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Ambulances Now Making House Calls

  • Upper Valley Ambulance Paramedic Stephen Sanborn checks the vital signs of Virginia Leon, 93, left, as her daughter Marie Brygider, middle, looks on during a wellness check visit to her home in Orford, N.H., Friday, Nov. 2, 2018. The emergency medical service has been making preventive house-calls in a pilot program with the Dartmouth-Hitchcock Lyme Clinic. Sanborn visits Leon roughly every three weeks. (Valley News - James M. Patterson) Copyright Valley News. May not be reprinted or used online without permission. Send requests to Valley News — James M. Patterson

  • Upper Valley Ambulance Paramedic Stephen Sanborn crosses back over the Connecticut River into Fairlee, Vt., after a house call in Orford, N.H., Friday, Nov. 2, 2018. The Fairlee based ambulance company serves seven patients in Piermont and Orford. (Valley News - James M. Patterson) Copyright Valley News. May not be reprinted or used online without permission. Send requests to James M. Patterson

  • After administering a flu vaccine, Upper Valley Ambulance Paramedic Stephen Sanborn weighs Virginia Leon, 93, as her daughter Marie Brygider stands by during a home visit in Orford, N.H., Friday, Nov. 2, 2018. Sanborn said the program allows him to get to know patients better and if he is called to an emergency visit at one of their homes he has a better understanding of their health histories. (Valley News - James M. Patterson) Copyright Valley News. May not be reprinted or used online without permission. Send requests to

Valley News Staff Writer
Published: 11/3/2018 1:14:26 AM
Modified: 11/3/2018 1:14:41 AM

Orford — Two Upper Valley ambulance companies are making house calls these days, with the philosophy that a preventive visit may help avoid an emergency call down the road.

The EMTs and paramedics are helping primary care providers monitor patients, especially those with a chronic disease, and also can spot hazards that may cause a problem later.

Incidents such as falls, for example, can result in unnecessary harm to patients and tax the emergency medical system, Geisel School of Medicine student Karissa LeClair said in a phone interview last week.

LeClair, who also is an emergency medical technician, said responders sometimes might be tied up responding to a fall in a home that lacked railings instead of being available when another emergency call, such as one for a heart attack, comes through.

Early intervention is “better in terms of efficiency of the system,” LeClair said.

To intervene before patients need to call 911, LeClair and fellow Geisel student Nicholas Valentini, also an EMT, have worked with Dartmouth-Hitchcock’s Lyme clinic and Upper Valley Ambulance to create a pilot project in which paramedics use downtime between emergency calls to visit patients in Orford and Piermont.

During these visits, paramedic Stephen Sanborn might examine potential safety hazards in the home, draw blood, give fluids, offer flu shots or check medication. If questions about a patient’s care arise, the paramedic will communicate with primary care providers at the Lyme clinic through a shared electronic medical record, said Clay Odell, executive director of Fairlee-based Upper Valley Ambulance.

When Sanborn is unavailable to visit patients in the program, Odell, who in addition to being a paramedic is a registered nurse, fills in.

The goal is to keep rural patients, especially those with chronic illnesses, “as healthy as we can for as long as we can and keep them in their home,” Odell said.

By checking on patients regularly, from as often as every couple of days for a more acute issue to every three weeks for a regular monitoring visit, Odell said the paramedic aims to “notice if there’s any decline.”

In addition to the Geisel students’ pilot community paramedicine project, which began operations about seven months ago, First Branch Ambulance, which serves Chelsea, Tunbridge and South Washington, Vt., has in recent years been offering preventive house calls to patients. First Branch recently formalized its relationship with the Chelsea Health Center, which is operated by the Randolph-based Gifford Health Care, through a memorandum of understanding.

The two programs operate under different models, First Branch deploys EMTs, who are able to provide basic life supportive care such as CPR, providing oxygen and administering glucose to diabetics; and Upper Valley Ambulance deploys paramedics, who have more advanced training in administering medications, starting intravenous lines and providing advanced airway management.

But both are examples of trends in emergency medical services care around the country.

“I think this is where EMS is going,” said Nick Mercuri, chief of strategy and planning for the New Hampshire Department of Safety’s Division of Fire Standards and Training and EMS. “It’s an exciting area for us ... to help our communities in a way that we don’t traditionally do.”

