On a hot morning last week, a man checked in with medics at a table under a shade tent outside the Portland Exposition Building to tell them he picked up his medications. He had arrived at the city’s homeless shelter a few days earlier and the medics helped him transfer his prescriptions to a local pharmacy after he had been off them for three days.
Paramedic Meg Letellier said afterward that making that call to transfer his medicines was simple but is not something that she would be able to do in the emergency setting of an ambulance, and it avoided an emergency down the line.
Letellier is part of a unique, grant-funded Mobile Medical Outreach program serving the homeless population in Portland through a partnership between Portland Public Health and the Fire/EMS department. It has been operating since 2017 and has resulted in a reduction of emergency calls from the shelter over that time. It is accomplishing some of the outcomes at a smaller scale that the Metro Fire Chiefs Coalition had hoped would come from a community paramedicine program the coalition tried to develop for the region in 2014.
After a couple of hours at the Expo, the three paramedics working that day – Letellier, Terri McGuire, and trainee Matt Garland – packed up and drove to Oxford Street, where they set up their station in front of the city’s homeless shelter.
From a locked case in the back of their vehicle, they handed out a lidocaine patch to a woman in pain, an ankle brace to a young man with joint problems, and ointment to a woman with a rash on her arms. They directed a man to Greater Portland Health for help with a clogged ear canal.
The paramedics also hand out ibuprofen and Tylenol – things they wouldn’t carry on an ambulance – and that shelter staff do not offer, and provide a lot of foot care for people who are on their feet all day carrying all their belongings with them.
Through these interactions, the paramedics on the Mobile Medical Outreach team establish relationships with people experiencing homelessness, substance use disorder, or other conditions, and who may be averse to seeking medical attention.
“The greatest impact these medics have had is improving the relationship between the clients at the shelter and first responders,” said Angela Calvo, division chief of EMS and Training for the city of Portland. “The trust that is built by having these paramedics interacting and providing care for the shelter clients carries forward to all interactions that many of these folks are having with all first responders.”
Letellier said that during her shift the day before she had seen a man with open wounds from a burn and an abscess from intravenous drug use. He was adamant about not going to a hospital emergency room, so Letellier did some wound care and the team will continue to monitor him.
“We just keep eyes on people like that and if they do reach a point where they need further care, we can get them that,” she said. “But oftentimes, our care alone is enough to prevent them from becoming an emergency.”
In the process, the medics can start conversations about other needs, and broach the subject of rehab for people with substance use disorder. Just the other day, Letellier said, a man with whom they had developed a relationship came to the tent saying he was ready to stop using. They set him up in a detox program.
Each emergency diverted saves ambulances for other calls, which is important for a department that received 12,500 calls for EMS service in 2019, according to Calvo – an average of 34 calls a day. When the five ambulances are out on other calls, and a call comes in they must rely on mutual aid.
In addition, the program saves the Police Department resources. Whenever a call for an ambulance comes from the shelter, police are automatically dispatched, too.
“People would be calling 911 if they have a headache or stomach ache or a sore toe,” paramedic McGuire said. “They had no way to mitigate that or get any care so they just call an ambulance, and the ambulance was going to the shelter multiple times a day.”
Bridget Rauscher, manager of the Chronic Disease Prevention Program at Portland Public Health, found money in a federal substance use prevention grant to get the program started and secured Community Development Block Grant funding from the city. In the last round of CDBG funding, for 2020-2021, Mobile Medical Outreach was awarded $67,500.
As part of their data collection, medics ask each client whether they would have called 911. From May 2017-November 2019, Rauscher said, 71 responded yes. With each ambulance trip costing approximately $1,200, she said, the program has saved $85,200 in these 71 instances alone. (For individuals with MaineCare or other insurance, a percentage is reimbursed; otherwise, the city absorbs the full cost.)
Because it is grant-funded, the medics must take the shifts on top of their regular 48 hours for the Fire Department. Even so, there is a strong interest in the program, and they recently increased the number of medics staffing it from six to 13.
Not ‘community paramedicine’
The medics worked out of a small office inside the Oxford Street Shelter for years, but when the coronavirus pandemic hit, they shut down for safety concerns. As the pandemic wore on, the medics wanted to get back to work, and they were sorely missed at the shelter.
So they decided to go mobile.
The team was allocated a vehicle fitted with locked cases and took the operation outside where they could observe physical distancing. Rauscher said the initial conception for the program was for it to be mobile but this is the first time they’ve had that ability.
“This is a really oddly exciting time due to COVID for us to be able to have a dedicated vehicle and be moving around the city and really reaching people who are in need,” she said.
If they are able to have continued use of the vehicle, she said, she could see the program expanding beyond its current locations.
Although it is mobile and some of the paramedics are trained as community paramedics, the Mobile Medical Outreach program is distinct from community paramedicine.
“Our medical director is a pretty big stickler about not calling this a community paramedic program,” Letellier said.
