Administration and Leadership, EMS Insider, Mobile Integrated Healthcare

NAEMSE Position Paper on Community Paramedicine and Mobile Integrated Healthcare

The National Association of EMS Educators (NAEMSE) has adopted the following positions on community paramedicine (CP) and mobile integrated healthcare (MIH) services, organizations, professional practices, education and the roles of EMS educators with regards to MIH-CP programs. 

Executive Summary

NAEMSE recognizes that the intellectual foundations of practice and roles of EMS providers have expanded beyond the rigidly-prescribed content originally established by the U.S. Department of Transportation (DOT) National Highway Traffic Safety Administration (NHTSA)  National Standard Curriculum for paramedics which transitioned to the National EMS Education Standards, approved Jan. 30, 2009.

The evolution of EMS and out-of-hospital care has included the development of a new practitioner, commonly termed Community Paramedic, and a new practice paradigm, commonly termed Community Paramedicine (CP), when it’s organized by EMS, or Mobile Integrated Healthcare (MIH), when it’s organized and administratively or clinically integrated with other healthcare entities.

As these expanding roles and practice paradigms become increasingly codified through state laws, administrative rules and academic education programs, nationally and internationally,2 it’s appropriate, if not essential, that EMS educators are fully informed about these trends and are prepared to fill the roles of education and training program directors, and primary or secondary instructors for such programs. 

Furthermore, NAEMSE recognizes that professional acceptance and endorsement by the general medical community and healthcare regulators, including federal, state and local governments and governing entities, professional accrediting agencies, health education accreditation agencies, sponsoring organizations of EMS educational programs, and third-party payers is dependent upon all stakeholders viewing MIH-CP as an authentic occupation with approved professional standards, third-party certification testing and national registries. 

Therefore, NAEMSE formally endorses federal recognition of both CP and MIH through the development and delivery of structured and broadly-recognized education programs that meet rigorous regulatory standards for curricula, instructional design and program accreditation. 

Further, NAEMSE acknowledges and supports that MIH-CP advocates have made several recommendations regarding the expansion of EMS practice under a CP or MIH model that include, but may not be limited to, the following: 

  • CP and MIH education begins in the classroom and progresses to a variety of non-traditional EMS clinical and field settings;
  • In addition to learning environments for general chronic illness prevention and management, clinical locations for CP or MIH education should include settings such as sobriety centers featuring the medical and holistic management of patients with chronic alcohol and/or drug dependency, the treatment of acute overdoses and promoting wellness strategies to assist these patients on the road to recovery;
  • Clinical opportunities should also include participation in family and community immunization programs as authorized by local jurisdictions; and
  • NAEMSE formally endorses and joins 10 other well-established national professional organizations in recognition of CP and MIH roles and nomenclature. 

Definitions

Community Paramedicine: One or more services provided by EMS agencies and practitioners that are administratively or clinically integrated with other healthcare entities.

Mobile Integrated Healthcare: Care provided by a wide array of healthcare entities and practitioners that are administratively or clinically integrated with EMS agencies. 

MIH-CP may include, but not be limited to, services such as:

  • Increasing access to care in underserved areas;
  • Providing telephone advice to 9-1-1 callers without requisite dispatch of response units;
  • Using community paramedics or other specially trained EMS practitioners for the management of high-frequency patients, patients who are at high risk for hospital readmission, for monitoring patient compliance and achievement of prescribed patient outcomes in their discharge plans, advocating for healthy choices and preventive care, and encouraging post-hospital discharge follow-up visits.
  • Transport or referral of patients to a broad spectrum of appropriate healthcare resources, not limited to only hospital EDs.3

History

The history and development of the MIH-CP movements has been well-documented.4 The specific title of Community Paramedic, in the most current iteration in the U.S., was formally adopted at a developmental meeting in Lincoln, Neb., in 2007. Attendees at the meeting included Dennis Berens, Bill Raynovich, Gary Wingrove and Ron Stewart, MD, among others. 

This was a challenging decision to make, as it was understood that the title of paramedic would imply a rigid paradigm of advanced-level EMS care (that may or may not include transportation). The intention was to expand the role of this new practitioner to include other healthcare professionals, with the understanding that adopting a title inclusive of the term paramedic would inevitably cause the specific title of paramedic to become less clearly defined. 

Compounding the challenge was the realization that the definition and scope of practice implied by the title paramedic was inconsistent both state to state and internationally. Thus, the broader international context was adopted, given that  other  titles were either less descriptive or misleading, such as Community Health Aide, as used in the pioneering Alaskan model,4 and Community Health Specialist, as used in the Taos County Red River, N.M., project.5 Importantly, identifying a practitioner with paramedic in the title placed the evolving initiative firmly within the domain of EMS, which would serve as a solid foundation during the seminal developmental stages.

