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Is Community Paramedicine the Next Step for EMS?
Healthcare continues to be a significant point of discussion in Washington, D.C. and state capitols around the country. Emergency medical services, which for the last decade has been a technologically driven field, has now begun to look at how it fits, or better yet integrates into the existing and changing healthcare landscape. Over the last 10+ years we have seen EMS expand in the area of critical care transport (CCT), industrial healthcare—often in remote or isolated areas—and disaster response. More recently, some EMS systems have begun to look at the feasibility and cost savings of “community paramedics.”
Community Paramedics
When community paramedics (CP) are first mentioned, many citizens say they already have paramedics where they live. So, what is a community paramedic? A CP is a paramedic or an EMT who already operates in their service area and/or community, and who has taken advanced didactic and clinical education in a number of areas enabling them to identify the healthcare needs in underserved communities such as the homeless, elderly or those living in rural or remote areas.These areas can include:
- Health and wellness
- Health screening assessments
- Health teaching
- Administering immunizations
- Monitoring of diabetic patients
- Monitoring of post-MI patients
- Advanced mental health issues and referral
- Wound care
- Safety programs.
The CP will work with other healthcare providers as a team to provide health teaching and disease management, and monitoring of the diabetic, congestive heart patient (CHF) or post-myocardial infarction (MI) patient in their home1. Other areas of involvement would be determined or identified by the needs of the community and healthcare organizations/providers within the community.
A CP program in one county might address significantly different healthcare needs than a program in another county based upon demographics, social-economic issues or distance to medical facilities. For example, the CP might staff a fast-response unit (FRU) working with a physician in a clinic, but be available to respond with basic life support units in a rural county to bring advanced life support to areas that otherwise could not support ALS in their community. In a suburban area, the CP might be trained in advanced procedures and respond on only critical calls while performing their regular CP duties between those calls. For example, the CP might respond in a FRU to a cardiac arrest and two weeks later when the patient is discharged perform an in-home follow-up.
The options and potential use of CPs are limited only by the creativity of the EMS provider, healthcare organizations and other healthcare providers in a community. The biggest misconception is that CPs are designed to replace other healthcare providers in a community. They are not! The role of the CP is to supplement and/or enhance the current organizations and providers in a community, in cases such as when a severe influenza outbreak sickens a significant number of home healthcare providers in a rural community; following a natural disaster when health screenings, immunizations, etc. are needed; and when a rural county is exploring the feasibility of providing ALS to an aging population in their community.
Existing Programs
The CP program is based off of similar existing and highly successful programs in both the U.S. and around the world. In the U.S., Alaska has utilized community health aides (CHA)2 since the 1950s in response to a number of healthcare concerns, including the tuberculosis epidemic, rural trauma and high infant death rates. Nova Scotia’s CP program centered on remote (small population) and isolated islands requiring 50 minutes of travel to the mainland via two ferries. The focus has been on diabetic patient management and in-home wound care. The program has resulted in a 23% decrease in emergency department visits by those living on the island3 with a substantial cost savings to both patient and provider. Australia’s Rural and Remote Paramedic (RRP) program looks at the RRP as an integral part of their rural and remote primary healthcare program which consists of physicians, nurses and indigenous health workers4.
The commonalities of these programs are first, they focus on primary healthcare with the ability of emergency response. Second, they are all remote and for the most part rural. For example, Alaska’s population is 1.2 persons per square mile (PPSM)5, Australia’s is 0.55 PPSM6, and Nova Scotia’s Long and Brier Islands year round population of 1,240, which does swell with summer tourism3. These areas resemble a significant part of the U.S. which is close to 80% rural and/or remote5 with many areas populations swelling seasonally with tourism. Roughly 9% of U.S. physicians practice in rural areas, which have 20% of the nation’s population7. It is easy to see how CPs can play a significant role in supplementing and enhancing existing healthcare organizations/providers in communities throughout the U.S.
Education
The CP program is typically 115 to 146 hours in length, consisting of didactic and clinical hours8 and is a certificate program. Since these programs are typically implemented for a specific area or community, the core courses or education will look the same, but following that, each program will add courses or education to address the specific needs of the community.9 The benefit of this is that as a community’s needs change, the CP can adapt to those changes by adding additional education. As with all fields, continuing education will play a role in maintaining knowledge, skills and addressing specific needs of the community.
The Future
The CP program has gained significant support in rural areas, and their utilization in metropolitan areas under other names, such as Washington, D.C.’s EMS “Street Calls” program,10 have been slowly increasing across the U.S. The three largest hurdles are delivery of the certificate program to rural providers; reimbursement for services provided; and a realization by healthcare organizations/providers that CPs are there to supplement and enhance healthcare delivery in a community, not to replace current organizations or providers. The CP, as part of a community’s overall EMS system, has been—and will continue to be—ready to respond when the community calls on them.
The author would like to thank Brian Lacroix, president, AllinaTransportation; Gary Wingrove, government affairs, Mayo Clinic; Kai Hjermst, director CP program, Hennepin Technical College; Dr. Mike Wilcox, medical director CP program, Hennepin Technical College, for their time and insight in preparing this article.
References
1. Community Paramedic https://156.98.150.11/divs/hpsc/hep/transform/dec10documents/communityparamedic.pdf
2. Alaska’s Community Health Aide program https://www.akchap.org/GeneralInfo.cfm
3. Nova Scotia’s Community Paramedics https://www.gov.ns.ca/health/ehs/documents/Community%20Paramedicine%20Article.pdf
4. Australia’s Rural and Remote Paramedic program https://www.micrrh.jcu.edu.au/News-Events/qas-launch-nov2006.html
5. https://www.census.gov/quickfacts/fact/table/US/PST045216
6. https://www.abs.gov.au/ausstats/abs@.nsf/PrimaryMainFeatures/3218.0?OpenDocument
7. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1071163
8. https://communityparamedic.org/Colleges.aspx
9. https://www.hennepintech.edu/program/awards/394
10. https://www.washingtonpost.com/wp-dyn/content/article/2008/03/28/AR2008032803285.html
Scott Tomek, MA, EMT-P, has been a paramedic for 25 years, 23 with Lakeview Hospital EMS in Stillwater, MN. He is a faculty member with the Century College paramedic program, and a curriculum development specialist.