Dr. Matt Sholl, who is the medical director for both the Portland Fire Department and Maine Emergency Medical Services, said the community paramedicine program is an official program of Maine EMS to which ambulance services must apply.
Certified community paramedics are trained for a different type of care and use different skills than paramedics and EMTs, and work directly with primary-care providers or hospitals to deliver routine medical care outside of a doctor’s office or hospital. Maine statute requires that community paramedic services be specifically requested or directed by a physician.
Twelve community paramedics services across Maine were approved in the initial pilot program in 2013, including two operated by private EMS services in Scarborough and Lewiston.
The Mobile Medical Outreach paramedics, in contrast, operate like regular paramedics, only outside of an ambulance, and try to engage people in the homeless community to connect them to medical resources.
Fire chiefs from the greater Portland area had high hopes for community paramedicine. In 2014, the Metro Fire Chiefs Coalition was awarded a $225,000 federal grant to train up to 24 paramedics to become certified in community paramedicine. Six of Portland’s paramedics, including McGuire, received the training in 2014, and they initially staffed the Mobile Medical Outreach program.
Scarborough Fire Chief Michael Thurlow said that at the time the idea of community paramedics taking on expanded roles was spreading across the country, and the Metro Chiefs were eager to take advantage of the possibilities that opened up. But they soon found out that Maine’s community paramedicine program was not the model they were looking for.
A 2014 report from the Portland Fire Department to the Portland Public Safety, Health & Human Services Committee articulated goals for the training grant: “One of the methods envisioned to reduce health-care costs is to train our first-responders to treat certain patients at home or refer patients with non-urgent injuries or illnesses to less expensive service providers than transport to the emergency room when that is appropriate.”
But Thurlow said that Maine EMS rules and regulations limit what EMS services can do.
“We can only transport to the emergency room,” he said. “There are very few things that we can treat and release. We can’t take somebody to an urgent care (clinic). … The only option we have is to take them to the most expensive place to get service.”
This is a problem because the way people use 911 has changed over the years, he said; it has become a catch-all, used for minor medical needs the system was not designed to handle.
The Metro Chiefs had difficulty finding a medical partner and funding source that could meet that need within the community paramedicine framework. Now he said the idea is on hold.
“To be honest, we banged our head up against a wall trying to find willing partners and at the time just didn’t have it,” he said.
McGuire, who has been with the Portland Fire Department for 27 years, was one of the six trained as a community paramedic through the grant.
“I learned so much,” she said about the training. “I really loved doing it and I was really hoping we could get some kind of an actual community paramedic program up and running.”
Since then, individual municipalities began working toward developing their own community paramedicine programs specific to their communities’ needs. In Cumberland, the local EMS is going through the application process now with Maine EMS.
The team has set up a room in the station ready for one-on-one private consultations with paramedics, where residents can ask about hypertension or diabetes for example. The paramedics would be able to tell people whether they need to take the next step and see a doctor, or just give them educational materials. If approved, they also plan to use the community room to host classes with medical professionals for health awareness purposes.
Fire/EMS Chief Daniel Small said the program would fill a gap that exists in the health-care system for addressing low-level concerns and would provide an option for people who are reluctant to go to the doctor for small questions because of the cost or, now, because of fears of catching COVID-19. The program would be part of the Cumberland paramedics’ and EMTs’ regular work, and they plan on providing the service for free for any Cumberland resident.
“The big thing that we’re working on is making sure that we’re not crossing any lines and that our operations are meeting the protocols that the state of Maine has established for our service,” Small said. To that end, he is working with doctors and their medical director to lay out exactly what their community paramedics can and can’t do.
Despite the constraints, he hopes that the certified community paramedics will be permitted to use their discretion when responding to emergency calls and provide care without having to take the patient to a hospital if it is not a true emergency, in order to reduce some of the burdens on the emergency rooms.
Future of MMO
In Portland, meanwhile, the Mobile Medical Outreach program is achieving some of those outcomes: engaging homeless people who are hesitant to seek medical help, and reducing pressure on first-responders.
Rauscher said the Mobile Medical Outreach program has enough grant funding to operate through September 2022 in its current format, but she said she would like to see the program become self-sustaining.
Sholl, the Fire/EMS medical director, said that before the pandemic, he and the partners had been in discussion about what the future of the program would look like, and the possibility of transitioning to a community paramedic program was raised. He said as they start to get more comfortable with operating under the conditions of the pandemic, they will return to that question.
For now, though, it is unlikely that they will transition soon to full community paramedicine. Division Chief Calvo said she does not see this work being integrated into the paramedics’ regular shifts anytime in the near future.
“We operate a very busy 911 service for the city of Portland,” she said, “but the City has been fortunate enough to expand the utilization of our paramedics through grant funding.”
Freelance writer Jordan Bailey is a former Phoenix staff writer.