EAGLE — One doctor said Bettie Tymkovich’s staph-infected toe had to go. Another doctor saved it but released her
from the hospital with strict rules about care and treatment. She also left with a diabetes diagnosis that required regular insulin shots and an entirely new diet.
“I was so terrified about changing the dressing,” the 56-year-old Eagle resident said. “Just even looking at it was pretty gross. I didn’t think I could do it. I was overwhelmed and scared to death.”
Kevin Creek came to her rescue. The paramedic arrived at Tymkovich’s home every other day. He arranged appointments with a local wound-care specialist. Changed her dressing. Tested her blood sugar. Recommended the right foods. Played with Jackie, her energetic heeler dog.
“It was like a friend coming in and taking care of me,” Tymkovich said, tears welling as Creek again checked the toe. “With Kevin coming here, I realized I can do this. It was just a learning curve, and the emotional support and friendship were critical. It was like having a guardian angel.”
Creek is the face of the pioneering Eagle County Community Paramedic Program, the first of its kind in the U.S.
Since it was formed in 2010, the program has spawned more than 250 just like it. The program’s third-edition handbook for expanding the role of paramedics as community caregivers has been downloaded five times a day since October 2011, and more than 200 colleges have adopted a national curriculum for training paramedics to do in-home medical services.
The programs — some grant- or self-funded or paid for through partnerships with area hospitals — are saving millions of dollars in health care costs across the country.
Through last December, Eagle County Paramedic Services’ Community Paramedic Program was paid for with grants, mostly from the Colorado Health Foundation. It’s now self-funded, seeing about 200 patients a year on an annual budget of about $90,000, said Christopher Montera, Eagle County Paramedic Services’ founder and chief of clinical services.
In Eagle County, home visits by paramedics in the past year saved $1,300 per patient visit by avoiding unneeded emergency room visits and hospital stays, Montera said.
“We know we can be part of the solution. Our goal is prevention of illness and stopping these unnecessary ambulance trips, ER visits, hospital admissions and readmissions,” Creek said. “We are there for physicians to use as an adjunct to their primary care. Our goal is to keep patients away from these high-cost problems by intervening early and often.”
Ferrying patients to emergency rooms isn’t always efficient, especially if that person has relatively minor medical needs that can be addressed at home.
The problem is that paramedics don’t get reimbursed if they do not transport a patient.
“Technically, I do not exist in the billing world right now,” Creek said as he returned from Tymkovich’s home.
But that could change with state legislation that would allow them to bill Medicaid for reimbursement.
citing, in part, community paramedic data from Eagle County. This summer Minnesota announced its nation-leading Medicaid reform initiative — which includes using community paramedics —
Despite the promise of cost savings, changing the Medicaid billing structure to expand reimbursement opportunities for community paramedics is not an easy task.
It requires insurers, home-care providers, nursing groups and primary care doctors to support community paramedicine, forging an uncommon collaboration in health care, where every group scrapes for limited resources.
A bill was drafted last year but didn’t reach the Colorado legislature.
“We are planning to put something forward again this year,” Montera said. “We are raising awareness on this, trying to gather broad support. I think people are catching on.”
While executives from the Home Care Association of Colorado say emergency medical services and home health care agencies could work together to get the right care to patients at the right time, they also say paramedics need more education to do what home-care nurses and therapists do. The association has proposed an additional level of state licensing for community paramedics.
“The home care industry is poised, competent and well-trained to provide these services,” executive director Don Knox said in a statement. “The only barrier to home care providing the services is reimbursement. This will be the same barrier for EMS.”
Community paramedics aren’t out to replace home health care services, Montera said.
Ideally a paramedic in the home can intervene before a patient needs the more intensive — and expensive — medical services provided by home health care providers or nursing homes. Community paramedics can reduce a patient’s need for daily home care to maybe a couple days a week.
“And we can fill the gaps on other days. It’s been a great partnership with all the stakeholders in Eagle County,” Montera said. “We can keep people healthier in their homes longer and yet still be a part of the home health care system.”
Community paramedics mention “filling in gaps” and “bridging gaps” — a lot.
Gaps are abundant in the suddenly strained health care system, which has added at least 15 million newly insured Americans under the Affordable Care Act. Hospital stays are shortening. Primary care doctors are whittling time spent with a growing number of patients down to a few minutes.
“It’s pretty astounding that big decisions are made and tests are ordered in a, what, seven- to 10-minute meeting with primary care physicians,” said Dr. Drew Werner, the former medical director for the Eagle County program and a primary care doctor aiming to help establish a community paramedic program in Denver.
Werner acknowledges his time with patients is dwindling.
“The most important aspect of medicine is communication, and it’s lacking in a lot of primary care doctor’s offices because we simply don’t have time,” Werner said. “Paramedics have that time.”
Garnering support starts with banishing the notion that paramedics are simply ambulance drivers.
Even though the U.S. essentially invented paramedics a half century ago, many in the health care industry and the general public are unaware that paramedics are intensively trained, often having completed as much as 2,000 hours of course work.
Community paramedicine does not change the scope of paramedics’ work, only their role, Montera said. Additional training does not necessarily include more medical or diagnostic education. But it does require empathy and more awareness.
“We know that most health care issues are not just about health care,” Montera said. “Some people don’t have food, heat, electricity. They have unmet needs socially that drive them into an emergency or health care crisis. Part of any new education connects patients with resources. We may not be the right person to do it, but we are the connector and navigator to help them find the help they need.”
In an overwhelmed health care system, that social aspect of medicine is getting overlooked. A paramedic can revive the long-gone era of physician house calls by visiting homes and providing busy doctors with a more complete picture.
“They see things and become aware of things that are just impossible to see in the office,” Werner said.
Everyone dresses up “in their Sunday best” for a doctor’s visit, Creek explained.
“They can’t dress up when we are there in the home,” he said. “We can see a lack of food, unused medicine, asthmatics in a dirty house — a lot of the stuff that can be the root cause of persistent medical problems.”
The success stories from the Eagle County program are plentiful.
There was the woman who stopped using her steroid inhaler because she saw a television news report about a boy who was blinded after spraying a similar type of medicine in his eye. And the diabetic whose insurance changed, requiring a different dose of a new brand of insulin. And the man with bloody stools who forgot to take stomach medicine and developed an ulcer.
In each case, Creek and his colleagues noticed the changes and educated their clients about the need for following prescribed doses of essential medication. Each intervention prevented an emergency room visit and a likely hospital stay with more serious implications.
Creek’s once-a-week visits to fill a pillbox and schedule a couple of doctor visits kept a 70-year-old man with a tendency to dial 911 from making an emergency call for almost a year. In the six months before, he had visited the local emergency room seven times, requiring four ambulance rides and five stays in intensive care largely because he fumbled taking daily pills.
Many of the patients served by Eagle County’s community paramedics are older. The help from Creek and his crew allow the county’s aging residents to live in their homes a bit longer.
In a community without a nursing home, that’s a big deal.
“This has been a godsend to our seniors,” Tymkovich said. “People want to stay in their homes. If my mom had had a program like this, she might still be alive today.”
Jason Blevins: 303-954-1374, jblevins@denverpost.com or twitter.com/jasonblevins
