Keri Smith of Lewiston landed in the emergency room so often that the doctors, nurses and support staff knew her by first name.

Caught in what she called a “vicious cycle” of symptoms from her anxiety, asthma and diabetes, she turned to costly emergency department care to help ease anxiety attacks, bad asthma flare-ups and spikes in her blood sugar.

Smith’s primary care doctor intervened and suggested that she might benefit from non-traditional home visits and care from a new line of defense in Maine’s medical system – community paramedics.

Community paramedics are health care workers connected with an ambulance service or first-responder system. They provide care at home to patients who may not qualify for traditional home health care visits, but still need a range of help from vital sign checks, nutritional support and access to food banks, to wound care or to monitor prescription use.

For the past year, Smith, 36, has received care from Daphne Russell, a community paramedic with United Ambulance. Through weekly or biweekly appointments at home, Russell has provided Smith with referrals to mental health care resources, has helped her get a volunteer job to provide distraction and ease her anxiety and has provided regular checks on her vitals, diet and self-care routines.

“The home visits helped me reduce the ER visits and supplied me with different resources,” said Smith, who has saved money and reduced stress through her paramedicine service.

“Instead of just focusing on the medical issues alone, Daphne looked at my problems as a whole and helped me navigate around different issues.”

Russell arrives for a patient visit.

GROWING INTEREST

Community paramedicine began in Maine under a pilot program in 2012 when 12 initial services were authorized by the Legislature. The program was paid for by participating ambulance services and first responder groups. Since then, two additional ambulance services have been approved and three to four more are applying for the CP program, said Jay Bradshaw, project coordinator for the program in Maine. There are 275 EMS groups in Maine, so those participating in the CP program represent a small fraction of providers.

But interest is growing. The topic was the focus of a two-day conference in South Portland last May that drew roughly 100 attendees from a range of emergency services providers across northern New England.

“The interest is definitely there,” said Bradshaw “Having a conference dedicated to this one topic is significant in and of itself.”

But stakeholders concede that the future expansion and sustainability of CPs in Maine remains unclear, due in part to funding.

Right now, the ambulance services pay for the CP personnel or time taken by EMTs to make CP-related house calls in some communities.

Kevin McGinnis, community paramedicine chief for North East Mobile Health Services, who coined the phrase community paramedicine in 2001, said “The math is complicated. It generally doesn’t work yet. CP programs have not quite figured out how to be in the black yet.”

Community paramedics check vital signs, monitor prescription use and provide a range of other types of support.

UNNECESSARY CALLS

The problems community paramedicine is trying to address are significant. According to a 2010 study in the Annals of Emergency Medicine, frequent users of emergency departments represented 4.5 percent to 8 percent of individual ER patients, but accounted for 21 to 28 percent of all visits.

A RAND Corp. study found that between 14 and 27 percent of all emergency department visits were for non-urgent care and could save $4.4 billion a year nationally if handled in other settings such as a doctor’s office or after-hours clinic.

Besides delivering health care to people in their homes, the CP program attempts to reduce costs by eliminating unnecessary ER visits, preventing hospital readmissions and cutting out ambulance calls. In the pilot programs, CPs handled 2,704 calls from July 1, 2013 through June 30, 2015, according to an evaluation by the University of Southern Maine’s Muskie School of Public Service.

“Every time an ambulance rolls, there’s a cost in it. If someone calls 911 for something that doesn’t require an EMT, that’s a waste of money and services,” Russell said.

Russell, who previously worked as a paramedic and studied to be a CP at Colorado Mountain College, said her incentive to become one of the state’s first group of CPs was to fill the gap between true emergency care and home health care for which many patients may not qualify or a lack of access to any care.

“Access to care is a big concern in Maine. The need is so great in our community. The CP program fills that gap and keeps people healthy,” Russell said.

McGinnis echoes that his company’s involvement stems from a desire to deliver needed services.

“For North East Mobile Health, we’re committed to doing it – not because it’s going to be a moneymaker – it’s the right thing to do,” McGinnis said. North East is the largest emergency medical service in Maine.

Still, Bradshaw acknowledges that the ambulance services “can’t do this forever for free. The services that jumped into it started it because they saw it as part of their community responsibility. It’s a give-back to the community. But as this continues, they need to at least get their expenses covered.”

EMS is largely funded by Medicare and Medicaid nationally, which reimburses the emergency services for transferring someone to a hospital. The services don’t get reimbursed for making house calls on patients to coordinate Meals on Wheels, or to check on how their wound is healing or to verify that a patient is complying with taking medication.

“Forty percent of EMS calls are urgent or emergencies. Sixty percent of EMS calls could be handled in another setting but we don’t get paid to do this,” McGinnis said.

Maine is looking at other regions for ideas. In Minnesota, for example, Medicaid now pays for most CP calls.

But a recent effort to have MaineCare funds used for CP programs in Maine suffered a setback. A study to understand the cost parameters associated with the CP program was supposed to be undertaken this summer by the state Department of Health and Human Services, but was derailed by political gridlock, said McGinnis. The study was intended to be used as the basis of a proposed plan to increase the use of community paramedicine throughout the state.

“But without the study, there can be no plan,” said McGinnis. “It’s extremely unfortunate that Augusta got in the way (of) a program that clearly demonstrates a delivery of health care for people whose needs are not being met and in a way that would reduce the cost of health care.”

The challenge in getting reimbursement for CP calls is that there are few good case studies to prove the cost – and cost-savings – from the program. In theory, it makes sense that keeping people healthier and out of the ER and away from hospital readmissions saves money, but it’s difficult to quantify, McGinnis said.

The Muskie evaluation noted that “because the health care services the community paramedic provides is one of prevention .. many pilot sites noted that it is difficult to put a cost on this service.”

“It’s a chicken and egg argument. You can’t get reimbursement without data to prove your argument. And you can’t get data without providing care – but who pays for that?” Bradshaw asked.

A report to the Legislature on the status of Maine’s CP program is expected in January.