Other examples of paramedics doing preventive work in New Hampshire include the safe station programs in Manchester and Nashua that invite those struggling with addiction to come to fire stations for a medical evaluation and referral to treatment. Along similar lines, the Granite State recently received a four-year, $3 million grant from the federal Substance Abuse and Mental Health Services Administration to support additional opioid prevention work, Mercuri said.

The funds have not yet been awarded to local emergency service providers, but Mercuri said the idea will be that providers will go out to the homes of people referred to the program and considered at risk of overdose. They will train residents in the home in basic CPR and teach them how to administer naloxone, an overdose reversal drug. In addition, they will try to connect people struggling with addiction with appropriate treatment services.

Overall, the goal is to “keep people out of the hospital through a visit at home,” Mercuri said. “... Or, with the opioids, trying to get them to where they need to go.”

Right now, the EMS services in the Upper Valley are not being reimbursed for the home visits. But the prevention programs may, eventually, provide a source of revenue for struggling EMS providers, Dan Batsie, Vermont’s chief of EMS, said last week. Community paramedicine programs are one way to demonstrate the value that such providers can add to a community in hopes that someday they will get paid for these prevention efforts, Batsie said.

“It’s the chicken or the egg debate,” Batsie said.

People with poorly treated chronic conditions can be heavy users of emergency services and can have a big impact, especially on a small service, Batsie said. Community paramedicine programs can help to reduce that usage, he said.

There are some patients who aren’t sick enough to be in a hospital or to qualify for care from visiting nurses, but they still would benefit from someone looking in on them, Batsie said.

One such patient is 94-year-old Orford resident Virginia Leon, who lives with her daughter Marie Brygider. Since last winter, Sanborn has been visiting their home regularly to check on Leon, who has a variety of medical conditions including rheumatoid arthritis and cellulitis.

Leon’s arthritis makes it difficult for her to get out of her house and into a car to get to doctor’s appointments, Brygider said.

“She still will have to go for her annual exams,” Brygider said. “In the meantime, Steve can keep track of how she’s doing.”

So far, Leon’s vital signs have been fairly consistent, and the interactions with Sanborn have been pleasant, Brygider said.

“He’s very nice,” she said. “He’s very thorough.”

While the services Sanborn provides are within his range of practice as paramedic, Odell said Sanborn prepares in advance to treat each patient’s condition by reading up on it in a nursing textbook.

While paramedics know what medications a patient with emphysema needs in order to survive an emergency trip to the hospital, they may not know what medications such a patient requires on a day to day basis, Odell said.

“I want the community paramedics to have essentially the same level of knowledge for a particular case as a med/surg nurse,” he said.

Providers at both Upper Valley Ambulance and First Branch said they do not want to step on the toes of the visiting nurses or community nurses who also make home visits. Instead, the ambulance services said they aim to fill in the gaps where these groups aren’t able to provide services and when families need help.

“We feel like we provide another piece of the puzzle so the patients don’t necessarily fall through the cracks,” Odell said.

The programs also help the ambulance crew get to know the people in their communities before they show up for an emergency, First Branch EMT Chase Ackerman said.

“You know ahead of time, before you get there, what their normal status is,” he said.

In such cases, Ackerman said he knows whether a patient has an advanced directive or a do not resuscitate order.

It “gives you a lot of direction dealing with people,” he said.

For now, First Branch has a group of about 15 people who the ambulance crew visits, some more regularly than others, Ackerman said.

Upper Valley Ambulance sees seven patients regularly, most every other week, Odell said. Sanborn fits in the preventive visits between the average of three emergency calls per day, Odell said.

In the near future, Odell said he’d like to expand the pilot program to some of the ambulance service’s Vermont towns, probably Fairlee and West Fairlee.

At least one other ambulance crew in the Upper Valley also is thinking about prevention. In Lebanon, ambulance crews have begun asking patients, particularly those at the city’s senior living facilities, to sign voluntary referral forms after calls for which they decline to be transported to the hospital, Fire Chief Chris Christopoulos said. The crews then can notify a patient’s primary care provider about incidents such as falls.

“It’s attempting to get follow-up with the health care providers that know these people the best,” Christopoulos said.

Moving forward, Christopoulos said, the Lebanon department is exploring other ways to improve prevention and improve communication between different pieces of the health care system.

“There’s a lot of dots out there, but we’re not connecting them,” he said.

Nora Doyle-Burr can be reached at or 603-727-3213.

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