Ru­ral health: Train­ing EMTS to pro­vide pri­mary care

Ru­ral ar­eas seek ex­panded roles for paramedics

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Ru­ral com­mu­ni­ties are at the cen­ter of an ef­fort to broaden the role of emer­gency med­i­cal per­son­nel in health­care by giv­ing spe­cially trained paramedics the abil­ity to work as pri­mary care­givers in se­lected sit­u­a­tions and set­tings.

The move­ment, which calls the ex­panded care­giver a “com­mu­nity para­medic,” aims to draw on ex­ist­ing skills and ap­ply them in new ways, such as in work­ing to pre­vent falls among the el­derly or per­form­ing fol­low-up vis­its for pa­tients who could ben­e­fit from as­sis­tance in the home but may not re­quire a tra­di­tional home health visit.

Pro­po­nents of com­mu­nity paramedics say they could bol­ster care in ru­ral set­tings, fill in a miss­ing piece in the ru­ral con­tin­uum of care and help take up the slack from volunteer paramedics, who are be­com­ing more dif­fi­cult to find and man­age. “This is a way to in­crease care to the pa­tients with­out in­creas­ing cost,” says Jim DeTi­enne, pres­i­dent-elect of the Na­tional As­so­ci­a­tion of State EMS Of­fi­cials and co-chair­man of a joint com­mit­tee on ru­ral emer­gency care formed by the state emer­gency med­i­cal ser­vices of­fi­cials group and the Na­tional Or­ga­ni­za­tion of State Of­fices of Ru­ral Health.

In ad­di­tion, the role of a com­mu­nity para­medic would be de­signed to be flex­i­ble and able to fill in the gaps of a par­tic­u­lar set­ting, some­thing that would be use­ful in ru­ral ar­eas, where EMS struc­tures and sys­tems vary widely, says DeTi­enne, who works as su­per­vi­sor of the EMS and trauma sys­tems sec­tion in the Mon­tana De­part­ment of Pub­lic Health & Hu­man Ser­vices, based in He­lena.

The panel that DeTi­enne co-chairs, the Joint Com­mit­tee on Ru­ral Emer­gency Care, in De­cem­ber pub­lished a pa­per that out­lines how com­mu­nity paramedicine could work in ru­ral ar­eas. The re­port says stud­ies in­di­cate that 10% to 40% of am­bu­lance ser­vice re­sponses are for none­mer­gent events that could po­ten­tially be taken care of by a com­mu­nity para­medic.

The chang­ing look of EMS

“Emer­gency med­i­cal ser­vices of the fu­ture, whether it in­cludes com­mu­nity paramedicine or not, will not likely in­volve an ini­tial pa­tient con­tact with two EMT re­spon­ders in a $150,000 am­bu­lance and an au­to­matic ride to the emer­gency room for many calls,” the re­port notes. “Fu­ture calls may be­gin with a pri­or­ity dis­patch sys­tem, which can triage and send a va­ri­ety of re­sources, in­clud­ing com­mu­nity paramedics, who then pro­vide a more com­pre­hen­sive triage fol­lowed by treat and re­lease to pri­mary care or other ap­pro­pri­ate treat­ment op­tions.”

Pro­po­nents also be­lieve that com­mu­nity paramedicine could play a role in im­prov­ing the qual­ity of care. “The place where we think we’re go­ing to have a ma­jor im­pact is on read­mis­sions,” says Gary Win­grove, govern­ment af­fairs spe­cial­ist for Gold Cross/Mayo Clinic Med­i­cal Transport, an emer­gency transport ser­vice run by the same foun­da­tion that op­er­ates the Mayo Clinic. “We should be able to catch prob­lems be­fore they go back into the hos­pi­tal.”

Re­duc­ing read­mis­sions is a ma­jor fo­cus for the in­dus­try for im­prov­ing qual­ity and re­duc­ing cost, with the CMS set to lower re­im­burse­ment to hos­pi­tals with ex­cess read­mis­sions for heart at­tacks, heart fail­ure and pneu­mo­nia af­ter Septem­ber 2012.

Though anec­do­tal ev­i­dence in­di­cates that ru­ral EMS providers are be­com­ing harder to find, get­ting a han­dle on how many care providers there are in ru­ral ar­eas is dif­fi­cult, a prob­lem not helped by the fact that EMS is largely reg­u­lated by the auto-cen­tric Na­tional High­way Traf­fic Safety Ad­min­is­tra­tion in­stead of the health­care-fo­cused HHS.

Na­tional 2010 data re­leased this year through NHTSA shows there were 956,000 cre­den­tialed EMS pro­fes­sion­als, close to 74,000 EMS ve­hi­cles and 19,000 cre­den­tialed EMS agen­cies. The data show there were 31.4 mil­lion EMS re­sponses and 22.7 mil­lion EMS trans­ports in 2010.

The con­cept of com­mu­nity paramedicine, while still fledg­ling, is not new. Com­mu­nity paramedicine has been prac­ticed for years glob­ally and can be found in se­lected sites across North America, in­clud­ing in Min­nesota, Ea­gle County, Colo., and in Nova Sco­tia, Canada, which has served as a model for U.S. ef­forts.

Min­nesota Gov. Mark Dayton in April signed a bill cre­at­ing cer­ti­fi­ca­tion for com­mu­nity paramedics. The pro­gram, cur­rently ru­ral-fo­cused, is set to be­gin re­ceiv­ing re­im­burse­ment from the state’s Med­i­caid pro­gram in 2012, Win­grove says.

