Administration and Leadership, Mobile Integrated Healthcare

EMS-Based Urgent Care in the Ramah (N.M.) Navajo Reservation

Issue 5 and Volume 43.

The Pine Hill urgent care model is a bold move away from more traditional MIH-CP programs. Photos courtesy Chelsea C. White

The Pine Hill urgent care model is a bold move away from more traditional MIH-CP programs. Photos courtesy Chelsea C. White

 

In the United States, there are currently 567 federally recognized American Indian and Alaska Native tribes, representing almost 2.2 million citizens.1 Many of these are concentrated in the Southwest, with 23 diverse tribes and pueblos across the state of New Mexico.2 More than 10% of the population (220,000 individuals) of New Mexico identifies as a member of one of these 23 cultures.2

New Mexico is ranked 47th nationwide for population density, with an average of 17.2 people per square mile, making the entire state largely rural.3 Of the state’s 33 counties, 14 have fewer than 6.5 people per square mile, making them not just rural, but also designated frontier counties.3

The frontier nature of New Mexico poses significant challenges for EMS response, with vast distances between agencies, few EMS-trained first responders in the volunteer fire departments, unimproved roads, and limited cellphone or GPS mapping capabilities. In addition, there’s one Level 1 trauma center in the entire state. With these constraints, strong prehospital healthcare becomes not just a challenge, but also a necessity.

Many of the tribes and pueblos in New Mexico have local EMS agencies that provide the emergency medical response within their communities. Often located in rural and frontier New Mexico, they’re all faced with the challenges of limited resources and lengthy ambulance transports, requiring novel problem-solving to address the community’s needs.

American Indian Healthcare

Protected and guaranteed healthcare for American Indians has been a lengthy process. It began in the early 1800s, when the Department of Indian Affairs was formed within the Department of War, enabling American Indians who lived near military forts to receive occasional medical care from doctors working in the forts.1

In 1832, Congress set aside $12,000 for smallpox vaccinations for American Indians, and in 1836 the first formal healthcare programs were started within the Ottawa and Chippewa tribes.1 Congress appropriated $40,000 for Indian health in 1911, and in 1921 ,the Snyder Act authorized federal health services for American Indian tribes.1

It wasn’t until July 1955 that federally guaranteed healthcare for American Indians began with the foundation of the Indian Health Service (IHS).

The initial IHS was established with 2,500 personnel, 48 hospitals, 18 health centers, 62 stations, and 13 school infirmaries, with the goal of “providing a comprehensive health service delivery system for the country’s American Indian and Alaska Native populations.”1

In 1976, the Indian Self-Determination and Education Assistance Act (ISDEAA) was passed. The ISDEAA allowed tribal governments the option to fund the development of their own healthcare programs based on the specific needs of their communities or continue to receive healthcare from IHS.1

Frontier EMS Pioneers

The largest American Indian reservation in the U.S. is Navajo Nation. It consists of 27,000 square miles that stretch across Arizona, Utah and New Mexico, and is home to approximately 250,000 of the more than 340,000 members of the Navajo tribe.

Navajo Nation is divided into 110 “chapters” that are mostly geographically contiguous—that is, each chapter borders other chapters. Three of the chapters, however, sit outside the main body of Navajo Nation.4

The Ramah Chapter is one of these non-contiguous chapters. Located in rural western New Mexico, it’s population of 2,500 tribal members live far from any major highway or urbanized area.5 The Ramah Navajo School Board, a group of elected officials that governs the Ramah Chapter, was ahead of its time in 1978 when it established the Pine Hill Health Center, the first community-operated healthcare facility in the country funded by the ISDEAA. The health center was run by family medicine physicians, who lived in nearby housing provided by the school board and would often come in after hours and on the weekends to administer care.

Pine Hill is one of the two main villages of the Ramah Navajo Chapter. It’s at least 45 miles away from the nearest hospital, which has a two-bed ED and limited services. The nearest Level 3 trauma center is more than 90 minutes away. The nearest Level 1 trauma center is more than 2.5 hours away, and is typically accessed via air medical resources.

Since 1978, the Pine Hill EMS program has been based out of the Pine Hill Health Center. EMS providers initially worked in the clinic and responded to emergencies in an ambulance parked outside the clinic.This novel approach to EMS in frontier New Mexico allowed providers exposure to more patients and illnesses than they saw in the clinic, resulting in improved clinical and critical thinking skills.

Many of the EMS providers have been with Pine Hill EMS for more than a decade, including one provider who began when the clinic opened in 1978 and has continued to work to this day—39 years later. It’s a contrast to the high levels of provider burnout and limited career longevity often experienced in other EMS agencies.

Due to increasing call volume, Pine Hill EMS providers no longer function as technicians in the clinic. Although the annual volume of 400–500 calls may seem small compared to busy urban EMS systems, the average time on task per call often approaches three hours. Many of the calls on nights and weekends are low-acuity, minor ambulatory complaints that come in when the clinic is closed and community members have no alternative.

These calls often require simple interventions that would otherwise force patients to seek care at the nearest urgent care facility, which can be more than 50 miles away.

It’s worth noting that the traditional American 9-1-1 dispatch system doesn’t exist on many New Mexico reservations, and often EMS agencies are notified of medical emergencies through a landline at their station, or when somebody drives to the station to lead them to the emergency. This was the case in 1978, and continues to be the case in Pine Hill.

Since 1978, the Pine Hill EMS program has provided care to the Ramah Chapter of Navajo Nation.

Building an Urgent Care Program

The Pine Hill Health Center’s limited clinic hours and significant distance from the nearest hospital have always been challenging for the community members, many of whom don’t have access to a vehicle.

