Beyond EMS

Community paramedics make house calls

 

 
 
 

Mannie Garza | | Saturday, July 26, 2008


Anyone involved with EMS in the U.S. for at least a decade no doubt remembers the push in the mid '90s to create ˙expanded-scope EMS.Ó Although that effort sputtered and appeared to have died, the concept of using EMS personnel as ˙community paramedicsÓ to provide primary care services when not responding to emergency calls lives on in Canada -- and is about to make a comeback in the U.S.

However, community paramedic proponents insist they_re talking about ˙expanded roles,Ó not ˙expanded scope,Ó for EMS providers -- a subtle but important difference. ˙Expanded scope implies that you_re expanding the paramedics_ skills and services, and others in medicine start saying, ÂHey, that_s what we do,_Ó says Nova Scotia_s former Provincial EMS Medical DirectorEd Cain, MD, a leader in the movement that created Nova Scotia_s community paramedicine program. ˙With expanded-role [EMS], we_re emphasizing that different professionals can do these various competencies, but in these settings, there are no other health-care professionals available to do them.Ó

Nova Scotia_s program began as a pilot in 1999 and has proven so successful that it has become a fixture on the islands, inspiring the creation of similar programs in remote areas of Canada.

The community paramedicine program has also captured the attention and imagination of rural health leaders in the U.S., some of whom are developing a pilot program and a community paramedicine curriculum that can be used to train U.S. EMS providers to provide primary care and prevention services.

In Nova Scotia

For the past eight years, paramedics on Long and Brier Islands have provided primary health-care and prevention services to some 1,200 residents (plus summertime visitors), both in a clinic and during home visits. (See ˙A note on Canada_s ÂParamedics,_Ó above, for an explanation on the country_s provider levels.)

Residents of the islands -- who are two hours, 20 minutes, and two ferry rides (in good weather) from the nearest hospital in Digby -- had asked provincial health officials to station a physician on the islands, which was not feasible. Instead, the province and island residents launched a multiphase pilot project using paramedics (who are stationed on the islands 24/7) to provide many primary care services.

˙[The program_s first phase] had paramedics providing [some primary] care to the community, but only within the scope of things they could do in the back of an ambulance,Ó says Marilyn Pike, former senior director of Emergency Health Services (EHS), Nova Scotia_s EMS system. ˙But we realized this wasn_t going to be enough. We held many meetings with [residents] to explain what paramedics could do. They expected the paramedics to do everything, including surgery and [obstetrical services], and it took a while to explain that paramedics couldn_t do that,Ó she says.

During this phase, which lasted 18 months, Cain says, ˙The paramedics did a lot of preventative things, and watched for signs and symptoms of something pending.Ó

An abandoned clinic in Freeport where a physician had formerly practiced was renovated to serve as headquarters for the Long and Brier Islands project. The paramedics began holding clinics there, as well as visiting patients in their homes between emergency calls. It would take half a day for a visiting nurse or home-care person from the mainland to visit a patient on the islands, Cain says ˙so paramedics do home visits.Ó

In the second phase, the paramedics began providing such services as flu shots, blood pressure and glucose checks, and home assessments (to detect fall hazards and other dangers). This required EHS to develop new policies, procedures and protocols.

The third phase brought a nurse practitioner (NP) to the islands through a collaborative practice agreement with a physician in Digby. Adding the NP allowed the paramedics (after further training) to perform wound care, blood draws and other types of primary care under the supervision of the NP in both the clinic and the field. They learned to assess patients with congestive heart failure and diabetes, assist with medication compliance, administer antibiotics, assess urine specimens, change dressings, and remove sutures and staples.

Michael McKeage, EHS vice president of clinical operations, noted that, ˙Not all paramedics will be able to do this; community health takes different skills that they_ll need to learn. And the approach to the patient in the non-emergency situation is unique, so paramedics need to be sensitive to that environment.Ó

In an unpublished report on the project, former coordinator of the Long and Brier Island Community Paramedicine Project Debbee Misner, RN, BScn, said, ˙The project_s focus dramatically altered the traditional work of the paramedics. Accustomed to quickly responding to emergency calls within a specified period of time, paramedics were now being called upon to, among other things, share a cup of tea with island residents as part of a falls prevention assessment where [they] assessed both residents and their environment for fall hazards.Ó Cain says, ˙They also created an Âadopt-a-patient_ program. They visit a shut-in on a regular basis and may be the only contact that person has.Ó

Misner noted that the community paramedics also work closely with medical first responders from the islands_ three fire departments, participating in monthly first responder training programs that provide lectures followed by skills stations on topics chosen by the first responders.