The movement gained national attention in 2012 among a gathering of interested physicians in Chicago. They reflected on the concept of CP and expanded the paradigm from the perspective of a sole EMS provider to a fully integrated healthcare role that includes practitioners other than paramedics—thus, the genesis of MIH.

CP and MIH models have continued to evolve through a plethora of independent and successful operational and educational initiatives that have been disseminated through numerous webinars and annual meetings of leading professional organizations. 

It’s noteworthy that three versions of a Community Health Education Cooperative Community Paramedic Curriculum have been distributed at no cost to nationally accredited post-secondary educational institutions and that a fourth version is in the final stages of manuscript development and review. Finally, the American Academy of Orthopedic Surgeons (AAOS) and Jones and Bartlett have published textbooks and educational resources for teaching CPs.

The Affordable Care Act began a major planned disruption of the healthcare system. Now, impending changes are adding more complexity and uncertainty as to how all covered lives may receive optimal care. It’s clear that all U.S. healthcare providers will need to transition business models or they won’t survive and thrive moving forward.

CP and MIH services are uniquely positioned to impact healthcare in a positive way. The current U.S. healthcare system is:

  • Fragmented with disconnected care points;
  • Facility, payer and provider centric, not fully patient-centered;
  • Procedure- and illness-oriented—not health outcomes-oriented; and
  • Evolving to a quality- and value-oriented system.

A survey of healthcare CEOs by the Advisory Board Company reports that they identify the biggest challenges for healthcare in 20178 and CP and MIH programs can address many of them, including:

  • Improving ambulatory access;
  • Innovative approaches to expense reduction;
  • Boosting outpatient procedural market share; and
  • Minimizing unwarranted clinical variation.

Recommendations

NAEMSE formally endorses and recommends the following:

  1. The broad adoption of current and future CP and MIH roles, services, education and training programs.
  2. The professional development of CP and MIH services and educational and training programs in compliance with federal and state laws, and administrative rules and regulations; development of evidence-based MIH-CP practice guidelines; oversight by existing or new accrediting bodies; collaboration with the local medical community for the delivery of MIH-CP services; development of third-party administered, psychometrically sound and legally defensible certification examinations consistent with current practice; and, creation of a registry for MIH-CP practitioners and educators.
  3. The creation of federal, state and local funding infrastructures and revenue streams such that CP and MIH programs are fiscally sound and longitudinally sustainable through established tax bases and third-party payers; and, that EMS providers and educators are equitably compensated for the professional services that they render.
  4. Education and training of CP and MIH practitioners and educators should ideally be conducted by and/or in collaboration with accredited post-secondary institutions and incorporate cooperative agreements with local healthcare entities. The education should be conducted with oversight of physicians and include full input and participation by local stakeholders. The CP and MIH educational programs and curricula should be based on a community health needs assessment that includes participation of MIH-CP educators.
  5. MIH-CP provider agencies should be fully integrated with state and local health departments, EMS systems, police, firefighting services, military organizations and mental health providers based on local need and governance structures.
  6. It’s strongly recommended that clinical education of Community Paramedics include sobriety centers, locating and managing patients with chronic addictions and acute overdoses, and active participation in family and community immunizations programs as allowed by state and local jurisdictions.

It’s the position of NAEMSE that CP and MIH should be fully integrated with community healthcare professionals and home health agencies, and that support and oversight should be provided by state and regional health departments and local EMS governance structures.

References

1. Zavadsky M. Reno roundtable report: Insight on community paramedicine from around the world. JEMS. 2015;41(1):14. 

2. O’Meara P. (Sept. 30, 2015.) The International roots of community paramedicine. EMS World. Retrieved Sept. 28, 2017, from www.emsworld.com/article/12120727/the-international-roots-of-community-paramedicine.

3. NAEMT, NASEMSO, ACCT, NAEMSE, IAED, AAA, North Central EMS Institute, NEMSMA, the Paramedic Foundation and NAEMSP. (Jan. 31, 2016.) Joint vision statement on Mobile Integrated Healthcare (MIH) and Community Paramedicine. NAEMT. Retrieved Sept. 28, 2017, from www.naemt.org/docs/default-source/community-paramedicine/MIH_Vision_02-06-14.pdf.

4. Alaska Community Health Aide Program. (n.d.) Retrieved Sept. 28, 2017, from www.akchap.org.

5. Hauswald M, Raynovich W, Brainard AH. Expanded emergency medical services: The failure of an experimental community health program. Prehosp Emerg Care. 2005;9(2):250–253.

6. Tan DK. EMS at the healthcare table. JEMS. 2013;38(4):48–50.

7. American Academy of Orthopaedic Surgeons: Community health paramedicine. Jones & Bartlett Learning: Burlington, Mass., 2017. 

8. Umansky B, Lee C. (May 2, 2017.) What 183 C-suite executives told us about their top concerns. The Advisory Board. Retrieved September 29, 2017, from www.advisory.com/research/health-care-advisory-board/blogs/at-the-helm/2017/04/hcab-topic-poll.