In the early era of the Pine Hill Health Center, EMS providers would provide simple after-hours urgent care interventions in the clinic on nights and weekends, when clinic providers were unavailable, but transport to a nearby hospital was unnecessary.

Providing these simple assessments and interventions mitigated both time and financial burdens on patients, and they kept Pine Hill EMS providers readily available for more traditional ambulance responses.

This practice of EMS providers offering non-traditional care to community members faded in Pine Hill, but the need to revitalize them was recognized as EMS call volume increased and began stretching the limits of Pine Hill EMS personnel.

In 2015, the University of New Mexico’s (UNM) EMS Consortium, a medical direction agency comprised of eight EMS physicians and three EMS fellows, began providing medical direction to Pine Hill EMS.

After conducting a needs assessment, the EMS Consortium modified the previous set of urgent care protocols developed by a prior medical director, addressing what were believed to be the most common complaints that EMS providers could care for in an urgent care setting.

Many traditional mobile integrated healthcare and community paramedic (MIH-CP) models focus on educating providers about chronic disease processes, rather than on expanding the scope of practice and focusing on less acute preventive healthcare and education. This approach improves overall chronic conditions, and can often mitigate the patients who request frequent ambulance transport to the hospital.

Although not a novel idea in Pine Hill, the urgent care model is a bold move away from more traditional MIH-CP programs. The Pine Hill urgent care program has the goal of reducing unnecessary EMS transports through acute intervention, rather than prevention. To do this requires significant medical direction with additional training, protocols, quality assurance and oversight.

The UNM EMS Consortium provides 24/7 access to online medical direction on urgent care (or EMS) calls from an EMS physician, rather than an ED physician who may not be familiar with the urgent care program. This helps to mitigate unnecessary ambulance transports and provides the most appropriate care for the patient.

To implement the urgent care program, additional training, protocols and skills were required. (See Table 1.) Providers received approximately eight hours of training per month over a period of six months, with additional monthly quality assurance reviews and 100% EMS physician review of all urgent care patient reports. Although the additional medications and interventions providers are administering aren’t overly complex, the pilot program still requires 100% on-line physician consultation to ensure appropriate diversion to EMS transport when necessary.

Table 1: Expanded Pine Hill EMS scope of practice to treat urgent care patients

Illness/Injury

Urgent Care Medications

Urgent Care Interventions

Simple lacerations

Acetaminophen, ibuprofen, lidocaine, antibiotics, Tdap

Wound care, suturing, stapling

Cold and flu symptoms

Acetaminophen, ibuprofen, oral rehydration or IV fluids

IV access

Mild allergic reactions

Diphenhydramine

Hypo/hyperglycemia

Oral or IV dextrose

Point-of-care testing

Urinary tract infections

Antibiotics

Urinalysis

Sprains/strains

Acetaminophen, ibuprofen

Splinting

Results & Lessons Learned

The Pine Hill EMS urgent care program began in early 2016. In 2016, 99 urgent care patients were seen after hours or on weekends when the clinic was closed. These patients received minor care and after consultation with an EMS physician, were released with advice to return or contact EMS should their symptoms resume.

The average time on task per EMS call is three hours. This means that, each year, providers remain in their response areas for approximately 300 hours, available to address the emergency medical needs of the community.

Building any type of MIH-CP program requires significant community involvement; the needs of the community should always stand as the catalyst. It’s important to have provider ownership of a program as well. Pine Hill EMS providers who worked in the previous urgent care program were asked for input and feedback on the previous program’s successes and failures.

Both EMS and clinic providers were asked about the most common types of illnesses and injuries transported by ambulance that could be treated on scene or at the clinic.

Training providers on a new set of skills can be challenging, and standardizing this training is difficult. Although in-person and hands-on trainings are most effective, it’s also important that training be easily replicated for new providers or across other programs.

One of the more significant lessons learned was that training EMS physicians is just as important as training providers. The program requires significant EMS physician oversight for both training and for consultation on most of the urgent care visits.

Although the UNM EMS Consortium physicians are experienced, they typically work with complex 9-1-1 medical direction issues, such as termination of resuscitation, forced transports and complicated refusals. Providing medical direction for urgent care is a different type of medical direction, which has required additional training and discussions with EMS physicians.

To implement the Pine Hill urgent care program, providers received approximately eight hours of training per month over a period of six months.

Conclusion

The Ramah Navajo community has benefited from the creative, collaborative approach between Pine Hill EMS, the Pine Hill Health Center, the Ramah Navajo School Board and the UNM EMS Consortium. Other remote and rural EMS programs with lengthy transports and limited resources may benefit from a similar expanded scope of practice.

For many agencies, this may involve treating patients with simple illnesses or injuries in their homes, rather than subjecting them to lengthy transports and significant financial burdens. Other agencies may wish to establish a treatment area in their station, or in a nearby clinic.

 

References

1. The Indian health service gold book: The first 50 years of the Indian health service. U.S. Department of Health and Human Services, Indian Health Service: Rockville, Md., 2007.

2. New Mexico’s twenty-three tribes and the Indian affairs department. (n.d.) New Mexico Indian Affairs Department. Retrieved March 26, 2018, from www.iad.state.nm.us/history.html.

3. Quick facts: New Mexico. (2017.) U.S. Census Bureau. Retrieved March 26, 2018, from www.census.gov/ quickfacts/NM.

4. History. (n.d.) Navajo Nation. Retrieved March 26, 2018, from www.navajo-nsn.gov/ history.htm.

5. Ramah Navajo agency. (n.d.) U.S. Department of the Interior, Indian Affairs. Retrieved March 26, 2018, from www.bia.gov/regional-offices/southwest/ramah-navajo-agency.