Community paramedicine is often cited as a potential solution emergency department overcrowding and long ambulance wall times, but critics point to potential problems, including emergency diagnoses being missed by EMS providers. Do paramedicine programs fill gaps in our health care system, as Melissa W. Costello, MD, FACEP, argues here? Or, do paramedicine diversion programs pose patient safety risks, as Thomas J. Sugarman, MD, FACEP, suggests? What do you think? Send your comments to acepnow@acep.org.
• “Mrs. A is back with her CHF. She was discharged yesterday, but she didn’t have a ride to go get her prescriptions filled.”
• “Mr. B is hearing voices again. They say it is cold outside, and he is hungry.”
• “Mrs. C is dying and with hospice. The family called her doctor when she started having trouble breathing, and the recording told them to call 911 if it was an emergency.”
• “Miss D is here because she wants to get off of drugs.”
• “Mr. E could go home, but he lives alone. I guess we will have to admit him.”

Every one of the hypotheticals above represents a case in which someone has fallen through a gap in our health care system. Successful 21st-century health care systems must provide continuous care across all aspects of inpatient and outpatient care from cradle to grave. Mobile Integrated Healthcare Practice (MIHP) is a growing and evolving practice of medicine that incorporates new and existing resources in the out-of-hospital environment in an effort to remedy the multitude of discontinuities that exist in our health care system. Some call this “community paramedicine.” While accurate to describe some systems, this discounts the enormous variety and potential of MIHP around the country and across the whole spectrum of providers and patients.

Powerful motivation exists for hospitals to develop care networks and teams of providers working collaboratively in the prehospital, in-hospital, posthospital, and clinic environments to help patients better participate in their care, smoothly navigate the system, and enjoy healthier and longer lives. We are seeing rapid consolidation of practices into bigger systems, but we have not effectively identified a way to handle the transition between different settings. There are gaps created by timing of discharges, availability of follow-up, communication failures between in-hospital and out-of-hospital physicians, legal barricades, high demands on outpatient practices, geographic distances, provider shortages, access to care, and, more generally, 24-7 needs in a nine-to-five world. Failure to address these gaps breeds increased length of stay, increased 30-day readmits, decreased patient experience of care, and, at worst, progression of disease or death.