Long before the first case of a mystery respiratory disease was identified in China and eventually became a global pandemic, and long before U.S. hospitals began developing surge capacity plans to meet the present public health crisis, the Commonwealth of Massachusetts created a pathway to expand the scope of the frontline medical workforce by giving paramedics a broader role in the health care system — a role that’s needed nationally now more than ever.
In October 2014, the Commonwealth’s Department of Public Health granted a Special Projects Waiver to the not-for-profit Commonwealth Care Alliance (CCA) in partnership with EasCare Ambulance. It allowed specially trained paramedics to respond to the urgent care needs of CCA patients in their own homes. These paramedics could start medical care, including the administration of intravenous antibiotics, nebulizers, and others treatments that would traditionally require transportation to emergency departments or local hospitals.
This model of health care delivery, called mobile integrated health or community paramedicine, has been widely used to expand access to care in the rural United States and in places around the world where inpatient beds, outpatient providers, and overall access to care is limited.
As Covid-19 spreads at an exponential rate, we can see in real time how health care resources even in big cities with strong health care systems are becoming scarce and access to care is limited. In Atlanta, home to the Centers for Disease Control and Prevention, more than 7,000 individuals in the metro area have been diagnosed with the virus. The mayor of Atlanta announced that ICU beds across the city were at capacity when there were fewer than 1,400 cases in Georgia. As of April 20, the state total topped 19,000, with roughly 20% of patients requiring hospitalization, straining hospitals not only in the Atlanta area but also the more rural areas across the state.
Covid-19 is forcing us all to change the way we think about health care. Outpatient appointments have moved online — your dermatologist can perform her visual inspection over Skype and Facetime now that federal regulations stipulating requirements for telemedicine have been waived. Scientists around the world are collaborating like never before to expedite the practical application of their findings. Physicians and advanced practice providers, once bound by state licenses, can now practice across state lines wherever they are needed most.
We also need to rethink how we provide emergency care, not only to offload the volume of non-Covid-19 patients in the face of thousands of Americans needing care for the coronavirus infection, but to also minimize the risks to patients requiring care for illnesses and conditions other than Covid-19 who would be at increased risk of exposure to the virus by going to a hospital or emergency department.
Mobile integrated health can be a valuable tool for bolstering U.S. health care systems in the face of this pandemic and beyond. It provides a way to evaluate patients in their own homes and to start treatment while minimizing cross-exposures, offloading crowded emergency departments, and decreasing potential inpatient hospitalizations.
Recognizing the value of an expanded role for paramedics even before the coronavirus pandemic, the Centers for Medicare and Medicaid Services (CMS) in August 2019 announced the Emergency Triage, Treat, and Transport Model (ET3). ET3 is a five-year payment model aimed at providing greater flexibility to ambulance teams to address emergency health care needs. This change expands the historic requirement that patients who are evaluated by paramedics must be transported to emergency departments, and further provides a framework to develop mobile integrated health programs. However, ET3 is limited to approved paramedic agencies and to patients enrolled as Medicare fee-for-service beneficiaries. Unfortunately, the program’s roll out has also been delayed until fall 2020 due to the coronavirus pandemic.
But mobile integrated health programs should not be delayed. Instead, they should be expedited nationwide. Massachusetts recently announced it will approve temporary licenses for mobile integrated health programs in light of the Covid-19 emergency, expanding on its existing frameworks for permanent programs. Massachusetts General Hospital, the largest hospital in New England with nearly 1,000 inpatient beds, where I work, received a waiver to develop the Covid-19 Mobile Response Program.
Working with a local ambulance company, Cataldo Ambulance, MGH’s Mobile Response Program sends paramedics to evaluate patients with confirmed or suspected Covid-19 infections in their homes. Using telemedicine visits for medical direction from advance practice providers and physicians, the paramedics support patients self-isolating at home, identify those who need to be hospitalized, and transport them to emergency departments.
States such as Colorado, Washington, and Tennessee have existing legislation and frameworks in place to license mobile integrated health programs but have not announced any plans to grant temporary licenses to combat the pandemic. Meanwhile, most states do not have state-level authorization for these programs, leaving guidance to local authorities and agencies.
More states should follow Massachusetts’ lead in authorizing temporary mobile integrated health licenses to support health care systems. Temporary waivers and authorization specific to Covid-19 could be implemented more broadly to preserve hospital capacity and the frontline workforce. Expediting the authorization of more mobile integrated health programs would bolster hospital capacity and allow patients who would otherwise warrant hospitalization to continue self-isolating with expanded in-home support.
The relaxation of telehealth requirements by CMS during the state of emergency triggered by Covid-19 further supports the implementation of these programs during the pandemic, and would continue to support health care systems long after it ends.
As the number of Covid-19 infections continues to climb, we must employ novel ways of thinking, shaping, and delivering health care to combat this unprecedented global health crisis. By sharing best practices between the states, including mobile integrated health, we can move the needle as part of the broader efforts to flatten the curve.
Stephen C. Dorner, M.D., is an emergency physician at Massachusetts General Hospital and a member of the board of directors of the Society for Academic Emergency Medicine.
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