Some Wake EMS Paramedics Are Mental

Here is one fact that is hard to dispute, when you get to know members of the Wake County EMS network you wind up with a seemingly uncontrollable urge to just want to hug them. They do a needed but tough job and they do it exceedingly well.

They do their jobs so well in fact that if you lived nearly anyplace else and knew you might have a heart attack, you should plan to come to Wake County for the event. Well that is if you wanted one of the best chances of surviving it.

Back in October we had the opportunity to sit down with Wake EMS members at Station 10 in Wake Forest. You can read that article here.

It was then, when we were talking with Wake Paramedic Jason Wells that we first learned of the deep respect he and seemingly every other paramedic we’ve talked to since have for their medical director Dr. Brent Myers.

So recently we had a chance to sit down with Dr. Myers and talk to him about the programs Wake EMS has been getting a lot of attention for.

The APP (Advanced Practice Paramedic) program is not an app you download on your smartphone that saves your life. Although, now that we think about that it would be totally cool.

Dr. Brent Myers being a good sport and giving us our required Captain Morgan EMS pose made famous in this article.
Dr. Brent Myers being a good sport and giving us our required Captain Morgan EMS pose made famous in this article.

The Wake EMS APP thing is a program to allow paramedics to have new skills and responsibilities. APP stands for Advanced Practice Paramedic and these EMS members are taking the first difficult baby steps towards making ground breaking changes in the way EMS assists the public in Wake County.

The rescue squad, ambulance, EMS solutions typically provided go back to the 1960s after the interstate highway system had been created. Someone back then decided there should be a coordinated way for people to pick up their hurt and injured motorists from the road and take them to one of those hospital places. That general approach remains today.

As silly as it is, EMS ambulance services come under the purview of the Department of Transportation because EMS is still seen as a transportation service and not primarily a medical care provider.

In Wake County about 8 percent of the population calls EMS on a yearly basis and yet everybody has to be treated as if they had just wrecked their car on the highway and has to be transported to an emergency department for care. It’s just the way the system works in the U.S.

And while EMS has changed a lot since those earliest days the basic premise of “you call, we haul” has not changed all that much. If you call 9-1-1 the accepted process is to drive to where you are, pick you up and take you to the emergency department if you need to go or not. Basically, if EMS is coming, you’re going, that is unless you refuse to go.

But both Dr. Myers and Wake County EMS say there is a better way to help people and they are doing the tough work to change things for the better. With big ideas, but small difficult steps, Wake EMS is delivering care for a segment of the population that otherwise would have been previously dragged to the emergency department (ED) of some local hospital for no good reason.

Take people with some mental health event. Historically some in a mental health crisis would be scooped up by EMS and taken to a local hospital where they would have been a lower priority patient and so would be placed in the waiting room for up to 12 hours while waiting to see a doctor.

Now stack up three or four similar patients in that situation into the same waiting room, all just waiting for care and what we have is a mental health circus. Expecting this is going to have a good outcome and people are going to be happy, that’s the crazy part.

But Wake EMS with the assistance of the specialized APPs is s-l-o-w-l-y moving to shift the screening and triage of mental health patients from the painful process at local EDs to giving the Advanced Practice Paramedic some control over directing that person to a mental health treatment facility and bypassing the emergency department all together.

It sounds like such a commonsense and logical solution but when this kind of paradigm shift changes the relationship of the healthcare field it is no wonder obvious progress is excruciatingly difficult.

Changing the way things have always been done means a never ending continuous set of increasing hurdles that must be jumped. From medical record integration, reimbursement, risk management, protocol development, insurance requirements, software changes, and billing modification, the obstacles that must be dealt with seems endless. Frankly, not rolling out the APP program would have been the easier thing for Wake EMS to do. Not because it’s better for us but because it would make their lives easier.

But since we are talking about crazy things, consider that Dr. Myers is pushing this string up a hill or trying to herd cats and taking on this monumental task of changing an entrenched system not because it makes his job and life easier but because it provides better care for us, the residents of Wake County and the consumers of medical services in the Raleigh, North Carolina area.