According to Misner, community paramedics have also developed collaborative relationships with local home-health services, including Victorian Order of Nurses, a non-profit organization that provides community-based health services for 10 provinces and three territories in Canada.

Cain says Dalhousie University in Halifax, Nova Scotia, has been studying the Long and Brier Islands program and is preparing to submit a paper for publication. An unpublished report on that study found that the Long and Brier project significantly reduced hospitalizations, visits to physician offices and emergency departments, and residents_ travel times and costs. Four other Nova Scotia jurisdictions are interested in adopting the program.

In Ontario

In late 2006, Beausoleil First Nation EMS on Lake Huron_s Christian Island started a program modeled on Nova Scotia_s. (˙First NationsÓ is the term Canadians use to refer to ˙Native Americans.Ó) Christian Island, which is a 25-minute ferry ride from mainland Ontario (or 15 minutes over the ice via snowmobile when the lake is frozen), has roughly 650 year-round residents and about 2,000 more in the summer. Prior to June 1, 2006, a clinic staffed by a community nurse and a home-care nurse, along with a physician who visited once a week, provided the only health care, and volunteer first responders transported emergency patients to an ambulance service on the mainland.

Beginning on June 1, paramedic service became available during the daytime, and in November, those paramedics began providing community care on Christian Island similar to that provided on Long and Brier Islands. The program ˙borrowedÓ Nova Scotia_s community paramedic curriculum, BFNEMS Manager Douglas Rawson says, and modified it to fit Christian Island residents_ needs. For example, BFNEMS added a module on insulin injections, which Nova Scotia community paramedics weren_t doing.

˙Most of our population is elderly, and the [home-care] nurse was overwhelmed by the acuity and amount of need out here,Ó Rawson says. ˙Many people were falling through the cracks. So we asked what we could do to help her, and she identified the patients who don_t need a lot of care but need to be seen.

˙Every day, we have crews going out doing everything from taking vital signs, doing blood-glucose monitoring, insulin injections, medication compliance and providing an overall view of the community and elder citizens_ health status,Ó he says. He notes that all those skills are within the paramedics_ scope of practice -- except for insulin injections, for which the paramedics received a half day of training.

˙In our first month, we found three people who needed acute interventions right away,Ó he says. ˙Our physician says that if we hadn_t seen them that day, they would have been [later] hospitalized for one to two weeks, likely in intensive care.Ó

According to Rawson, BFNEMS is now planning to greatly expand treatments this fall to include sterile wound care, suturing and immunizations. The agency also plans to teach the paramedics to do phlebotomies because ˙it makes no sense to travel three hours for a 10-second prick, [and] many people who should have routine blood work don_t get it.Ó

Rawson reports that between November and July 9, BFNEMS paramedics provided 1,000 home visits, lasting almost 495 hours, in addition to handling their usual emergency-call volume (approximately 300 calls a year). Community paramedics do an average of six daily home visits, checking on the same three patients every day and sometimes visiting as many as nine.

He notes that in the six months before the community paramedic program started, BFNEMS had transported one elderly couple six times, although none of those transports resulted in a hospital admission. ˙Since this program started, we visit them daily to check up on them and haven_t transported them once,Ó he says.

One patient ˙who wasn_t comfortable crossing the iceÓ to visit a doctor during the winter had an acute episode of hypertension, Rawson says. Paramedics doing a home check recognized that the patient_s blood pressure was dangerously high and contacted the physician; the doctor changed medications and the paramedics continued to provide daily monitoring. ˙That patient is now doing well,Ó he reports.

The biggest challenge to BFNEMS came on a winter day when two patients with ischemic cardiac disease called in distress within five minutes. Bad weather prevented anyone from leaving the island via snowmobile or air ambulance, leaving a single paramedic crew to handle both cardiac emergencies.ChristianIsland has three ambulances --frontline, backup and first-responder units -- so the two-person, on-duty BFNEMS paramedic crew split up and paired with first responders to go to both patients at once.

