Beyond the Emergency Department, Part 1: When the ED Is the Only Door
How community paramedicine, nurse navigation, and telehealth are changing the U.S. EMS model
A patient calls 911 because something is wrong.
The concern may be a fall, difficulty obtaining medication, a worsening chronic condition, an unresolved minor injury, anxiety, a behavioral-health need, or a symptom that the patient cannot confidently interpret.
The concern is real.
The patient may need assistance quickly.
But after an appropriate clinical assessment, that patient may not need the resources of a hospital emergency department.
For decades, however, the American EMS system has often offered only two practical choices:
Transport the patient to an emergency department.
Or leave the patient behind, frequently through a refusal or non-transport process.
That is not much of a care continuum.
It is a fork in the road with only one well-paved lane.
The question facing modern EMS is not how to prevent people from receiving emergency care.
It is how to connect clinically appropriate patients with the right care without abandoning them, delaying necessary treatment, or creating unacceptable risk.
That distinction is fundamental.
Redirection should never mean denial.
Treatment in place should never mean “nothing was done.”
Non-transport should never be counted as a success unless the patient received a safe plan, appropriate follow-up, and a reliable route back into emergency care if the situation changed.
The Objective Is Not to Keep Patients Out
Discussions about “low-acuity patients” can quickly become dismissive.
The patient does not know the final diagnosis when calling 911.
A symptom that sounds minor over the telephone may represent a more serious condition. Older adults, children, pregnant patients, immunocompromised patients, people with disabilities, and patients facing language or health-literacy barriers may present in unexpected ways.
Low acuity should therefore be a conclusion reached after appropriate assessment and risk stratification—not an assumption made because a complaint appears inconvenient.
The objective is not to keep patients out of the emergency department.
The objective is to identify patients who can safely receive better-matched care somewhere else.
For one patient, that may mean an urgent-care clinic.
For another, it may mean a behavioral-health facility, sobering center, federally qualified health center, primary-care appointment, home-health response, mobile crisis team, or telehealth consultation.
Some patients may be safely treated where they are.
Others may need transportation, but not necessarily in an emergency ambulance.
And many patients will still need the emergency department.
A successful alternative-care system preserves that option and makes escalation easy.
Why Did the ED Become the Default?
The emergency department became the default destination for several understandable reasons.
First, it is reliably available.
Emergency departments operate around the clock. They do not require an appointment, and they provide access to laboratory testing, imaging, specialty consultation, medication, observation, and inpatient admission.
Many community alternatives cannot offer that combination.
Second, the American ambulance system was built primarily around emergency response, stabilization, and transportation.
The ambulance was not historically financed as a mobile healthcare clinic. It was financed as transportation to a covered destination.
Medicare regulations traditionally tied ambulance payment to transportation to a limited group of destinations, most commonly a hospital emergency department. CMS acknowledged that this structure created an incentive to transport patients even when another setting might better meet their needs. The Emergency Triage, Treat, and Transport model was designed specifically to test alternatives to that arrangement.
Third, transportation to the ED is operationally familiar.
The destination is known. The handoff process exists. The hospital is open. The ambulance crew does not have to determine whether a clinic accepts the patient’s insurance, whether a behavioral-health center has capacity, whether a primary-care office can receive an unscheduled patient, or whether transportation will be available later if the patient deteriorates.
Fourth, emergency systems are appropriately cautious about risk.
It is easier to defend a decision to transport than a decision not to transport after an adverse outcome.
Finally, healthcare data remain fragmented.
EMS clinicians may not have access to the patient’s complete history, recent test results, care plan, medication changes, or scheduled appointments. The primary-care clinician may never learn that the patient called 911. The EMS agency may never learn what happened after a referral.
The result is a system in which the ambulance can become a very expensive hallway leading to a single door.
A Vision That Is Not New
The idea of a broader EMS role did not suddenly appear with smartphones or video visits.
The 1996 EMS Agenda for the Future envisioned EMS as community-based health management integrated with the overall healthcare system. It anticipated that EMS could provide acute care and follow-up, contribute to chronic-condition management, participate in prevention, and help communities use acute-care resources more appropriately.
That was 30 years ago.
Expanded-role programs subsequently developed in rural and underserved communities where paramedics were often among the few healthcare professionals capable of reaching patients in their homes. Similar needs were being recognized internationally. Community paramedicine programs began developing in Nova Scotia in 2003 and 2004, and representatives from Australia, Canada, Scotland, and the United States met in Halifax in 2005 to discuss comparable models, according to the Agency for Healthcare Research and Quality’s community-paramedicine review.
