from scope of practice and which types of products to house in ambulances to how to ensure that paramedics and EMTs are competently educated and following protocols established by appropriately informed physicians. Possibly most important, these questions include how to address instances in which an emergency call may come in while a wound care patient is being treated during a regularly scheduled visit.

COMMUNITY PARAMEDICINE: QUESTIONS TO CONSIDER

As a former lieutenant paramedic with the Detroit Fire Department (MI), Eric J. Lullove, DPM, CWS, FACCWS, rarely found himself responding to calls for patients living with chronic wounds. “But [I was a paramedic] during the 1990s, and wound care was not where it is today,” said Dr. Lullove, a podiatrist and certified wound specialist who has operated his own podiatric and surgical practice in Florida since 2005. The sophistication of modern wound care services, coupled with the increased number of patients living with complex wounds, leads Dr. Lullove to raise a few questions that he believes should be addressed among any companies engaging in community paramedicine or assuming they ultimately will. 

“At the beginning of the day, the question has to be ‘who’s asking for these services?’ and ‘what’s the goal?’” Dr. Lullove explained. “What are [wound clinics and paramedics] trying to accomplish?”

Despite a connection between community paramedicine and rural areas, Dr. Lullove also questions how sustainable this approach will be for wound patients specifically in these regions due to distances between residences and hospitals. “Does wound care have a place in these visits, or is the goal just to get these patients to more qualified providers?” Dr. Lullove questions. If the answer is “yes, wound care does have a place,” Dr. Lullove believes the questions raised become more direct and intense. For example, aspects to consider in a wound care-community paramedicine model could include who would educate the emergency staff members caring for wounds and developing the protocols, what would the scope of practice be for first responders seeing patients at home and should these providers be required to be board-certified wound specialists, and how would state-by-state jurisdiction potentially complicate streamlining this type of service, Dr. Lullove challenged. 

“Paramedics in different states and different jurisdictions have different levels of care,” he continued. “Some paramedics can administer drugs and some cannot. You also have different levels of paramedic. What type of training would be required to conduct wound care?”

Even when assuming scope definitions and education standards are established, Dr. Lullove still warns of big-picture questions that would need to be addressed. “Would training come through drills or coursework that would have to be conducted on the side [of one’s actual job duties]? What would the format be? How’s it going to be funded?” He also offered the potential that community paramedicine eventually could develop into something similar to telemedicine, in which paramedics enter the field under the direction of a physician. “And [if that were true], who is that physician giving the orders? Because as of now, the way the system is set up, the only people that the paramedics can talk to is the emergency department,” Dr. Lullove commented.  

This is not to suggest that he believes the concept of community paramedicine is inappropriate for chronic wound care. “There are pros,” Dr. Lullove continued. “[Community paramedicine] would alleviate the stress on a 9-1-1 system of patients going to the emergency room for a wound evaluation. It would allow the patient to have an interim visit with an allied health care professional without [the patient] having to travel distances to hospitals and wound care centers on a regular basis. And it could lessen complicated skin and soft tissue infections that could potentially become a septic issue.”

Dr. Fife, who also worked as an EMT in the late 1970s for the fire department of Houston (TX), also said she could see where positives could be gleaned for the wound care patient population. “As wound care physicians, I don’t think everyone realizes how frail our patients are,” she said. “But they don’t all need skilled nursing. They need somebody to check on them and to let them know when they are sick, and that’s something paramedics and EMTs are really good at, probably better than home nurses in some ways.” 

Also the Executive Director of the U.S. Wound Registry, an organization created in 2005 in response to the ongoing need for clinicians to        aggregate patient data, Dr. Fife said 70% of patients who were diagnosed with venous disease and were receiving treatment in a wound clinic cannot dress their lower bodies unaided as an activity of daily living. “And 24% of my patients are in congestive failure and atrial fibrillation,” she continued. “These people can tip over into failure so fast and end up being rehospitalized. That is a wildly expensive thing.”

Related to financials, reimbursement also is reportedly one of the largest barriers to the functionality of community paramedicine programs. EMS typically is not reimbursed by payers unless a patient is transported to an emergency department.6 “But hospitals might care enough about congestive heart failure readmissions to pay paramedics to go see those patients,” Dr. Fife suggests, somewhat anecdotally. “The lever that the [Centers for Medicare & Medicaid Services] is applying now is readmission rates. They’re applying that to the physicians and hospitals. And the hospitals are the ones that collaboratively have enough money to care.”