Colorado’s Ea­gle County, which is west of Den­ver and in­cludes the ski re­sort of Vail, be­gan its ef­fort in 2008 by ex­plor­ing the op­tion of re­ly­ing on com­mu­nity paramedics and soon be­gan ap­ply­ing for grants, says Chris Mon­tera, chief of West­ern Ea­gle County (Colo.) Am­bu­lance District. The pi­lot pro­gram has com­mu­nity paramedics per­form­ing such tasks as med­i­ca­tion rec­on­cil­i­a­tion, mi­nor dress­ing changes and blood pres­sure checks, Mon­tera says.

He says there al­ready have been cases in which a com­mu­nity para­medic saved a pa­tient’s life. In one case, a com­mu­nity para­medic no­ticed symp­toms on a pa­tient—sig­nif­i­cant weight gain and high potas­sium lev­els—that in­di­cated the pa­tient needed more care. Mon­tera says the doc­tor who later treated the pa­tient told them the com­mu­nity para­medic “un­equiv-

ocally” saved the pa­tient’s life.

Win­grove says ex­panded roles for paramedics might help ru­ral com­mu­ni­ties in their strug­gle to main­tain ad­e­quate per­son­nel for emer­gency med­i­cal ser­vices, which are of­ten staffed by hardto-find vol­un­teers. Un­like volunteer fire­fight­ers, where there is a rel­a­tive amount of free­dom while on call, volunteer emer­gency medicine per­son­nel have to com­mit to be­ing in town and sign up for spe­cific time blocks. And given dwin­dling pop­u­la­tion in ru­ral ar­eas and the fact that more families have both par­ents work­ing, it is more dif­fi­cult to find peo­ple to volunteer.

By bol­ster­ing the role of a ru­ral para­medic, it may draw pro­fes­sion­als to the job, re­move the need for vol­un­teers and im­prove health­care qual­ity in the area, Win­grove says.

How­ever, pro­po­nents rec­og­nize that re­im­burse­ment is an is­sue, par­tic­u­larly given ru­ral EMS’ cur­rent weak fi­nan­cial state, driven in part by the strug­gling econ­omy and the cur­rent fund­ing ap­proach. The EMS of­fi­cials as­so­ci­a­tion web­site offers a laun­dry list of woes fac­ing ru­ral EMS that in­cludes poor provider re­im­burse­ment, re­cruit­ment and re­ten­tion dif­fi­cul­ties, a dwin­dling pool of vol­un­teers, aging in­fra­struc­ture and com­mu­ni­ca­tion tech­nol­ogy prob­lems.

Ru­ral EMS providers al­ready are strug­gling, with many still re­ly­ing on such things as bake sales and other fundrais­ers to sur­vive, says Troy Ha­gen, di­rec­tor for Ada County (Idaho) Paramedics and pres­i­dent-elect of the Na­tional EMS Man­age­ment As­so­ci­a­tion. “Fund­ing is the big is­sue for most ru­ral (EMS) providers,” he says.

Am­bu­lances, ru­ral or ur­ban, gen­er­ally get paid only if they transport some­one. So hav­ing paramedics do even more than they do now with­out a struc­tural change in fund­ing is not go­ing to work in the long term, pro­po­nents ac­knowl­edge. Even though they can save money over­all, “the long-term fund­ing of these pro­grams is in ques­tion,” DeTi­enne says.

In ad­di­tion, groups that al­ready de­liver care in the home—mainly home health and pub­lic health providers—could ob­ject to a com­mu­nity paramedicine pro­gram de­pend­ing on the scope of prac­tice in a par­tic­u­lar pro­gram. Min­nesota’s law at­tracted op­po­si­tion from the Na­tional As­so­ci­a­tion for Home Care & Hospice and the Min­nesota Nurses As­so­ci­a­tion, which were con­cerned that the EMS providers were try­ing to grab some of their turf.

The NAHC dropped its op­po­si­tion to Min­nesota’s law af­ter changes were made prior to pas­sage that clar­i­fied the role of a com­mu­nity para­medic and gain­ing an un­der­stand­ing that it wasn’t a turf-grab. “We ended up be­ing OK with the Min­nesota model” af­ter changes were made that as­sured it would be used to fill gaps in care and not of­fer du­plica­tive ser­vices, says Wil­liam Dombi, vice pres­i­dent for law with the NAHC.

But the Min­nesota Nurses As­so­ci­a­tion, which is af­fil­i­ated with the la­bor union Na­tional Nurses United, never dropped its op­po­si­tion, ar­gu­ing that the law al­lowed paramedics to en­croach on the du­ties of a nurse and that the train­ing re­quired in the law was com­pa­ra­ble to pub­lic health nurs­ing.

Pro­po­nents make it clear that tak­ing on the du­ties of home health or pub­lic health nurs­ing is not a part of the plan. Com­mu­nity paramedicine is “not a ter­ri­tory grab” or in­tended “to take over home health,” says Matt Womble, ru­ral hos­pi­tal and EMS spe­cial­ist for the North Carolina Of­fice of Ru­ral Health and Com­mu­nity Care who also co-chairs the joint com­mit­tee on ru­ral health emer­gency care. Rather, he says, it’s about us­ing avail­able care re­sources more ef­fi­ciently.

Ad­vo­cates are push­ing for na­tional recog­ni­tion. Com­mu­nity paramedics are a part of a Medi­care med­i­cal home pi­lot project in Min­nesota that was ap­proved by the CMS, Win­grove says. And he says he ex­pects a bill that would give Medi­care broader au­tho­riza­tion to pay com­mu­nity paramedics to be in­tro­duced next year, though pas­sage is un­likely. It’s a first step, Win­grove says.

Paramedics par­tic­i­pate in a sim­u­lated ex­er­cise in­volv­ing a drown­ing vic­tim near Flat­head Lake, Mont. Ru­ral health of­fi­cials are push­ing ex­panded roles for EMS per­son­nel.

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