Terri Smith’s husband is a cop. When she responds to a 911 call in her work vehicle, patients sometimes think she is, too.

“We drive an Expedition,” says Smith, a community paramedic for Huron Valley Ambulance. “People confuse it with a police vehicle even though it’s white with blue stripes.

“There’s a lot of confusion until we explain what we’re there for and that there is an ambulance coming if they want to go to the hospital,” she says. “But we explain that there’s a chance that we can treat them at home and save them three hours and the thirty-five to forty-five hundred dollar bill [for] taking an ambulance to the ER.”

“We’re not like a regular ambulance,” explains Ryan Chadderton, an HVA community paramedic based in Jackson County. Instead of “picking people up and taking them to the hospital,” they look for ways to keep them out of it.

“We have everything a regular paramedic ambulance has except a stretcher and a partner,” Smith says, “plus we have extra equipment. We can assess the patient, do some labs, evaluate how dehydrated they are, give them an IV and a series of fluids. We video chat with the doctors and decide whether we can keep the patient at home.”

“We can set appointments for them and drive them there,” Chadderton adds. “We can drive them to urgent care. We can drive them to their primary care physician and specialized appointments. We can call them the day before to remind them.”

“If we can get them where they need to go and free up the ambulance and the ER system, that’s the goal,” Smith says. “We don’t make a lot of money, but we save a lot of money. And the families are so thankful. They will call back later and say ‘send that person'” next time.

Community paramedics answer a crying need in emergency medicine. Washtenaw County’s population grew 19 percent over the last twenty-five years, but the number of non-emergency, non-acute 911 calls skyrocketed 400 percent.

“It comes from a combination of things,” explains HVA president emeritus Dale Berry. “It’s aging in place. Grandma and Grandpa aren’t going into nursing homes as fast. And the state’s mental hospitals are all closed.”

Calls also increased because of the opioid epidemic, and there’s still that old devil, alcoholism. On top of that “there’s a certain element of society that uses the emergency department for primary care,” says Berry. “And those folks use 911. For thirty, forty years we’ve said to people ‘call 911.’ Now we have people who call us fifty times a year.”

The cost of sending an ambulance to all those calls adds up fast, and not just for HVA. The biggest bills are run up in hospital emergency departments.

“We had growth [in calls] every year, 7 percent some years.” Berry says. “In ’14, the chief emergency physician from St. Joe’s called me up and said, ‘We want you to rethink bringing everybody to the emergency department.'”

Insurance changes forced the issue. “The pay system is changing,” Berry says. Insurers have started to penalize hospitals if patients are readmitted for the same problem soon after being discharged. “The Blues and other insurance companies are structuring [payments] where if you lower those incidents you get a higher payment.”

So HVA researched the problem and found a solution. “Around the county people were starting to talk about community paramedics.”

When Smith, forty-seven, heard of the concept, she thought “it seemed cool. I was in the first class” trained, in 2015. “It’s nice to get in on the ground level and see it grow and change.”

“Education is 160 hours plus seventy-six hours of clinical time,” says Chadderton, thirty-five. “And you have to be a seasoned paramedic. Not just anybody can walk in and be a community paramedic.”

“I have all the skills of a regular paramedic plus additional skills to keep people at home,” Smith says. “We can dip urine to check for urinary tract infections. We can do urine pregnancy tests. We [can] give first-dose antibiotics and call in prescriptions.

“And we have the benefit of seeing in the houses. Maybe the patient is falling multiple times because there’re rugs everywhere and they keep tripping on them.”

So far HVA has trained about thirty community paramedics. Fourteen are currently on the road in two Expeditions, one each in Washtenaw and Jackson counties. Berry says it costs about $600,000 to staff one vehicle round-the-clock, “plus the cost of operating the vehicle.”

“We can’t sustain that forever,” he continues. “Medicare is not funding it, and half of our patients are covered by Medicare. HVA and Emergent Health Partners, our parent organization, agreed to fund the program while we analyze it and see if we can get insurance companies and hospitals and doctors to fund it. They’re the ones who financially benefit if we can keep the patient out of the emergency department.

Insurers are getting the message. “We just had the medical director for Blue Cross Blue Shield of Michigan [tell us that] when we get called out to one of their insureds, they’re going to pay for it,” Berry says. “And they’re the ones that set the standard for other insurance companies.”

Last year, HVA’s community paramedics responded to 1,881 calls and diverted 831 folks from emergency departments. Through May this year, they’ve handled 832 calls and diverted 465. But the program could get much bigger.

“St. Joe’s has amassed a number of grants, and they have created a program called Whatever It Takes: whatever it takes to keep somebody at home,” Berry says. “They’re enrolling 30,000 [patients], and they’re calling our community paramedics in.”

The main objective, he says, is to reduce trips to emergency departments. The current program is already “avoiding about two a day at $2,000 a crack … And we’re only hitting the tip of the iceberg. Physicians are beginning to call us and say, ‘would you go check on somebody?'”

It’s still officially experimental–HVA is running the program under a special certification from the state. “The test is three years,” says Berry, and nearly complete. “The state is pretty convinced. We’ve had zero problems with the program. They see that it’s the right thing to do and that we are making progress. I think it’ll be mainstreamed.”

The test is just in Washtenaw and Jackson counties, each with a single vehicle on the road. But more white-and-blue Expeditions are coming. “We’re putting on a second car and a fifth community paramedic in Ann Arbor this summer,” Smith says. “The new car is going to start out as a ten-hour car,” on the road from 1 p.m. to 11 p.m. Monday through Friday.

“This is the future of EMS,” she concludes. “They have huge numbers of baby boomers, and there’re only so many beds at hospitals. What are we going to do? We’re going to monitor them at home and help try to keep all these people home, ’cause there’s nowhere for them to go.”

Local EMS will move into the future without Dale Berry: he retired in April. “I’ve been here thirty-six years, and I was twenty-nine when I got hired,” he says. “We were little then. We had six ambulances and covered just Washtenaw County.”

Now they have 135 ambulances and serve fourteen counties. They’re the biggest ambulance service in the state and getting bigger all the time.

HVA has a long history of picking up other ambulance companies but keeping the local name–in Jackson, for instance, it’s Jackson Community Ambulance. Emergent Health Partners was created in 2012 to oversee operations and centralize human resources, billing, and accounting.

In January, Emergent acquired Battle Creek’s LifeCare Ambulance Service. Founded in 1983, it now serves six counties. A nonprofit with a volunteer board, Berry says it is “almost identical” to HVA. “The boards got together and looked [into] combining them, and they did.”

LifeCare CEO Ron Slagell is Berry’s successor. Now fifty-six, he joined LifeCare as an EMT a year after it started and rose through the ranks to become CEO in 2006. He’s now CEO of HVA as well.

“LifeCare and HVA are set up similarly with identical governance structures and a similar vision,” Slagell says. “That’s because Larry Anderson of St. Joe’s put fingerprints on both organizations. He helped found HVA then came to Battle Creek,” where he helped form LifeCare.

“Dale Berry and I do a lot of things together at the state level,” Slagell says, “and with his retirement, the time was right for the organizations to run side by side under Emergent Health Partners.”

LifeCare doesn’t have community paramedics yet, but it will. For the right patients at the right time, says Slagell, “community paramedics are a great opportunity” to stay safe at home.

“Community paramedics will be well established in the future,” HVA’s new CEO predicts. “It’s a better way to deliver patient care.”