How one Indiana town is reinventing emergency medical services
It’s a late-September morning and paramedic Darren Forman steps up to a front door showered with dried corn stalks and fall-themed decor. Forman, holding a bag in one hand and a scale in the other, has arrived for his second appointment of the day.
Ashley Newkirk, 31, opens the door. Right inside the house hang spooky-themed wedding photos with her husband.
“I love fall,” Newkirk said. “We got married on Halloween. It's our favorite.”
Forman waves to Newkirk’s twin toddlers — her son sports a baseball hat and her daughter wears a bow. Forman talks to them in a sweet cadence that contrasts his normally serious demeanor and graying mustache. On the sofa, Newkirk’s husband holds their five-week old newborn, Wilder.
Forman asks Newkirk if she has any questions, and then checks her blood pressure and weight. Next, he puts Wilder on a scale and listens to his heart and lungs.
Forman has run Project Swaddle for the Crawfordsville Fire Department since its launch in 2018. It is a service that aims to provide health care to mothers with risky pregnancies. Each day he meets with at-risk pregnant women and new moms and their newborns with a goal to improve maternal and infant outcomes.
Forman, a long-time paramedic, was tapped for Project Swaddle because of his more than 20 years of experience as a car seat technician for the fire department. Also — his love for working with moms and children.
“Every medical has a social aspect, and every social has a medical aspect,” Forman said.
The project, which runs alongside several other community health initiatives at the fire department, is part of the way Crawfordsville, Indiana is redefining emergency medical services.
Typically an ambulance arrives to find a person in mid-crisis and requiring immediate care. But this new approach — called community paramedicine — aims to prevent emergencies in the first place. Several people consider it the most developed program in the state, and it’s garnered national attention.
“He's always there, “ Newkirk said about Forman. “He's only a phone call away.”
During Newkirk’s first pregnancy she developed gestational diabetes. As a result of that condition her second pregnancy was deemed more risky. As a participant in Project Swaddle, she regularly met with Forman throughout her pregnancy to monitor her diabetes or other issues that could arise. The preemptive care will continue until Wilder is 1-year-old.
Project Swaddle aims to help moms with pregnancies expected to have complications. Foreman said when he’s able to help women reach nine months — which directly correlates with better outcomes for mothers and children — it keeps him going.
“They're just no better feeling,” Forman said. “I get that picture of the baby in the hospital with the mom and all's right with the world.”
But Forman faces challenges with some patients. One goal of the program is to explain how health and lifestyle changes can lead to better health outcomes for them and their newborns. Recently, a young pregnant woman arrived for her appointment in the community paramedicine building with a lit cigarette. She extinguished it and stuck it behind her ear.
Mobile integrated health, or community paramedicine, is an emerging approach to health care that strives to meet people where they are. When a paramedic steps inside someone’s home, they can better identify barriers to staying healthy — food insecurity, trouble paying bills or unsafe conditions.
“Provide more holistic services, make sure all the social determinants are taken care of, and really identify needs that would be hurdles to keeping somebody healthy,” Crawfordsville Fire Department EMS Division Chief Paul Miller said.
The goal of community paramedicine is to improve health outcomes by connecting EMS, patients and doctors. The impact is lower costs by reducing hospital admissions and keeping people out of assisted care. There’s not much data on the efficacy of Project Swaddle in Crawfordsville because it's only been operating for about three years. But research on similar mobile health programs suggests it works.
In one study of a mobile integrated health initiative, there was an 83 percent reduction in inpatient utilization among the patients seen by community paramedics.
Since 2017, the Crawfordsville Fire Department has been expanding its community paramedicine program to respond to needs in the community. Its services now range from assisting people manage chronic illnesses, access treatment for substance use disorder to helping elderly people stay in their homes to improving vaccination rates.
Soon, the fire department will offer medication assisted treatment for substance abuse in people’s own homes. This is a stark difference from clinics that would require patients to come in every day for their medication.
“Fire departments — 80 percent of their call volume is actually in the medical nature,” Miller said. “We need to get upstream of a lot of these health care issues preventatively and we can do it through community paramedicine.”
The community paramedicine program partners with the local hospital to create a continuity of care. Doctors at the hospital can view notes written by the paramedics in a patient’s medical history. The hospital helps financially support the department.
A model for others
Crawfordsville’s community medicine program grew with the help of grant money, a cooperative mayor and town council, and an engaged hospital and fire department.
Now the idea is becoming more popular and some public health and safety officials are trying to replicate Crawfordsville’s program.
“The idea was to take the model that is in Crawfordsville, and then replicate it in at least three different locations with different sets of resources and different circumstances and profits,” said Amnah Anwar, senior director at Indiana Rural Health Association.
Anwar is managing a grant from United Health Foundation that assists hospitals develop community paramedicine programs modeled after Project Swaddle. Unlike Crawfordsville, the hospitals hire and train their own community paramedics outside of a local fire department.
Anwar said she’s now familiar with the barriers other communities face to implement a community paramedicine program of their own.
For example, a volunteer fire department can have extremely limited manpower and funding, local leaders may be resistant to the idea, and it can be difficult to recruit paramedics who are interested in leaving the fast-paced field to help moms and babies.
“The need to provide that access is there,” Anwar said. “But the resources are not there in terms of workforce, as well as vehicles, along with just the proper training.”
As with many grant-funded projects, sustainability is also a concern. Will the hospitals be willing to continue the program when they need to support it themselves?
“One of the reasons why we wanted to replicate what's happening in Crawfordsville, in different adaptations of the same model, is because we want to actually gather evidence that this is really helping the hospitals in terms of the return on investment,” Anwar said.
This return on investment is the prevention of costly emergency room visits, inpatient stays and repeat admissions, which will lower hospital costs. However, it remains to be seen if these outcomes will convince hospitals and communities to consider this type of novel health care.