By Paul Barr

modernhealthcare.com

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 “unequivocally” 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 hard-to-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.

But given the way emergency care is structured and funded, community paramedicine faces some big obstacles in gaining acceptance. “I think there (are) a lot of challenges to that idea,” says Colbey Reagan, a partner with law firm Waller Lansden Dortch & Davis, Nashville, who works with rural providers. Rural EMS programs already are underfunded and short staffed, and requiring even more of the programs will be difficult to pull off, Reagan says. There are other practical obstacles, such as, “you've got to license this somehow,” Reagan says.

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.