Wake EMS APP Chris Gherardi

We spent a lot of time with APP Chris Gherardi. He can often be found in a Wake EMS vehicle that says Medic 93 on the sides and hovers around the North Raleigh and Wake Forest area. Check around a Starbucks. “That’s a real mans coffee,” he says.

Chris Gherardi and his Medic 93 car with all the gear he carries to save lives.
Chris Gherardi and his Medic 93 car with all the gear he carries to save lives.

At one time Chris worked as a paramedic in New York City but today was one of the first to become a Wake EMS Advanced Practice Paramedic. He says the paramedic services provided by Wake EMS are among some of the finest in the country.

Chris has gone beyond his New York City days of scoop and run as the only solution he can offer sick people. As part of the APP initiative he’s not only working hard to help those struggling with mental illness issues but also part of a study to save assisted living patients who take a tumble, from having to go to the hospital needlessly.

Most assisted living facilities in the country today have a grossly bureaucratic process and procedure in place that basically says “if resident succumbs to gravity and falls down, call 9-1-1.” And what happens when the paramedics roll up, they take you to the emergency department because that’s the assisted living facility protocol.

So picture what happens now, grandma falls down and she’s not hurt. Paramedics are called and take grandma to the hospital even if she does not want to go, where she sits around the ED for some undetermined amount of time and then doctors order all sorts of cover your ass diagnostic tests to make sure grandma is okay. Eventually grandma gets back home and prays she doesn’t trip again.

The inadvertent carpet trip grandma took costs the EMS system money, the hospital money, the insurance company money, and for what? Just to be able to bill Medicare?

Today in about nine assisted living facilities in the Raleigh area, Wake EMS APPs are running falls calls. The APP has the approved protocols that are necessary to make safe screening determinations if grandma actually fell because she is ill and needs to go rapidly to an emergency department or she just took an inadvertent tumble over an improperly discarded Ensure bottle.

Under the trial program the APP is able to evaluate grandma, call a doctor in for further evaluation if necessary, or get one of those expensive boxes on wheels with lights and sirens to take grandma for emergency care.

Studies show that in a large number of those assisted living falls the patient does not want to go to the hospital, the family doesn’t want their loved one to go to the hospital, and in fact there is no reason for the person to go to the hospital. And right now about 50 percent of the falls calls the APP have assisted with did not require a visit to the emergency department. Outside of that small limited study it remains now that a healthy patient that falls down goes from being a patient to a victim because of a greater crappy standard policy.

As we sat with Chris Gherardi in Starbucks he shared a story of a situation he had handled recently where a call to 9-1-1 triggered an EMS team to roll to a work place. But what they found when they arrived was a boss who had rightfully called for help over concern for one of his employees who was upset at not being able to properly kill himself that morning before he came to work. The EMS team called for the APP and Gherardi was dispatched. The initial EMS responders had realized the patient didn’t necessarily need a trip to the emergency department but more substantive mental health assistance and direction to a treatment facility.

EMS Paramedic Chris Gherardi giving us our requested Captain Morgan pose we now consider to be required for EMS.
EMS Paramedic Chris Gherardi giving us our requested Captain Morgan pose we now consider to be required for all EMS interview pictures.

Chris talked with the patient, who suffered from depression and had been under the care of a psychiatrist but stopped, and together they agreed that direct transport to a local mental health treatment facility was both appropriate and what the patient ultimately needed and wanted. Not a trip to a hospital emergency department and five hours in a waiting room.

Chris called for a police car to transport the patient, since they have cages to make sure the patient doesn’t do something stupid, and the guy was taken for specialized and qualified care as Chris followed along in Medic 93.

Right now you might be thinking the same thing we did, taking a suicidal person and putting them in handcuffs to transport them to a mental health facility sounds crazy. But they once you think about it the options are limited when you attempt to come up with a solution that protects both the patient in a mental crisis and the driver.

APP services will eventually expand beyond the falls calls and mental health screening services. These services might include more field intervention in substance abuse issues and maybe even more community healthcare one day, like giving vaccines and doing more end of life care. The possibilities are huge, the hurdles are tough and we are still three years into a six month project to move mountains to make this all happen.