During the following decade, American programs expanded into chronic-disease monitoring, post-discharge visits, fall prevention, frequent-caller outreach, medication reconciliation, behavioral-health support, home safety, and care coordination.
Telehealth added another capability: the ability to bring a physician, advanced-practice clinician, nurse, mental-health professional, or other qualified clinician into the encounter without requiring that person to be physically present.
Community paramedicine, however, did not begin with telehealth—and telehealth alone does not create community paramedicine.
A video connection is a tool.
It is not a complete care pathway.
The Terms Are Related, but They Are Not Interchangeable
These programs are often discussed as though they all mean the same thing.
They do not.
Community paramedicine generally involves EMS clinicians working in expanded, community-based roles, frequently outside the traditional emergency-response system.
Community paramedics may conduct scheduled home visits, provide post-discharge follow-up, monitor chronic conditions, perform health assessments, support medication reconciliation, evaluate fall risks, provide education, and connect patients with clinical and social resources.
The Centers for Disease Control and Prevention describes community paramedics as clinicians who help fill gaps in care through home-based assessment, preventive services, chronic-disease support, post-discharge care, health education, and care coordination.
A community-paramedicine encounter does not necessarily begin with a 911 call.
In many programs, the purpose is to intervene before the patient reaches the point of needing 911.
Mobile integrated healthcare is the broader system within which mobile clinicians, medical oversight, hospitals, primary care, payers, public health, behavioral health, social services, and other partners coordinate care outside traditional facilities.
Community paramedicine may be one component of mobile integrated healthcare.
A useful distinction is that community paramedicine often describes the clinical role or delivery model, while mobile integrated healthcare describes the larger network supporting it.
A 2026 National Association of EMS Physicians position statement emphasizes that successful programs require a community-needs assessment, engaged medical direction, multidisciplinary collaboration, appropriate education, competency evaluation, reliable data, and sustainable payment that is not dependent solely on transportation.
Nurse-navigation programs typically connect selected 911 callers with a registered nurse or another qualified clinician for a more detailed assessment.
Depending on the program, this may occur before an ambulance is dispatched, after dispatch but before arrival, or following an on-scene EMS assessment.
The navigator may recommend self-care, schedule or facilitate an appointment, connect the patient with telehealth, arrange alternative transportation, refer the patient to a community resource, return the caller to 911, or recommend an emergency response.
A safe program must always retain a clear path back to emergency dispatch.
Telehealth allows a remote clinician to participate in the encounter through audio or video technology.
The field crew can provide vital signs, physical findings, medication information, environmental observations, and other information that the remote clinician could not obtain from an ordinary consumer video visit.
The remote clinician may help determine whether the patient requires ED evaluation, can receive treatment in place, or can be referred to another service.
Telehealth can strengthen decision-making, but it does not eliminate the need for protocols, competent field assessment, reliable connectivity, documentation, medical oversight, or follow-up.
Treatment in place means that an eligible patient receives clinically appropriate care without being transported to another facility.
That treatment might be delivered by the EMS clinician, an in-person healthcare partner, a telehealth clinician, or a combination of those resources, depending on local law and program design.
Treatment in place is not the same as obtaining a refusal.
The patient should receive an assessment, a defined intervention or care plan, instructions, escalation criteria, documentation, and follow-up appropriate to the condition.
Alternate-destination transportation means the patient is transported somewhere other than a hospital emergency department.
Potential destinations may include urgent-care clinics, behavioral-health centers, federally qualified health centers, sobering centers, mental-health crisis facilities, primary-care offices, or other approved locations.
The destination must be clinically capable of caring for the patient and operationally prepared to receive the patient.
Simply placing a clinic’s name on a destination list does not create capacity, and a locked clinic door at 2 a.m. is not an alternative-care pathway.
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How a Right-Care Pathway Works
Although local programs differ, a strong pathway generally contains six connected steps.
Initial screening
The process may begin during the 911 call or after an emergency response is dispatched.
Screening identifies possible candidates, but it should also identify symptoms, risk factors, or circumstances that require an immediate emergency response.
Telephone screening alone may not be sufficient to determine final eligibility.
On-scene assessment when indicated
EMS clinicians perform an appropriate assessment and apply defined inclusion and exclusion criteria.
