My immediate reaction to seeing that revenues for the Dallas Fire-Rescue's community paramedicine program were "below expectations" was anything but surprise. In fact, anyone surprised by this news doesn't have realistic expectations of novel EMS business models.
The reality is that community paramedicine programs across the country are learning how to be self-sufficient. Fire and EMS administrators are being forced to look at their balance sheets and bank accounts in a way that doesn't jibe with traditional EMS funding or reimbursement.
But when it's the health of the patient on the line, taking a chance on such a program is worth every ounce of uncertainty and political pushback. Congratulations to Dallas Fire-Rescue, and especially to Assistant Chief Norman Seals, for knowing how to respond when facing a reporter asking tough questions about a program that has yet to make any money.
No man is an island, and in our well connected world neither is any mobile integrated health care or community paramedicine program. If you're thinking about starting one in your area there are a few things that Dallas and other programs like it can teach us.
Before your start: Learn from others
Gaining information about a community paramedicine program similar to the one you're hoping to create isn't hard to do. For an industry with so many different versions of reality, EMS is well connected and Google can be your best friend.
Given Dallas' proximity to MedStar in Fort Worth I'd hazard to guess that they studied that program. But it also seems safe to assume, that MedStar wasn't the only program that Dallas Fire-Rescue examined.
Step 1: Set realistic expectations and stick to them
Community paramedicine is a new program with a new funding model trying to exist in a new health care landscape. So having a strategic plan that critically evaluates what your agency is trying to accomplish within a given market is imperative. Moving forward on an idea of this size without a plan in place is like going treasure hunting without a map; it's fun for the first 30 minutes, but it gets frustrating not long after.
Keeping stakeholders engaged means you can't promise the stars when the moon will do. Setting these realistic expectations from the beginning allows for open and honest dialogue as the program has its first successes and hits its first roadblocks.
And don't think you'll be immune to the roadblocks. Every successful EMS program has faced issues. It's how EMS leaders handled those issues that predicted how the program fared on the back end.
Step 2: Build relationships
Dr. Marshal Isaacs, Dallas Fire-Rescue medical director said it best. "It's safe to say that every major health care hospital system in Dallas is interested in this topic and this program."
It's also safe to assume that the same could be true in your area, if only the key stakeholders knew what community paramedicine actually is. But it's hard to advocate for program if someone don't know its possibility.
Meet with stakeholders of brick and mortar facilities. Sometimes bigger is better because they have economic flexibility. Other times smaller is smarter because they have less hoops to jump through in order to build a partnership. But you can't know until you're sitting across the table from them.
Step 3: Prove that it's working
Success needs to be measured beyond the single outcome of saving money. Your program will change the structure and/or process of how health care is delivered in your area. This leads to a wide variety of non-traditional outcomes favoring organizations that may not even know you exist — unless you already met with them. Those non-traditional outcomes include:
- Call volume
- Emergency department visits
- Primary care visits
- Medication adherence
- Patient satisfaction
- Employee satisfaction
- Employee retention
- 30-day readmissions
Reach out to local researchers and ask for help with the more advanced analytics. They may not have time to help you, but they probably know someone — perhaps a doctoral or masters student in search of a dissertation or thesis topic — who can.
Step 4: Share what you've learned
Once you've created a program, publish and distribute your results, even if they are preliminary and don't reflect positively. Submit a presentation for local, regional and national conferences; write an article for a peer-reviewed journal and then write a column for EMS1, and always make sure to pitch news story ideas to your local media.
Most importantly, make sure the audience knows that you are more than happy to answer any additional questions they may have.
Step 5: Don't forget where you started
Whichever step you're on, don't forget the patients and the providers who are on the ground floor. They will feel every hiccup as your program tries to expand and integrate more fully into the surrounding health care industry. Make sure they are appreciated and have an opportunity to contribute to the program's successful evolution.
Dallas Fire-Rescue may momentarily be in the hot seat with local media, but the great thing about this increased scrutiny is that it means more people within the community are aware that Assistant Chief Seals and his team are trying. Although goodwill won't pay the bills, it can have powerful impact on the success, or failure, of any new enterprise.
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Objective: The rate of nicotine metabolism, determined primarily by CYP2A6 activity, influences tobacco dependence and smoking-induced disease risk. The prevalence of CYP2A6 gene variants differs by race, with greater numbers in African Americans compared with Caucasians. We studied nicotine disposition kinetics and metabolism by the CYP2A6 genotype and enzymatic activity, as measured by the nicotine metabolite ratio (NMR), in African American smokers. Methods: Participants were administered intravenous infusions of deuterium-labeled nicotine and cotinine. Plasma and urine concentrations of nicotine and metabolites were measured and pharmacokinetic parameters were estimated. Results: Pharmacokinetic parameters and urine metabolite excretion data were analyzed by CYP2A6 genotype and by NMR. A number of gene variants were associated with markedly reduced nicotine and cotinine clearances. NMR was strongly correlated with nicotine (r=0.72) and cotinine (r=0.80) clearances. Participants with higher NMR excreted significantly greater nicotine C-oxidation and lower non-C-oxidation products compared with lower NMR participants. Conclusion: CYP2A6 genotype, NMR, and nicotine pharmacokinetic data may inform studies of individual differences in smoking behavior and biomarkers of nicotine exposure.
