Every time a paramedic walks into a hospital and hands off a patient, Jonathan Washko, assistant vice president at the Northwell Health Center for Emergency Medical Services and SkyHealth, notices something: The emergency room workflow is usually structured. But once a patient gets admitted, the coordination often dissolves. Nobody is running the whole show.
“I look at it as an orchestra, right? And there’s all these different sections doing all these different things, but yet there’s no conductor,” Mr. Washko said. “There’s no central person managing the flow of that patient from the time they walk in the door until they’re out and back.”
Mr. Washko has been in EMS for 41 years, starting as a paramedic then moving into administration. He has advised the Trump and Biden administrations on federal EMS policy and has spent the last 15 years as assistant vice president inside a major health system — long enough to see clearly what hospitals can learn from the people who show up before they do. In total, Mr. Washko has been with New Hyde Park, N.Y.-based Northwell for 20 years, including five years as a consultant to the system before stepping into his current role.
Northwell’s Center for EMS is the ambulance and emergency transport division of Northwell Health, the largest hospital-based ambulance service in the New York City area. SkyHealth, jointly owned by Northwell and Yale New Haven (Conn.) Health System, is a specialized air ambulance program integrated into the center for EMS.
What EMS figured out first
EMS has operated under intense financial constraints since its inception. Paramedics are classified as suppliers under Medicare Part B — reimbursed for transportation, not for the medicine they deliver on scene without transport, he said. They get paid only when they move a patient, forcing innovation out of necessity.
“We’ve had to learn how to do it better, faster, cheaper, and do no harm,” Mr. Washko said. “And ultimately a lot of things that we see entering healthcare today, like using Lean and Six Sigma, and command centers, we’ve been doing that since the 1970s.”
EMS had a version of the concept hospitals now call the Institute for Healthcare Improvement’s Quadruple Aim back in the ’70s and ‘80s. Mr. Washko calls it the EMS success triad: great quality of care, great experiences and financial sustainability. The difference is EMS had no choice but to operationalize it.
That scarcity-driven discipline produced highly structured, data-rich operations. Every ambulance call at Northwell is tracked from the moment the 911 call comes in until the unit is back in service. Predictive analytics determine how many ambulances are needed by hour and day of week, he said.
Vehicles are repositioned dynamically across the service area to specific street corners identified through historical call volume data. Deployment hubs are designed like rental car returns: paramedics arrive, equipment is staged and ready, every ambulance is cleaned, restocked and standardized so every bag is identical across the entire fleet.
“The item you need is always in the same place on every ambulance, regardless of what ambulance you’re on,” Mr. Washko said. That standardization, he argues, is not just about operational efficiency — it is a patient safety issue.
A data infrastructure hospitals lack
One of the less-discussed structural advantages EMS holds over the broader healthcare system is standardized data. The federal government established NEMSIS — the National EMS Information System — requiring that all EMS electronic medical records speak the same data language. States collect that data and route it to the federal level, enabling national-scale analytics on patient outcomes.
“All of our electronic medical records use this NEMSIS standard, and our data then is interoperable,” Mr. Washko said — a contrast with hospital systems, where EHR fragmentation remains a stubborn and costly problem.
That data backbone is now being used to build National Quality Forum-level outcome measures through the National EMS Quality Alliance, shifting the industry’s focus from measuring response times to measuring patient outcomes. For a heart attack patient, that means tracking whether they received the right medications on scene and were transported to a facility equipped to treat them, not just whether the ambulance arrived quickly.
“Response times only matter in a very small number of patients,” he said. “Really it’s the medicine that we’re providing, and are we doing the right thing for the patient?”
The command center difference
Hospitals have been investing heavily in command centers, and Mr. Washko is supportive — with one important distinction: Monitoring information and coordinating a patient journey are two very different things.
In EMS, command center personnel function as conductors, managing each phase of the patient journey, from dispatch to scene to transport to hospital handoff. The data is not just visible; it’s being used to direct action in real time. In hospital command centers, Mr. Washko has observed, information is often present but not coordinated at the system level.
“What we often find is we have a platform, but it’s not necessarily an integrated platform,” he said. “There’s not one person overseeing the flow of that patient from start to finish.”
His advice for health systems building command centers is to start with the pieces that are easiest to coordinate — transport, cleaning, housekeeping — and then expand into imaging, labs, physician rounding, nurse rounding and discharge planning.
“Do a better job of trying to conduct the orchestra that’s providing great care,” he said. “We just have to get the system coordinated.”
From ‘scoop and run’ to ‘keep people home’
Perhaps the most tangible thing EMS can offer health systems right now is already playing out in community paramedicine: the use of specially trained paramedics to deliver nonemergent care directly in patients’ homes, with the goal of keeping people out of the ED and preventing readmissions.
Northwell launched its community paramedicine program in 2011, making it the first and most comprehensive of its kind in New York state, a system spokesperson told Becker’s. The model pairs community paramedics handling unscheduled, acute home visits with physicians overseeing scheduled visits and telemedicine consultations.
Through the house calls program, 72% of patients are kept home. In the cancer program, that number climbs to 93%. Through Northwell’s Emergency Telehealth Services, 71% of community paramedicine responses result in the patient staying home.
