Like many communities in the U.S., small town Eagle Valley, Colo., has a health-care crisis on its hands, but it's not waiting for Congress to legislate a solution. The Western Eagle County Ambulance District and Eagle County Public Health Department collaborated to create a community paramedic program that aims to improve access to health care in their rural area, where primary care physicians are scarce, 26% of people in the county are uninsured and 46% of the ambulance district's residents are uninsured.
The program is modeled after two similar community paramedic programs in the U.S., one in Minnesota through Indian Health and another in North Carolina. However, "This is the first program in the United States, that we know of, that focuses in on primary care, public health and social services -- all the aspects of health care wrapped into one location," said Chris Montera, chief of the Western Eagle County Ambulance District.
The five-year pilot program, sanctioned by the state EMS office, will redefine paramedics' role in the community within their scope of practice. The ambulance district has partnered with its local community college to bring the community paramedic curriculum developed at Hennepin Technical College in Minnesota to students in Colorado.
"They developed this program and presented it to their first class in Minnesota [in January 2009]," Montera said. "We're going to be the second pilot for that class." Coursework will include about 100 hours of didactic training along with 100 hours of clinical work over and above what a regular paramedic would receive.
A formal credential or certification is not offered, but the college will award continuing education hours and college credits that can be applied to a degree or certificate if desired. A $60,000 grant from the state of Colorado will go toward the initial training course to fund student mileage to and from courses as well as pay for the tuition of 12 attendees. Coursework begins this winter and spring, with community paramedics scheduled to take to the streets in the summer.
"This program is 100% physician-driven," Montera said."Our goal is not to take away from anything the physiciansare doing, but to become the eyes and ears in the home -- to extend primary care and public health services back into the home."
Paramedics will provide patient assessments, blood draws, immunizations, medication administration, wound care and the like, as well as create a vital communication link between primary care physicians and their patients.
"It's driven from a physician's order with a very set standard list of what the program can and cannot do," said Anne Robinson, nurse manager with the Eagle County Public Health Department. "The community paramedic would report backto the primary care provider after the visit to close that loop and link up what was going on. It's a continuum of care."
Training will extend to the physician's office, and paramedics would receive orders over the phone, Robinson said. "We also foresee them doing rounds with our hospitalists when patients are being discharged, so they can meet the patient, know what the physicians are wanting and needing, and follow up with the patient at home."
Community paramedics will also play an important role in the overarching public health mission, Robinson said. "There is a public health agency in every county of every state. Linking public health and EMS together is crucial. It's a very simple concept, yet we have different silos of public health, hospitals, EMS, primary care physicians. Public health works to link all those silos, but this program really does break them down."
Working with public health partners, which have the "knowledge and experience to know what the health priorities are in the community," paramedics will address prevention by assessing for fall risks and providing services, such as car seat or infant home safety inspections, Robinson said.
Linking the patient information community paramedics collect in the home to patients' permanent health records at their primary care physician's office will be a challenge. "We have one of three ways we're going to do to it. One is to use our current electronic patient care record. Both of our family practice clinics here in town use electronic patient records; if we could tie those together, that would be great," Montera said. "The other two options would be to enter the information directly into the physician's system or go back to pen and paper, at least initially, until we can work through those issues."
The paramedics will be equipped with digital cameras, laptops and wireless internet cards, Montera said. "We're going to try to take this idea of telemedicine and make it very simple. The physician, instead of taking time away from their practice, could log on and take a look at what's happening with their patient and refer for further care or refer for a new prescription."
Is it Sustainable?
Everyone is concerned about shrinking health-care reimbursements and budget shortfalls. The goal of this program over the long run is to save health-care dollars by preventing unnecessary ambulance transports and hospital readmissions, and reducing illness and injury in the first place. However, cost concerns at the EMS agency level are ever present.
"My hope is that we can become so integrated with public health that they'll use some of their dollars to pay for the community paramedic program," Montera said. At year three, he hopes to have enough data to present a strong case to the insurance companies for reimbursement. They're also hoping the program will prove so beneficial to the primary care physicians that they'll contribute as well.
"Year three is going to be very important to us as we look at the long-term success of this program and really see that it's been beneficial, or it hasn't, and where we go from there," Montera said.
To provide the best chance for success, they're using state grant money to hire a consultant to establish memorandums of understanding between the agencies and physicians' offices.
"The documentation piece is going to help lead the way of really establishing this program as a benchmark," Robinson said. "This will be the first time this process has been documented in order to help other agencies and counties adopt a similar model." Data collection will also be vital to proving the program's financial worthƒcrucial if they're to convince the insurance companies to reimburse for their services.
Selling it to the Troops
Is the staff receptive to the idea of community paramedics? "That was one of my initial concerns, and it continues to be," Montera said. "They thought I was a little crazy at first, and they weren't really sure how this was going to fit into an EMS role. Over time, they've started to understand what this could look like."
The initial class of 12 will include seasoned paramedics, including Montera, the deputy chief, training captain and five others from this staff. "The remaining four spots we'll open up to surrounding agencies. I already have two agencies nearby that want to start this program."
As for scheduling, Montera said the details are yet to be determined, although heallows his staff to do "quite a bit of decision-making along with the management team." Some have expressed an interest in only working as community paramedics; others want to mix shifts in with their regular field work. To prevent skill erosion, Montera said the ideal schedule, in his mind, would be to spend a month on the ambulance and then a month in the community paramedic program.
Montera said the program is garnering a lot of attention. "I want to make EMS better across the spectrum, not just here in my local community. My vision of this is not to create a cookie cutter mold but to have a template so that people across Colorado and across the nation could take this very simply and start adopting easy programs in their community that will, through partnerships, make a real difference in health in their communities."
The next couple years will prove crucial, and Montera didn't mince words: "There's a lot at stake in this program -- that we do it right -- because the people in the state of Colorado have said all eyes are on us."
Visit Western Eagle County Ambulance District online atwww.wecadems.com. For more information on the HennepinTechnical College community paramedic course, please visitwww.jems.com/news_and_articles/articles/paramedics_for_the_people.html.
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