FORT WORTH, Texas — Her mother’s breathing had become labored in the wee hours of the night, during what would prove to be the Fort Worth woman’s final days living with lung cancer. Distraught, the daughter called 911.
“Her mother was having some pretty severe shortness of breath,” said Tim Gattis, the third paramedic to arrive on scene late last year. “She was certainly working very hard to obtain a breath, and was just not being successful.”
Gattis pulled up in a sports utility vehicle shortly after the ambulance had arrived, and the first two responders were already loading the 64-year-old woman into the back. The daughter was insisting that her mother go straight to the hospital, Gattis said.
But the role of Gattis and other Fort Worth paramedics trained for this type of hospice support — part of a local partnership with VITAS Healthcare, the country’s largest hospice organization — is to spend a longer stretch of time on the scene to determine if the symptoms that triggered the 911 call can be addressed without a trip to the emergency room. MedStar Mobile Healthcare, a governmental agency created to provide ambulance services for Fort Worth and 14 nearby cities, is one of several ambulance providers nationwide that have teamed up with local hospice agencies. The paramedic backup, enthusiasts argue, not only helps more hospice patients remain at home, but also reduces the potential for costlier and likely unnecessary care.
On average, 18 percent of hospice patients go to the emergency room at least once before their death, according to an analysis of Medicare data published last year in the journal Medicare data published last year in the journal Medical Care. Melissa Aldridge, the study’s lead researcher and an associate professor at New York City’s Icahn School of Medicine at Mount Sinai, describes paramedic-hospice partnerships such as Fort Worth’s as “forward-thinking” in promoting better patient care.
Hospices also can financially benefit, she said, since they’re paid a flat rate — typically just under $200 a day — regardless of where their patients are treated. So, any hospital treatment related to the patient’s condition, such as pain stemming from advanced cancer, would come out of that payment, she said. “For [the agencies], it could definitely be worth it, particularly for the one or two outlier families who seem to be using the emergency department fairly heavily during a hospice stay,” Aldridge said.
An Expanding Role
These emerging programs rely upon a new type of emergency responder. Dubbed community paramedics, they can offer a range of in-home care and support for home health patients, frequent 911 callers and others to reduce unnecessary ambulance trips. MedStar’s community paramedicine program had already been launched, when VITAS got in touch.
The Affordable Care Act had been passed, and with it the inclusion of financial penalties for hospitals if their patients return too quickly to the hospital. John Mezo, senior general manager for the Fort Worth region of VITAS, said that since many VITAS patients come from hospital referrals, it’s important that the hospice not become “a big problem for our referral sources,” he said.
So in 2012, Fort Worth’s VITAS program began contracting with MedStar, targeting patients who have been flagged during the hospice admissions process as moderately to highly likely to call 911 or end up in the hospital. (VITAS pays a flat monthly fee to MedStar for each patient enrolled.)
Once signed up, hospice patients calling 911 can be identified through various routes, including their address, name or phone number. Then a community paramedic like Gattis, who is available for home health and other types of calls, including hospice, is dispatched along with the traditional ambulance response, said Matt Zavadsky, MedStar’s chief strategic integration officer. The ambulance provider now contracts with two hospice agencies and is in talks to add others, he said.
In Ventura, Calif., a similar hospice initiative is being piloted through a state agency — part of a larger multicity effort there to study the use of community paramedics. That pilot, which has worked with some 20 hospice agencies since 2015, sends out a community paramedic to any 911 call involving a hospice patient. Also, a large Long Island, N.Y.-based health care system added similar paramedic backup last year for a portion of its hospice patients living in Queens under a grant-funded project.
If any of those nearly 180 patients or their family members calls the 24/7 hospice number with an urgent situation, a community paramedic can be immediately sent, said Jonathan Washko, assistant vice president of emergency medical services for the system, Northwell Health.
It’s “extremely rare” that patients call 911 directly, Washko said, “because we get them help, just as if they would have called 911.”
Navigating Final Days
The uncomfortable truth is that a patient on hospice can develop unsettling and sometimes scary symptoms during their final weeks or days. Secretions can accumulate in the throat, which might sound like choking, even though the patient is not, Mezo said. The patient might suffer a breathing crisis or a seizure.
VITAS stresses that a hospice nurse is available around-the-clock, by phone or to stop by. But family members can understandably be loath to wait for a nurse who might have to drive from an hour away, Mezo said.
“When it’s your loved one there and you’re in charge of them, it’s very frightening,” he said. “If you’ve ever had to call 911, even five minutes waiting on an ambulance seems like an eternity, right?”
For paramedics involved, the work has proven to be challenging and gratifying, requiring a mix of psychology and social work skills along with medicine. “You can’t Google what to do in these situations,” said Ambrose Stevens, a Ventura community paramedic, who has responded to about 40 hospice calls.
By the end of 2016, Ventura paramedics had responded to 258 hospice calls, but paramedics needed to access hospice-provided medications for pain, nausea and other symptoms in fewer than 2 percent of those calls, said Mike Taigman, project manager of Ventura County’s Hospice Community Paramedicine Pilot Project. “Most of what we do is really helping coordinate, talk people down from being upset, helping remind them of what hospice is all about,” he said.
Offering The Option
Patients or their family members can still insist on going to the emergency room, and sometimes they do. Of the 287 patients enrolled in Fort Worth’s program for the first five years — all of whom had been prescreened as highly likely to go to the hospital — just 20 percent, or about 58 patients, were transported, according to MedStar data. In Ventura, ambulance transports for hospice patients calling 911 also have declined — from 80 percent shortly before the program’s start to 37 percent from August 2015 through December 2016, according to data provided by Taigman.
That difficult night in Fort Worth, Gattis put the VITAS nurse on speaker as they talked to the daughter about ways to keep her mother more comfortable at home. The daughter agreed to hold off on ambulance transport and see if anti-anxiety medication and morphine would ease her mother’s breathing struggles.
Within a half-hour, Gattis said, it was apparent that the medicine was helping. “She was feeling better to the point that she could eat a little bit of a sandwich.”
Gattis stayed for more than an hour until the hospice nurse arrived. The woman died several days later in her own bed.