COLLABORATIVE CARING

The potential benefits of these types of programs evolving and growing also includes the development of a collaborative relationship between EMS services and wound clinics, with the goals of both service lines being to keep patients out of the hospital, Dr. Fife said. “I have to admit a wound center patient to the hospital about every other week,” she continued. “And more than half the time, it is not due directly to their wounds; it’s because they’ve had an exacerbation in their heart failure or something in their underlying medical condition has worsened. And for all that wound centers are supposed to do to keep patients outside of the hospital, we can’t do anything about their heart failure, or their arrhythmias, or their diabetes management. We are just trying to slow down what is going on. We’re hoping to keep them from getting osteomyelitis. We’re hoping that we can keep them from getting cellulitis.” 

Additionally, the wound care interventions needed are frequently needed at home. 

“So, we can do a lot for these patients that may keep them from getting an amputation or that may improve their quality of life,” Dr. Fife added. “There are barriers in which I know that patients need some extra help, but I don’t have a trigger to make that help happen. So I need to ask these patients if they can afford to hire somebody to take care of them, because if they can’t, the only other option I have is to call adult protective services and report them for neglecting themselves because I cannot allow that to go on. That’s a horrible thing to have to do to someone.” 

This is where community paramedicine can come into play. 

“We don’t need people to be [in the home] all day, but we do need people to go into the home [and perform basic wound care] for these patients, including triage,” Dr. Fife said.

Should traditional emergencies arise during a scheduled visit, Dr. Fife likens this scenario to something that can happen to any first responder or EMT at any time. “It’s a challenge to respond to an emergency regardless of whether you’re in someone’s home at the time of a 9-1-1 call or if you are in the store picking up groceries,” she said. “That is an issue these professionals always have to deal with. Of course, when it comes to an emergency, you would much rather have an EMT or a paramedic in your house than a visiting nurse.”

VIEWS FROM THE FIELD

At Longwood Fire Company in Kennett Square (PA), Matt Eick, EMS Captain, is not experiencing a vast patient caseload with difficulty healing their chronic wounds beyond the care they receive in outpatient centers. But he does envision a means in which he and his colleagues could benefit wound care patients and wound clinics, should a need arise in the region. “In general, with good collaboration, the community paramedic could essentially be an ‘agent’ of the wound care clinic and could help to keep the patients in their homes more often and serve the needs of the wound care clinic to make sure wounds are healing appropriately,” he said. “The community paramedic is almost like a catch-all for whatever service that patient may need immediately after discharge and return home. The community paramedic is also another set of eyes that can identify a wound that is potentially becoming infected or not healing appropriately. A lot of times, the community paramedic is going to fill in that gap and help educate that patient on how a simple visit to their doctor could prevent them from ending up back in the hospital for a long period of time.” n

Joe Darrah is Director of Alumni Relations at Rosemont College, Rosemont, PA.

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References

1. Sen CK, Gordillo GM, Roy S, et al. Human skin wounds: a major and snowballing threat to public health and the economy. Wound Repair Regen. 2009;17(6):763-771.

2. Community Paramedicine. Rural Health Information Hub. www.ruralhealthinfo.org/topics/community-paramedicine#role. Updated June 26, 2018.

3. Introduction to Community Paramedicine. California Emergency Medical Services Authority. https://emsa.ca.gov/community_paramedicine. Published 2019.

4.  Zavadsky M, Hagen T, Hinchey P, McGinnis K, Bourn S, Myers B. Mobile Integrated Healthcare and Community Paramedicine (MIH-CP). Clinton, MS: National Association of Emergency Medical Technicians; 2015.

5. IAFCCP Offers New Online Community Paramedic Course. EMS World. www.emsworld.com/press-release/221278/iafccp-offers-new-online-community-paramedic-course. Published September 18, 2018.

6. DeCherrie L. Community Paramedicine is at the Forefront of Home Care Medicine. American Academy of Home Care Medicine. www.aahcm.org/page/cp. 

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