The Christian Hospital EMS MIH-CP program is called the Community Health Access Program (CHAP) and targets community healthcare needs. At the forefront of CHAP are specialty-trained paramedics. These advanced practice paramedics (APPs) work closely with the department medical director and other physicians to ensure the right patient resource is given at the right time.
CHAP focuses on a number of community healthcare needs, including:
Navigation through the healthcare system: APPs perform full medical screenings on all patients to determine if a life threat or potential life threat exists. If there’s an emergency, the patient will be transported to the hospital by ambulance. If the APP determines no emergency condition exists, the patient will be navigated three ways: home treatment, an appointment with a primary care physician, or direction to a community resource such as one of two health resource centers where patients are assessed from a holistic standpoint—medical status, nutritional needs, competencies on literacy, as well as socialization in their communities.
Hospital readmission reduction: APPs make weekly home visits on potential high-risk readmissions (e.g., congestive heart failure, myocardial infarction, chronic obstructive pulmonary disease and pneumonia) and answer common questions like what foods a patient should eat or how certain medications affect someone to increase the patient’s overall confidence in remaining healthy in their home. APPs can also provide advanced assessments in the home and catch subtle symptoms that could lead to a readmission.
High-utilizer program: APPs make up to 12 weekly visitations to ensure EMS and ED high utilizers have the needed resources to manage their care and avoid countless visits to the ED.
Working with our Accountable Care Organization: Similar to the high-utilizer program, patients are given up to 12 weekly visits by an APP. The first visit includes a functional assessment, health assessment, fall risk assessment, nutritional assessment, advanced medical assessment, medication reconciliation and a psychological assessment. APPs outline care plans for these patients based on their needs through the direction of the medical director and the patient’s primary care physician.
Initial APP Training
APPs are required to take a critical care course, which includes 100 hours of didactic training on pharmacokinetics/dynamics, respiratory and cardiac pharmacology, neuropathophysiology, gastrointestinal emergencies, renal and respiratory pathophysiology, pulmonary emergencies, left ventricular assist devices, special considerations in the elderly, and lab values. It’s important APPs have a true understanding of what’s happening inside the body based on their patient’s illness. As follow-up with the education in the classroom, the students also complete 24 hours of clinical rotations in the ICU, eight hours with a respiratory therapist and 12 hours in a pediatric ICU. Our critical care paramedics are confident and prepared to provide an advanced assessment and treat difficult medical patients after this course, and it’s only at this level that they be considered for advanced training to the level of APP.
Specialty APP Training
Once we choose a group of APPs through a selective process, they’re provided advanced training focusing on the needs of our community. Initially our training is focused toward community resources and the connection of patients to medical homes and assistance: Social workers provide didactic training over the resources available in our area, and a resource coordinator from the health resource center discusses the most common resources provided to patients and how they qualify. Following resource education, our APPs have eight clinical hours with a resource coordinator to obtain a better understanding of how to provide solutions to our patient’s needs. Case studies are worked through as a group, deciding the most appropriate navigation for patients based on the presenting challenge.
Before APPs begin training with an APP preceptor, they’re required to understand the CHAP mission, protocols and processes. APPs also undergo competency-based testing on providing a full medical screening, assessed by a designated physician. The final step is five shifts with an APP preceptor where they put what they learned to the test out in the field.
Our APPs continue training throughout the course of their tenure with our program. Since CHAP inception, over 300 training hours have been logged. Training has included diabetes care; nutrition; ear, nose and throat assessments; wound care; advanced cardiology; common chronic medical illnesses; point of care testing; behavioral health; and more. APPs also are certified with vascular access devices through education and clinical rotations, understand how to manage and utilize peripherally inserted central catheter lines, and attend an eighthour clinical with a cardiologist in the hospital to assist with the assessment and treatment of cardiac patients. On average, APPs receive continuing education once a month and most of our educators are physicians or subject matter exerts in a particular area of medicine.
Being an APP isn’t everyone’s goal at this particular time in his or her career, and it’s important candidates fit the mold of this different type of provider—one that’s focused on preventive medicine and healthcare resource navigation. It takes a special type of person who wants to have an ongoing relationship with patients and isn’t in EMS for only trauma and emergency response. Most APPs have a lot of experience in EMS and are ready to try something new because they know this program truly changes the lives of their patients. It’s wonderful to see this program evolve and watch our APPs assist in the development of a healthier community.
Shannon Watson, NREMT-P, is the community health supervisor for Christian Hospital EMS in St Louis, Mo. Shannon is an author, national speaker and advocate for the EMS career field.