The purpose is not simply to decide whether the patient looks sick.
It is to evaluate whether a proposed alternative can safely meet the patient’s needs.
Clinical consultation
A nurse, physician, physician assistant, nurse practitioner, medical-control clinician, behavioral-health professional, or other qualified practitioner may participate through telehealth or telephone consultation.
This provides additional clinical judgment and can help address prescribing, follow-up, and destination decisions.
Shared decision-making
The patient should understand the available options, their risks and benefits, possible costs, what will happen next, and how to seek further assistance.
An alternative should not be imposed merely because it is less expensive.
Care coordination
The system connects the patient with the selected resource.
That may involve scheduling an appointment, confirming that a destination will accept the patient, arranging transportation, transmitting relevant clinical information, or providing treatment at the scene.
A referral without confirmation is merely a suggestion.
Safety-netting and follow-up
The patient receives clear instructions about warning signs and when to call 911 again.
The program should determine whether the referral was completed, whether the patient later visited an ED, whether another 911 call occurred, and whether an adverse event developed.
Without that information, the system cannot determine whether the alternative was safe.
How These Models Can Help
Well-designed programs can create value in several ways.
For patients
Patients may avoid an unnecessary ambulance bill, a prolonged ED visit, exposure to a crowded clinical environment, and the disruption of being transported far from home.
They may receive care that is better connected to their actual needs, particularly when the underlying issue involves chronic disease, medication access, behavioral health, mobility, housing, food insecurity, caregiver support, or primary-care access.
For EMS systems
Appropriate navigation may preserve ambulances for time-sensitive emergencies.
Community-paramedicine programs may also address the causes of repeated 911 use instead of responding to the same unresolved problem repeatedly.
The objective should not be to make frequent callers disappear from a dashboard. It should be to understand why they keep calling and provide a safer, more durable solution.
For emergency departments and hospitals
Reducing avoidable transports may reduce a portion of ED demand and prevent some admissions or readmissions.
It is important not to oversimplify ED crowding, however. Crowding also reflects inpatient boarding, staffing, discharge delays, hospital capacity, and other problems that cannot be solved by redirecting ambulance patients alone. Reviews of ED crowding consistently describe it as a system-wide problem rather than simply the result of too many low-acuity arrivals.
For communities and payers
Alternative-care programs may reduce unnecessary utilization while improving access for people who struggle to use traditional healthcare services.
The strongest financial argument is not that every avoided transport automatically creates savings.
It is that the system can direct resources toward the setting capable of meeting the patient’s needs at an appropriate level of cost and intensity.
What Does the Evidence Show?
The evidence is encouraging, but heterogeneous.
Community-paramedicine programs do not all serve the same patients or provide the same services. A post-discharge heart-failure program should not be evaluated as though it were the same intervention as a behavioral-health response team, a rural primary-care program, or a 911 nurse-navigation service.
A 2023 systematic review found that mobile integrated healthcare and community-paramedicine programs were associated with fewer ED visits, but variation among program designs and study methods limits broad conclusions. Other reviews have similarly found promising results alongside a shortage of rigorous, longitudinal comparisons.
That does not mean the programs lack value.
It means leaders should resist borrowing a favorable percentage from an unrelated program and presenting it as the guaranteed outcome of their own.
The experience of CMS’s ET3 model makes that caution particularly important.
What ET3 Taught the United States
CMS announced the Emergency Triage, Treat, and Transport model in 2019 and began its first performance period on January 1, 2021.
The model allowed participating Medicare-enrolled ambulance organizations to offer eligible, consenting Medicare fee-for-service beneficiaries two alternatives after a 911 response:
Treatment in place, delivered by a qualified healthcare partner in person or through telehealth
Transportation to an approved alternate destination
CMS intended the ambulance component to operate for five years.
Instead, the model ended on December 31, 2023—two years early—because participation and intervention volumes were lower than expected.
At the end of the model, 147 ambulance suppliers and providers were participating, but only 72 had billed for an ET3 intervention. CMS reported 3,397 total interventions: 3,144 treatment-in-place encounters and only 253 alternate-destination transports.
Those numbers matter.
The United States did not test ET3 at the scale originally envisioned.
