Today’s community paramedics are pioneers, navigating through largely uncharted waters. One of the most frequent questions I get from agencies interested in developing an MIH-CP program is, “What do you teach your community paramedics?” Essentially they’re asking, “What should we do when we finally see a patient?” After more than a decade of community paramedic visits and with hundreds of agencies running similar programs, we have a better idea today than we’ve ever had before.
Expanded Patient Assessment
In EMS we teach students to focus on the patient’s physiological status. We take vital signs, ask our SAMPLE (symptoms, allergies, medications, past medical history, last oral intake, events leading to present illness/injury) history questions and then choose the appropriate intervention. A community paramedic assessment is much broader. While we’re interested in the patient’s medical history, we need more than a list. We need to know what the patient knows about their diseases. We need to know more than just what medications they’re taking, but also whether they’re being taken as prescribed. We ask questions about their mental health history, a very common comorbidity that makes managing a chronic disease much more challenging.
Community paramedics then significantly diverge from their traditional EMS assessments as they ask about other barriers and resources for healthcare. We ask the patient about their social support systems, their environment, their income and any transportation issues. We ask whether they’re currently working with other communitybased organizations. In short, we look for issues affecting their healthcare beyond what’s happening physiologically. We then ask something else we rarely ask in traditional EMS work: “What would you like us to help with first?”
That question reflects a fundamental difference between MIH-CP and traditional EMS work. In our traditional roles, we are problem solvers. We assess the patient and use our knowledge to stabilize, if not resolve, the patient’s illness or injury. However, in MIH-CP, the patient is the only one who can solve their problems. If we focus on an issue that’s of no importance to the patient, regardless of the potential consequences, the patient will likely not do what’s necessary to change.
This shift in roles requires us to rethink how we talk to patients. Fortunately, there’s an evidencebased style of patient interaction known as motivational interviewing (MI) to help us support the patient in our new role. In MIH-CP, MI helps providers actively listen to the patient and to avoid reflexive actions like giving advice or assuming the role of the expert in the relationship. Instead, MI focuses on asking open-ended questions, giving affirmations, using reflective listening skills and skillfully summarizing the patient’s statements to help the patient think about how best to solve their own problems.
Understanding Mental Health
Communication skills are particularly important when interacting with those with a mental health issue. In Pittsburgh, 70% of our patients report having a mental health diagnosis in addition to an average of three chronic medical conditions. Traditional EMS education places little emphasis on understanding mental health, focusing primarily on the issue as a potential safety concern. Community paramedics need a deeper understanding of mental health and what it’s like to live with these diseases every day. That understanding helps us work within the capabilities of the patient to identify the most helpful forms of assistance.
Patient Navigation & Advocacy
In traditional EMS work, our assistance comes primarily in the form of medical interventions. We defibrillate, intubate, insert IVs, administer meds and provide a whole host of other therapies that manage the acute conditions facing the patient. Although medical help can be an important part of an MIH-CP program, these patients are much more likely to need social services than medical interventions. That means community paramedics have to become familiar with the various organizations in their community that can provide financial subsidies, social support, transportation or other services the patient requires to be able to better manage their whole life, not just their medical needs.
From our traditional medical perspective, managing your health would seem to take priority over other issues. However, our experience is that when a patient is about to be evicted from their apartment, buying glucometer strips to better manage their diabetes drops to the bottom of their priorities.
Some patients just need the community paramedic to steer them to an organization that can help. In those cases community paramedics can provide lifesaving assistance just by navigating the patient to the right agency and providing their phone number to start the application process. Other times patients are overwhelmed by the application and enrollment process, which often requires the client to gather the medical and financial records needed to prove they need help. In those cases, community paramedics play a critical role in helping the patient successfully enroll in the programs by advocating on the patient’s behalf.
Community paramedics need to be responsive to the cultural practices of their patients & their local communities.
Most organizations appreciate our assistance when we accompany patients to their appointments as we speak the same language, can help translate instructions for the patient and can be less temperamental than our clients when approvals take longer than expected.
Traditional EMS uses the ED as the sole source of definitive care. Community paramedics try toavoid the ED, and have many more options available for definitive care. Those options, however, require a solid educational foundation for the community paramedic to be able to navigate and advocate successfully.
Conducting an expanded patient assessment, developing better therapeutic communication skills, having a deeper understanding of mental health issues and providing patient navigation and advocacy services are just a few important examples of core competencies that most community paramedics should have. The list is by no means all inclusive. However, the scope of services provided by MIH-CP programs will always be largely dependent on what specific populations are being served, which stakeholders are involved and what resources are available in the local communities. For example, programs targeting mothers in high-risk pregnancies will be very different from programs that try to improve hospice care.
In addition to the different stakeholders involved, community paramedics need to be responsive to the cultural practices of their patients and their local communities to ensure they’re delivering appropriate services for the patients and their families.
Each of these variables needs to be addressed in the initial training programs for the community paramedic. Programs designed to supplement primary care practices, home nursing agencies, hospitals seeking to reduce readmissions or accountable care organizations providing chronic disease management services will have to spend time building the community paramedic’s knowledgebase in each of those domains and will differ from those who are providing immunizations or biometric screening services.
As with any employee, the operational policies and procedures for the MIH-CP program will also need to be included in their initial training. EMS agencies providing MIH-CP programs need to develop patient and provider safety practices, medical direction guidelines and clinical protocols, information-sharing practices that address HIPAA and other medical-legal issues and documentation, quality improvement, and program evaluation metrics that are unique to their program. These policies and procedures are vital components of an MIH-CP program, and will have to be described in detail to community paramedics during their original training programs.
Dan Swayze, DrPH, MBA, MEMS, is vice president and COO of the Center for Emergency Medicine of Western Pennsylvania Inc. and is the project manager for the CONNECT Community Paramedic program. He can be contacted at [email protected].