Traditionally, ambulance crews arrive with sirens blaring — ready to rush someone to the hospital. In Fort Worth, some paramedics are doing the opposite and scheduling visits to treat patients in their homes. It's known as "mobile integrated health care," and a ride along shows it's gaining traction.
For more than a decade, John Farris traveled through the streets of Fort Worth, working 911 calls.
“Seeing all the things humans shouldn’t see,” he says.
He couldn’t help but wonder: Could he prevent the 911 call in the first place?
It’s a question that went against the very business model of Medstar until recently. It's a question most EMS companies don’t talk about because the more trips to the hospital, the more money the company makes. But it still mattered to Farris. So, sometimes, after stabilizing a patient in the back of the ambulance, he’d try and squeeze in a conversation about nutrition or hydration. He’d be lucky if he got 10 minutes to hear their story and offer advice for staying out of the ER.
Now, he gets a full hour with five patients each day.
Stepping Away From The Ambulance
Farris still works for MedStar. He still carries a bag with a CPR kit and gauze and gloves, but he rides in a four-door sedan, not an ambulance.
Farris is what’s called a community paramedic.
It’s his job to see the trickiest patients, those who keep landing back in the ER and are re-admitted to the hospital.
Since the Affordable Care Act, the government penalizes hospitals for readmissions. So these patients have the equivalent of scarlet letters on their medical charts because they’re costing hospitals across the country hundreds of millions of dollars.
Farris is trying to figure out why they keep returning.
The second stop of the day for Farris is at Sandra Guevara’s apartment in Fort Worth.
It’s dark, and the black curtains are closed. Guevara, who is in her early 30s, sits on her couch wrapped in a Dallas Cowboys blanket while she gets her blood pressure taken.
Last year, Guevara went to the emergency department more than 20 times, occasionally needing a ventilator to breathe.
“My asthma has been going on since I was 14 years old,” she says. “My anxiety triggers it when I go places so I tend to shelter myself and stay home all the time.”
While a few visits to the ER might have saved her life, Guevara says mostly they made her feel worse. Sometimes she’d get so upset she’d walk out.
“I don’t like going to the ER," she says. "Especially when they put me in a little itty bitty room. And they want to keep me there for the whole day. I’ll literally start crying and shaking and everything, because I can’t deal with it."
Farris says that from the perspective of the doctor in the emergency room, patients like Guevara are labeled as “non-compliant." They’re seen as patients who won’t follow orders. If you spend time trying to understand the situation, that’s not usually the case, he says.
“The mental health needs that [Guevara] has, tied in with her asthma, tied in with her allergic asthma, tied in with her clotting factor, all of this stuff together, even her dehydration, all of it together is combining factors to make her worse," Farris says. "And every time she was out of the hospital, she was back in a couple of days."
He’s helped Guevara modify her diet and convinced her to drink more water and consistently take her medication. He’s also made sure her doctors know what’s going on and connected her to a psychiatrist. During their next visit, they plan to tackle one of her fears and take a short walk outside.
Taking walks with patients, talking to them about their fears, setting up social services like Meals on Wheels -- this is a major shift in emergency medicine.
A Nationwide Community Paramedic Movement
When MedStar started enrolling patients for its mobile integrated health care program in 2009, it was one of the first in the country. Today, there are more that 260 similar programs.
Dr. Darrin D’Agostino, associate dean of community medicine at UNT Health Science Center, says data shows this approach is working. For example, he says patients with congestive heart failure who are paired with a community paramedic don’t end up right back in the hospital.
“Some programs are actually showing decreases of 80 to 90 percent readmission because the services that are needed are things that are not necessary provided by the physician,” D’Agostino says.
That includes things like making sure a patient has the right medicine -- and calling the electricity provider to pay a bill and keep the lights on.
Although initial studies show managing chronic diseases like asthma and diabetes through community paramedicine can save money, D’Agostino says securing that initial funding is a major concern. Right now, most emergency services are paid for ferrying patients to the hospital.
Medstar has partnered with JPS Health Network, Texas Health Resources, Baylor and many more. It’s also working with students at Texas College of Osteopathic Medicine in Fort Worth. D’Agostino says fourth-year medical students like Parth Wohar are the first in the country to experience clinical training with community paramedics.
“We usually get such little time to speak with a patient we don’t see the true obstacles involved in taking care of them,” Wohar says.
'A friend who I can talk to'
Parth thinks in the future, telemedicine and community paramedicine will make it possible for a team of physicians to care for many more patients than they could from an office.
And patient Sandra Guevara says the type of care she gets from John Farris isn’t just medical.
“He gave me the support that I needed, I’m not going to lie,” Guevara says. “It’s like I have a friend who I can talk to now.”