The final CMS evaluation identified substantial barriers:
Difficulty securing alternate-destination partners
Limited destination hours and capacity
Patient unfamiliarity and refusal
EMS clinician uncertainty or disengagement
Technology and connectivity problems
Difficulty accessing information
Challenges creating healthcare partnerships
Disruption associated with the COVID-19 public-health emergency
The evaluation found that treatment-in-place encounters were associated with moderately lower Medicare Parts A and B spending than matched low-acuity ED episodes.
However, treatment-in-place recipients also had higher follow-up ED use and higher hospitalization within five days. Mortality did not differ significantly.
CMS emphasized that the cross-sectional evaluation could identify associations but could not establish that treatment in place caused those outcomes. Differences between the patients receiving treatment in place and the comparison population may have contributed to the results.
The appropriate conclusion is not that treatment in place is inherently unsafe.
It is that avoiding an initial ED visit cannot be the only measure of success.
If the patient visits the ED several hours later, is hospitalized after deterioration, cannot complete the referral, or repeatedly calls 911, the program needs to understand why.
ET3 also demonstrated that changing a payment rule does not automatically create destination capacity, clinician confidence, patient acceptance, interoperability, or round-the-clock access.
Payment reform is necessary.
It is not sufficient.
Although ET3 has ended, CMS states that Medicaid programs may continue covering ET3-like treatment-in-place and alternate-destination services. Commercial payers, health systems, municipalities, and accountable-care organizations may also establish locally designed arrangements.
The national experiment ended.
The need did not.
Avoided Transport Is Not the Primary Outcome
Programs naturally track how many patients were not transported to an ED.
That number is operationally useful, but it is incomplete.
A high non-transport rate could reflect excellent navigation.
It could also reflect overly permissive eligibility criteria.
A low non-transport rate could mean a program is ineffective.
It could also mean clinicians are appropriately cautious during an early implementation period.
A balanced evaluation should examine:
Successful connection with the recommended service
Subsequent ED visits
Hospitalization after navigation or treatment in place
Repeat 911 calls
Clinical deterioration
Delays in definitive care
Patient understanding and satisfaction
Patient choice
Differences by race, language, disability, insurance, age, geography, and socioeconomic status
Ambulance availability
Total cost of care
Clinician adherence and confidence
A 2021 scoping review of alternate routes after on-scene ambulance assessment found support for improved patient-centered care and operational efficiency, but it also identified incorrect triage, inadequate training, weak partnerships, and insufficient measurement of patient safety as recurring concerns. The authors warned that recontact rates and agreement between clinicians are not adequate substitutes for actual patient outcomes.
That lesson should guide every program.
The Risks Are Real
Alternative-care pathways introduce risks that must be openly addressed.
Under-triage
A serious condition may initially appear minor.
Programs need conservative exclusions, access to consultation, competent assessment, and a low-friction path to emergency transport.
The referral may not be completed. The clinic may be closed, lack capacity, decline the patient, or require payment the patient cannot afford.
The EMS system must know whether the handoff actually occurred.
Patients with limited English proficiency, disabilities, unreliable internet, limited transportation, unstable housing, or inadequate social support may be less able to use an alternative pathway.
A digital solution that works only for patients with broadband, privacy, transportation, and a primary-care relationship may widen disparities.
Patients should not feel pressured to accept a lower-cost option.
Consent must be meaningful, and emergency transport must remain available when clinically necessary or when required by applicable rules and patient choice.
Workforce preparation
Traditional paramedic education emphasizes acute assessment, stabilization, and transport.
Community-based practice may require additional preparation in chronic disease, geriatrics, behavioral health, social needs, care coordination, shared decision-making, telehealth presentation, documentation, and referral processes.
The competence required should reflect the services actually being provided.
Many programs begin with grants, temporary waivers, hospital support, municipal funding, or short-term payer agreements.
A program cannot become a dependable component of the healthcare system if its funding disappears after the pilot presentation.
The Right Question
The question is not:
How many patients can EMS keep out of the emergency department?
The better question is:
How many clinically appropriate patients can the system safely connect with care that meets their needs—and how will the system know what happened afterward?
That wording changes the objective.
It replaces diversion with navigation.
It replaces transport avoidance with completed care.
It replaces a single operational number with patient outcomes.
And it recognizes that some of the patients initially considered for an alternative will appropriately be transported to an emergency department.
That is not program failure.
That is the safety system working.
Coming in Part 2
The United States is not alone in reconsidering the ambulance-to-ED pathway.
England measures telephone resolution, on-scene treatment, referral, and conveyance while expanding urgent community response services.