˙We had to bunker down and treat them in their homes,Ó Rawson says. ˙They did 12-leads and faxed them to the doctor, who changed their medications. We also have limitations on the prehospital administration of nitro, so we were able to modify that [rule] and allow the paramedics to give more.

˙We have a great staff, which has taken a lot of initiative,Ó he adds. ˙Although home visits were foreign to EMS, they say they like going out and visiting people in their homes.Ó

In theU.S.

Nova Scotia_s EHS also recently gave permission for rural health leaders in the U.S. to use and modify the Canadian curriculum.

Gary Wingrove, director of government affairs for the Mayo Clinic_s ambulance service in Minnesota, and Dennis Berens, director of the Nebraska Office of Rural Health, have joined forces to develop a ˙community healthcare specialistÓ curriculum and conduct a pilot program to show how EMS personnel can fill health-care gaps in rural and frontier areas of the country. To accomplish those goals, they recently developed the Community Healthcare and Emergency Cooperative, a consortium of rural health, EMS and academic organizations in Minnesota and Nebraska. They also secured federal grant funding through their states to get this program under way.

˙We need a new model that can serve as the front end of public health, primary care, emergency service, mental health and maybe even dental care,Ó Berens says. ˙We_re looking at using the EMS model and infrastructure, especially in the Great Plains states, where most of our EMTs are volunteers. We_d like to create some jobs for those EMTs while better caring for the health-care needs of our citizens.

He says these health-care workers don_t need to be paramedics. ˙In fact, they wouldn_t even need to be [from] EMS; but I_d like to use the volunteer EMTs we have, if we can expand their training and get some reimbursement,Ó he adds. ˙This model has the potential to break down the old EMS paradigm, which could lead to a new reimbursement paradigm.Ó

Wingrove aims to create a community paramedicine bachelor_s degree by adding the Nova Scotia models to the Minnesota Community Health Worker college certificate program. ˙We want these workers to have a broad background in EMS, public health and mental health. Then we can start spreading this degree program across the country. Our goal is to have everyone doing the same thing so that we can create a Âresearch bed_ on the effectiveness of community paramedics,Ó he says. ˙A county in Nebraska has a recently retired deputy sheriff with a PhD in mental health. He has been the first responder to every mental-health call in that county, so he knows just what EMS people need to know to handle a mental-health event.Ó Wingrove is trying to find $25,000 in federal money for the deputy sheriff to develop this segment of the University of Nebraska curriculum.

Wingrove is a founder of the International Roundtable on Community Paramedicine (IRCP), which has a mission to ˙promote the international exchange of information and experience related to the provision of flexible and reliable health-care services to residents of rural and remote areas using novel health-care delivery models.Ó In 2006, IRCP held a three-day meeting in Nova Scotia, and another in Rochester, Minn. It will hold its third-annual meeting in Australia this month and expects participants from Australia, Canada, Scotland, the U.S. and England. In between those meetings, IRCP has been holding monthly conference calls involving 30Ï50 people involved or interested in community paramedicine.

When asked what the difference was between these community paramedic programs and the ill-fated, expanded-scope programs (e.g., in Red River, N.M.) a decade ago, Wingrove says, ˙I consider this more expanded role than expanded scope. Expanded scope leaves you with the impression that EMS is expanding paramedics into the next level of health care, say into the nursing or physician level, but this is simply expanding the paramedic_s role into public health.Ó

The Dalhousie study concluded that the Long and Brier project ˙has clearly demonstrated the effect of this innovative model on increasing accessibility to a full range of comprehensive primary health-care services along with a high level of resident acceptance and satisfaction with the model of care and the positive impact of the model of care or residents_ health and reductions in health-care costs.Ó

This model certainly seems promising for filling the widening health-care gaps in remote parts of the U.S. However, finding the revenues to fund such programs could prove daunting until far-sighted policy makers agree to pay for paramedic treatment separate from transport.

Mannie Garza is news director of JEMS and editor of the management newsletter EMS Insider. She has a BA in journalism and has been writing about EMS for nearly 20 years.


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