“We use paramedics to do all unscheduled care in the home, and we use physicians to do scheduled care in the home,” Mr. Washko said. “And then we use telemedicine to help coordinate the care in the unscheduled situations where we respond and send a community paramedic into the home with the goal of getting the diagnostic data necessary for the physician to do a care plan change, med change, something like that or treat the patient at home.”
The framing Mr. Washko returned to is platform thinking.
“Using the same platform to do something else,” he said. “Using an ambulance service and the medicine that we can do — how do we use that instead of to get people into the hospital? How do we do it to safely keep people at home?”
The Westchester proof point
That same model is now being put to work at a smaller scale at Northwell’s Phelps Hospital in Sleepy Hollow, N.Y. The Westchester Community Paramedicine Program is a separate initiative from Northwell’s systemwide effort — launched in early 2024 as a partnership between Phelps Hospital and the Ossining Volunteer Ambulance Corps — but it is driven by the same goal: keeping people home and out of the emergency department.
Its first full year of data, running from October 2024 through September 2025, is generating its own compelling results.
The program served 339 patients across 1,081 encounters, delivered nearly 3,000 medical services including labs, screenings, medication administration, and EKGs, helped 454 patients avoid unnecessary ED visits, and reduced hospital readmissions by 34% for enrolled patients compared to those not enrolled. In a focused analysis of 800 encounters between January 2025 and August, 43% of patients would have otherwise been transported to an emergency department — yet thanks to in-home interventions, only 4% of all encounters ultimately required transport.
Barry Geller, MD, associate chief medical director and chair of the emergency department at Phelps Hospital and medical adviser for the Westchester community paramedicine program, has seen the impact across the populations EMS most frequently encounters: people managing chronic disease, patients in mental health crises and those who use the 911 system not because they have an emergency but because they have nowhere else to go.
“The community paramedicine professional who goes into a patient’s home understands what their living situation is, what their economic status is, what their understanding is of their own disease, what their compliance is,” Dr. Geller said. “I think that they would be able to address gaps in any of the things that I mentioned in a far more concrete way.”
The Westchester program extended into palliative care as well, where community paramedics supported patients with serious illness. Ninety percent of patients referred to hospice were accepted, and 77.4% of patient deaths occurred at home, far exceeding national averages.
A mental health gap EMS sees clearly
If there is one area where paramedics have a vantage point that hospitals and health systems routinely miss, Dr. Geller said, it is behavioral health.
“A big gap that EMS has a bird’s eye view to is our mental health and substance use crisis,” Dr. Geller said. “A disproportionate number of people who use the 911 system are those that have mental health issues, they have substance use issues, and are unable to get care in other types of settings.”
The traditional response — transport to the ED — is not always the correct one. Community paramedicine offers a different pathway, he said.
Rather than defaulting to the ED, a community paramedic can assess the patient, coordinate a virtual consultation with a psychiatrist, connect them to social case management or arrange transportation directly to a mental health clinic or detox center — bypassing the emergency department entirely.
“The paramedics are really trained clinicians. They’re capable of comprehensive patient assessment and on-scene treatment, and they’re also able to navigate the patient to appropriate care settings, which is not always the emergency department,” Dr. Geller said. “And that can be an urgent care center, it can be a detox center, it can be a mental health facility.”
Fragmented care is a particular problem for this population — patients who move in and out of crisis without a consistent thread connecting their episodes of care. Dr. Geller sees community paramedics as uniquely positioned to address that fragmentation, precisely because they are in the home, seeing the full picture of a patient’s life in a way that a clinician in a clinical setting cannot.
“Fragmented care occurs because there is at times lack of coordination, and there’s also lack of the understanding of what factors prevent this coordination,” he said. “By going into the patient’s home, they can form a relationship with the patient, which will really help to engage the patient. That’ll increase the likelihood of making them more compliant, and they’ll also be able to educate them on specific gaps in their knowledge.”
That ground-level visibility — combined with the ability to connect patients to social workers, facilitate virtual psychiatric consults and help patients stay connected to care between crises — is what Dr. Geller believes community paramedicine is a meaningful intervention in a behavioral health system that has long struggled with continuity.
The reimbursement wall
Despite the outcomes, community paramedicine still collides with the same structural barrier as traditional EMS: a reimbursement model that rewards transportation, not care.
“Right now, if we only pay them when they bring patients to the hospital, that’s going to probably drive that behavior to happen more often than it needs to,” Dr. Geller said.
Although some legislative progress has been made on reimbursement for treatment-in-place, both Dr. Geller and Mr. Washko see the industry as far from where it needs to be. The path forward, in Washko’s view, runs through tighter system-level coordination: using command centers not just to watch dashboards, but to actively manage the patient journey; extending EMS’ “platform” into the home through community paramedicine and telemedicine; and applying standardized, interoperable EMS data and outcome measures to guide continuous improvement.
Until that happens, the gap between what EMS is capable of and what it gets paid to do will remain wide. But the data is accumulating in support of the models, and the argument is getting harder to ignore.
“Once the government and private payers understand the tremendous value in community paramedicine, I think we’ll see a much greater adaptation to it,” Dr. Geller said.”But we need to do a much better job within the EMS community to really make people understand all the advantages that come about from having a robust community paramedicine program.”
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