OLD-FASHIONED HOUSE CALLS — WITH A TWIST
Reno paramedics keep patients out of ER
Paramedic Ryan Ramsdell pulled up to a single-story house not far from Reno’s towering hotels and casinos in a Ford Explorer.
No ambulance, no flashing lights. He wasn’t there to rush 68year-old Earl Mayes to the emergency room. His job was to keep Mayes out of the ER.
Mayes, who has congestive heart failure and chronic lung disease, greeted Ramsdell and told him that his heart was fluttering more than usual.
“Let’s take a look at it,” the paramedic responded, carrying a big red bag with medical supplies. “We’ll put you on the monitor.”
Since Mayes was released from the hospital a few weeks earlier, paramedics had visited him several times to monitor his heart and lungs and make sure he was following his doctor’s orders.
“With these guys coming by and checking me all the time, it makes it so much better,” Mayes said. “When they leave, you know where you stand.”
Ramsdell is part of an ambitious plan in Reno to overhaul the 911 system to improve patient care and cut costs. By using specially trained paramedics, health officials hope to help reduce avoidable trips to the emergency room and fill gaps in health care. They also hope to connect 911 callers — particularly repeat ER users — to the regular health care system.
Around the country, the role of paramedics is changing. In various states, they’re receiving extra training to provide more primary and preventive care and to take certain patients to urgent care or mental health clinics rather than more-costly emergency rooms. Ramsdell and others in his program, for instance, spent 150 hours in the classroom and with clinicians learning how to provide ongoing care for patients.
The changes are driven by the 2010 health law, which aimed to cut spending, expand patient access and improve quality of care. The federal government is funding the Nevada project and others in Arizona, Connecticut, Washington state and elsewhere.
These projects face some challenges. The American Nurses Association and other professional organizations have raised concerns about whether paramedics are receiving enough extra instruction to provide direct care. Some programs need government waivers or legislation to exempt them from restrictions on what paramedics can do. In addition, insurers and the government typically only pay for ambulances and paramedics if people are transported to the hospital.
Perhaps the greatest obstacle, however, is changing the habits of those who call 911 in non-emergencies.
“We have a fire truck and an ambulance going to a toothache,” said Jim Gubbels, CEO of the Regional Emergency Medical Services Authority, which is spearheading Reno’s project. We are trying to redirect those folks.”
Using a $9.8 million federal grant, Gubbels’ agency launched three different projects.
In addition to providing paramedic home visits and offering 911 callers options besides the ER, the agency started a nurse-run health line to give people another number to call in non-emergency situations.
An early evaluation by the University of Nevada, Reno, which was based on insurance claims and hospital data, shows that the projects saved $5.5 million in 2013 and 2014.
They helped avoid 3,483 emergency department visits, 674 ambulance transports and 59 hospital readmissions, according to the preliminary data. The federal government plans to do its own evaluation.
One of the most successful ventures has been the nurse health line, said Trudy Larson, director of the university’s School of Community Health Sciences. About 2,000 calls a month have come from patients concerned about such problems as stomach pain, flu symptoms or falls.
“There was a real need for a readily available, easy-to-access source of health information,” Larson said. “It was really clear that 911 was not the solution.”
Sometimes, however, the best option becomes clear only after someone has called 911.
Recently, a man fell in in a casino and hit his head. Upon arrival, paramedic Jordan Carter quickly realized that the man was drunk. He determined that there weren’t any immediate medical problems or underlying health issues.
Carter asked if the man wanted to go to a detox facility rather than the emergency room. He agreed. “They’ll give you a place to sober up safely,” Carter told the patient.
The paramedics and EMTs follow strict medical protocols on when to offer choices besides ERs to patients. For example, if their heart rate or blood pressure is too high, that requires a trip to the hospital.
On a recent day, Carter took back 56-year-old Tommie Jones, who had already been to the emergency room several times in two months. She’d called because her blood sugar was high and she’d left her insulin at home. On the way, Carter urged her to pack a small diabetes kit with her wherever she went.
Carter said the patients don’t always know how to manage their illnesses, so they wait until they are really sick and then end up in the hospital. “Then the cycle happens again,” he said.
Ramsdell is trying to break that cycle for Mayes. “People heal better and heal faster if we are able to treat them at home,” he said.
“People heal better and heal faster if we are able to treat them at home.”
Ryan Ramsdell, paramedic