Frequent Flyers

The EMS system has some people the medical field previously called frequent flyers or repeat offenders. Today to be more politically correct they are actually called “familiar faces.” These familiar faces often call EMS for recurring issues like blood sugar troubles or recurring mental health episodes.

This repeat non-emergency traffic simply lands in the emergency departments of local Raleigh hospitals and gums up the works. They are simply going around and around in a revolving door of emergency department visits because that’s the way the system works.

Dr. Myers and the APPs want to break that cycle and provide more assistance for those familiar faces, screw it, frequent flyers, and intervene before they just make the next trip back to the ER.

You know the problem with that approach, it makes sense. Providing help and assistance for people so a big flashing EMS box on wheels with sirens and two people on board and a fire truck don’t have to go out, makes something more than good sense.

In our time with paramedic Chris Gherardi he shared multiple examples of people who he had helped and dealt with outside of needing to take them to the hospital as previously happened.

Taking someone to the hospital who is having a panic attack or a bipolar flareup is actually the crazier thing. Sending an APP to help provides trained and competent assistance at the moment it is needed, not four hours later after sitting out the crisis in an emergency department waiting room.

It seems that the battle Myers and the Wake EMS system is facing in changing the system is to be able to provide more relevant care by trained professionals at the top of their license to people who need help when they most need it. In a way it’s kind of sad that approach has to be broadcast as revolutionary.

Paramedics in Action

While we were with paramedic and soon to be District Chief Jason Wells we had the good fortunate to run into Bernard who was dealing with managing his asthma.

Bernard told us before meeting the paramedics that his asthma became a problem only after a bad batch of beige cocaine. The episode nearly a decade and a half ago now not only caused him to seek emergency care for not being able to breathe but convinced him to avoid drugs as well. For some people a near death experience is the kind of swift kick in the ass that initiates change.

Paramedic Jason Wells talks to Bernard about managing his asthma.
Paramedic Jason Wells talks to Bernard about managing his health issues and provides help in the park.

It turned out when we mentioned the new APP program to Bernard and the mental health skills that were rolling out Bernard said he has a nephew who is struggling with a mental health issue. Luckily paramedics Jeff Hamerstein and Jason Wells were there to turn to their resources to provide Bernard with information that could get his nephew into treatment. Bernard was very thankful for the help.

Hammerstein and Wells both look up information to assist Bernard to get his nephew into treatment for his mental health issue.
Hammerstein and Wells both look up information to assist Bernard to get his nephew into treatment for his mental health issue.

Dr. Myers Shares His Experience With Change

The rapid talking Brent Myers began his medical career in a very obtuse way. As a teenager in Orange County he was looking for a job to make some money to buy a car. He found a job working as an orderly in the local hospital emergency department. On his third day at work, charge nurse Geraldine McCall said to him if he stayed working at the hospital for a month he’d never want to do anything else in his life. Turns out she was right and he hasn’t.

Myers, with the encouragement of McCall went on to become an EMT at the Orange County Rescue Squad in Hillsborough when he was an undergrad at UNC. So he’s been on the front lines and can relate to what paramedics deal with.

When Myers first created the APP program the intention was to utilize these highly trained paramedics for the most urgent life threatening calls but it soon became apparent the APPs could do more since only about 20 percent of EMS calls are for urgent emergencies where people are really sick, 80 percent are not. The highly skilled APPs had more available time to utilize to help the community.

Soon the APPs will be able to provide medical care at mental health treatment facilities instead of having to transport those patients back to an emergency department for treatment for things like isolated high blood pressure or blood draws for screening, and medical clearance for admission.

Myers says the big roadblock holding up the works of more APP services is financial reimbursement. While the North Carolina Medicaid office sees the value in providing some reimbursement to take people to alternative care destinations other than the emergency department, other medical insurance providers, including Medicare, have not changed their approach yet.

Currently if Wake County EMS transfers a patient to the most appropriate care facility and does not go through the emergency department the county loses about $400 for that ambulance ride. It’s not reimbursable. See, we said the current process was crazy.

We asked Myers why tax payer dollars should be used to pay for the APP program that does not fund itself, yet. He said, “If we don’t do this then we have to continue to add expensive ambulance resources to transport people needlessly.”