Canada has developed community-paramedicine programs in social housing, rural communities, private homes, and long-term-care populations.
Australia combines secondary triage, video-assisted assessment, virtual emergency clinicians, and alternative services. Ambulance Victoria reported that during 2024–2025, 22,122 of the 35,092 cases using its video-assisted triage process were redirected from emergency ambulance resources to other services.
Sweden and the Netherlands have developed broader non-conveyance and primary-care referral practices, while continuing to study recontact and patient-safety outcomes.
Germany is examining how EMS patients with unmet primary-care needs might be connected with outpatient care, although recent research demonstrates how difficult it can be to identify suitable patients consistently.
These systems use different clinicians, payment structures, referral networks, regulatory models, and definitions of success.
Part 2 will examine what they are doing, what the evidence shows, and which lessons may—or may not—transfer to the United States.
Call to Action
Does your EMS system still offer only two practical outcomes for most 911 patients: emergency-department transport or refusal?
Astera Global Solutions works with EMS agencies, fire departments, municipalities, healthcare organizations, medical-oversight programs, and payers to evaluate and develop alternative-care pathways.
That work may include:
Community-needs and call-volume analysis
Community-paramedicine program design
Nurse-navigation and telehealth integration
Clinical eligibility and exclusion criteria
Alternate-destination partnerships
Education and competency development
Implementation planning
Clinical governance and quality improvement
Performance scorecards and balancing measures
The objective is not simply to avoid transportation.
It is to build a dependable system that delivers the right care, in the right place, at the right time—and can demonstrate that the patient remained safe.
To discuss community paramedicine, nurse navigation, telehealth, or alternate-destination planning, visit Astera Global Solutions or contact info@asteraglobalsolutions.net.
Call to Action
Does your EMS system still offer only two practical outcomes for most 911 patients: transportation to an emergency department or a patient refusal?
Consider three questions:
How many clinically appropriate patients could benefit from another care pathway?
Which services are available to receive them safely?
Can your organization determine what happened after the referral?
Astera Global Solutions works with EMS agencies, fire departments, municipalities, healthcare organizations, medical-oversight programs, and payers to evaluate community needs and identify appropriate opportunities for community paramedicine, nurse navigation, telehealth, treatment in place, and alternate destinations.
The goal is not simply to avoid transportation. It is to connect patients with the right care while preserving emergency resources and maintaining a reliable clinical safety net.
To begin evaluating your system’s opportunities, visit Astera Global Solutions or contact info@asteraglobalsolutions.net.
Stay tuned for Part 2, where we will examine how ambulance and healthcare systems around the world are managing lower-acuity demand—and what the United States can learn from them.
References
Blodgett, J. M., Robertson, D. J., Pennington, E., et al. Alternatives to direct emergency department conveyance of ambulance patients: A scoping review of the evidence. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, 2021.https://link.springer.com/article/10.1186/s13049-020-00821-x
Centers for Disease Control and Prevention. The Value of Community Paramedicine.https://www.cdc.gov/ems-community-paramedicine/php/data-research/community-paramedicine/index.html
Centers for Medicare & Medicaid Services. Emergency Triage, Treat, and Transport Model.https://www.cms.gov/priorities/innovation/innovation-models/et3
Centers for Medicare & Medicaid Services. Emergency Triage, Treat, and Transport Model: Final Evaluation Report. January 2025.https://www.cms.gov/priorities/innovation/data-and-reports/2025/et3-model-final-eval-rpt
Lurie, T., et al. Mobile integrated health-community paramedicine programs’ effect on emergency department visits: An outcome study. 2023.https://pubmed.ncbi.nlm.nih.gov/36640693/
National Highway Traffic Safety Administration and Health Resources and Services Administration. EMS Agenda for the Future. 1996.https://rosap.ntl.bts.gov/view/dot/3623
Pearce, S., et al. Emergency department crowding: An overview of reviews describing measures, causes, and harms. 2023.https://pmc.ncbi.nlm.nih.gov/articles/PMC9974385/
Thurman, W. A., et al. A scoping review of community paramedicine: Evidence and implications. 2021.https://pubmed.ncbi.nlm.nih.gov/32233898/
Ulintz, A. J., et al. Mobile Integrated Health Care and Community Paramedicine: A Position Statement and Resource Document of NAEMSP. Prehospital Emergency Care, 2026.https://pubmed.ncbi.nlm.nih.gov/40748333/
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