Each new ambulance that is added to the Wake EMS system winds up costing about $450,000. By offloading care outside of the medical taxi service it saves the county a lot of money. That can be seen by the slow growth of the EMS system despite the accelerating growth in the Wake County population. And that saves the taxpayers money.

But the county only provides about 25 percent of the budget for Wake EMS, the rest comes from billing revenue the system generates.

On top of all these reimbursement, funding, and billing issues there is also the problem of bidirectional data exchange between EMS and the hospitals. Currently EMS has worked out a large part of the issue with WakeMed and they are able to exchange some data. But all of the Raleigh region hospitals are moving to the Epic software so with a standard regional software platform provider the integration with Wake EMS might just be a little bit easier.

Dr. Myers estimates within 24 months EMS will have the ability to access medical records, test, and lab results from those hospitals in the field to allow paramedics to have a more comprehensive view of the medical situation at hand, including who the primary care physician is, and the results of the last hospital visit.

Myers says the model implemented in Ft. Worth, Texas is more akin to his vision of the future. In Ft. Worth they refer to their EMS process as patient navigation and Mobile Integrated Healthcare.

The Ft. Worth MedStar EMS Approach

9-1-1 Nurse Triage – Low acuity (emergency) 9-1-1 callers are referred to a specially trained RN in our Call Center who helps the patient find appropriate resources for their medical issue.

“EMS Loyalty” Program – Patients who use 9-1-1, 15 or more times in 90 days are enrolled. MedStar’s Mobile Health Providers (MHPs) conduct regular home visits, connect the patients to available resources and teach the patients how to better manage their own healthcare. Typical enrollment is 30-90 days.

CHF Readmission Avoidance – CHF (congestive heart failure) patients at risk for a 30-day readmission are referred to MedStar by the patient’s Case Manager or PCP (primary care physician). MedStar conducts a series of home visits to educate the patient and family on appropriate care management and loops the patient to their PCP. If the patient needs intervention, the MedStar MHP may coordinate in-home diuresis with the patient’s PCP, along with a follow-up PCP appointment.

Hospice Revocation Avoidance – Patients/families at risk for revoking hospice status by calling 9-1-1 for an urgent trip to the ED are identified by the Hospice agency. MedStar and the Hospice agency coordinate efforts to reduce the possibility of the patient/family revoking hospice status.

Observation Admission Avoidance – Working with our local ACO (accountable care organization), patients who may be admitted to 23 hour observation status may instead be referred by the ED physician to the MedStar CHP program. The MHP provides an overnight visit to do an in-home assessment and coordinate the transition of care back to the patient’s PCP the next day. – Source

Since its inception, MedStar’s Mobile Healthcare Programs have saved more than $3.3 million in healthcare expenditures, and reduced 9-1-1 use by these patients by 86.2 percent in 12 months post-enrollment.

Ft. Worth no longer calls their paramedic system EMS. It's now called Mobile Healthcare.
Ft. Worth no longer calls their paramedic system EMS. It’s now called Mobile Healthcare.
It is the opinion of Dr. Myers that Wake County is “at the precipice of really opening the door. And we are trying to crawl before we walk.”

The possibility exists today for Wake EMS to contract with groups like hospice care or local hospitals to provide CHF patient monitoring on a flat per person basis. Think of it like joining a real health club. The reimbursement models and contracts have to come first and Wake EMS is ready to answer the call with exceptional customer focused care.

Myers says the most appropriate name for the services Wake EMS provides is “unscheduled medical care where some of it occasionally involves and emergency.” Of course we think “Oh crap, help, I think” seems to sum it up as well.

Who knows, it’s quite possible in the next decade that what we know now as EMS will greatly expand to provide more community based medical care and work more closely with people to help them get to the most appropriate medical provider for their situation.

1 thought on “Some Wake EMS Paramedics Are Mental”

  1. An excellent and well-timed piece, as this conversation is starting to occur all over the country. One point though, I think the sentence “to make sure the patient doesn’t do something stupid,” might have been phrased a little better. “Harmful,” “injurious,” or “irrational” maybe, but the word “stupid” is perhaps a little harsh, even if we have difficulty understanding the person’s actions.

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