Implementing a community paramedicine program in rural Laguna Pueblo, N.M.
Mobile integrated healthcare/community paramedicine (MIH-CP) is an exciting and evolving topic in the field of EMS. Primarily because of location of resources and economies of scale, most MIH-CP programs are in metropolitan areas. Rural areas, however, are often medically underserved, and could benefit significantly from such programs.1
The Laguna Pueblo is a federally-recognized Native American tribe located approximately 45 miles west of Albuquerque, N.M. “Pueblo” refers both to the people and to the reservation itself, a term applied by the Spanish who entered the American Southwest in the 1500s.
Laguna Fire Rescue is an ALS-transporting agency that staffs three stations, 24/7. The department operates on a typical 48/96 model, with eight providers per shift, along with a fire chief, a captain and an EMS lieutenant. All firefighters are at minimum EMTs; each shift has two paramedics and several EMT-Intermediates as well.
The Laguna reservation, which covers 825 mi2, has 4,043 residents, resulting in a population density of 4.9 people/mi²–well below the federal definition of “frontier” (< 6.5 people/mi²). Though Laguna Pubelo is bisected by a major interstate highway and transcontinental railroad, the reservation, like many other Native American reservations, remains geographically and culturally isolated from the rest of New Mexico. Such isolation is much more drastic among the pubeblo’s medically fragile elders.
MIH-CP has taken on different forms in different locales, and has been used to address a variety of healthcare issues such as hospital readmission rates, healthcare navigation and delivery of minor ambulatory care. Some programs involve a separate MIH-CP crew that responds to low acuity calls that are unlikely to generate EMS transports.2 Others focus on patients that have recently discharged from hospitals and are at high risk for readmission.
Several programs in Albuquerque have recently gained attention in the EMS and health insurance industries because of their healthcare and financial successes.3 Many of these MIH-CP programs are in urban areas, with high call volumes and a pool of experienced paramedics. One of the first community paramedicine programs actually started in in the early 1990s in Red River, N. M.– a very rural area.4
The Red River project was innovative; it was designed to create semi-independent practitioners who provide minor, low-acuity healthcare in a rural area otherwise lacking regular access to such care. The Red River project ultimately failed for many reasons, among them a lack of close medical director oversight, and it was discontinued several years after its inception.5 Studies of more recent rural MIH-CP programs have shown that rural programs can succeed in patient outcome measures and financial savings, like their big city counterparts.6
Like the Laguna Pueblo, many Native American reservations are classified as rural or frontier and medically underserved–but they also have a mobile health infrastructure upon which an MIH-CP program can be built.
Origins of the Program
The Indian Health Service (IHS) is the agency within the U.S. Public Health Service Department of Health and Human Services responsible for providing federal health services to the 2.2 million American Indians and Alaska Natives who belong to 567 federally recognized tribes. In 1968, IHS established the Community Health Representative (CHR) program. Since then, CHRs have operated on American Indian reservations as paraprofessionals that attend to the general health needs of tribal members.
CHRs visit patients in their homes and help with general health maintenance, health promotion and advocacy, and often help with health-related transportation. They also work closely with patients and their primary care providers (PCPs) to further healthcare outside of regular doctor’s office visits. Patients are referred to the program by local hospitals, patients’ physicians and by word of mouth, which is perhaps one of the more powerful and reliable means of referral into the program.
The Laguna Community Health and Wellness Department has five CHRs who work together to follow a total of 100—150 unique patients yearly for their various medical needs. The CHR scope of practice is limited, however, and doesn’t allow representatives to provide many medical treatments.
In late 2015, the Laguna CHRs realized that although many of their patients had relatively simple medical needs, their patients regularly required long trips to Albuquerque for specialist appointments. Having identified the need, the CHRs approached Laguna Fire Rescue about adding paramedics to the team to help address simple medical needs in patients’ homes. The CHRs, Laguna Fire Rescue Administration, two of the Laguna Fire Rescue paramedics, and the Laguna Fire Rescue medical director, held a meeting, and the Laguna Community Paramedicine Program (LCCP) was born.
Initiating Patient Care
Though they hadn’t performed a formal needs assessment, the CHRs’ intimate knowledge of their community suggested that care of poorly healing wounds was a top priority. Many of their geographically isolated, elderly patients had wounds that were slowly worsening, and getting regular care was challenging. Specialized wound care appointments were usually in Albuquerque, and because round-trip travel alone could sometimes take three hours, many patients were missing appointments and languishing in their homes.
Before patients could be treated, community paramedics (CPs) had to learn the logistics of the CHR program. The first phase of the program involved CPs shadowing CHRs on their daily rounds, focusing primarily on the patients with chronic wounds.
Though paramedics are very familiar with visiting patients in their homes, arriving with the CHRs helped introduce the paramedics to patients and allowed the paramedics better to understand the pace and goals of the non-emergent home visit. CPs soon began accompanying patients and CHRs to wound care appointments, helping them to develop rapport with the patients and the specialists.
To further their wound care skills, both CPs were sent to Oklahoma City, Okla., to become certified wound care providers by the American Society of Wound Care Professionals. This training gave them more than just skills–it gave them the vocabulary to discuss wounds and wound care at a professional level with patients’ wound care clinicians, and gave those clinicians the confidence in the CPs to include them in more complicated home care regimens.
Upon their return, and after they became comfortable with the CHR-style workflow, the CPs began visiting patients on their own. This level of professional cooperation has allowed several patients to increase the amount of time between specialist visits.
Soon after becoming comfortable with wound care, the CPs began offering medication management services as well, helping patients and their families understand medications and their indications, effects and side effects. Given that most common medications are familiar to paramedics, this required minimal training; any questions that they couldn’t answer could be looked up or discussed in real time with the program medical director.
Training
Though the Laguna CPs are now seeing patients on their own, they’re still part of a multidisciplinary team charged with managing the health needs of each patient on the CHR census. By working with the CHRs, public health nurses and the medical director, the Laguna CPs are perhaps better described as “CHR extenders.”
The program continues to use the term “community paramedic” because it’s a term familiar to the EMS community. However, the skill-by-skill development of the Laguna Community Paramedicine scope of practice is very different from the more comprehensive training and scopes of practice that CPs in other areas employ.
Formal MIH-CP training curricula are often aimed at creating semi-independent practitioners. In contrast, though the Laguna Community Paramedics have had specialized training to treat specific conditions, they aren’t semi-independent practitioners like their counterparts in some of the more well-known, urban and suburban MIH-CP programs. This approach to program development has allowed the Laguna Community Paramedicine Program to grow based on the needs of the residents of the Laguna Pueblo, without subjecting the providers to lengthy, more formal MIH-CP training.
In fact, all of the Laguna community field providers–the CHRs, the public health nurse and community paramedics–work closely and communicate frequently with the program medical director. To better facilitate direction of the entire team, the role of the Laguna Fire Rescue medical director was recently expanded to medical director of Community Health and EMS Programs, covering both the lights and siren aspects of EMS as well as the community health and MIH-CP activities on Laguna Pueblo. This has helped with program operation and development as well with coordination between the team and the patients’ PCPs. Relationships with the PCPs are critical to the success of patient treatment plans–and to the success of the Laguna Community Paramedicine Program itself.
Results
Laguna CPs saw their first patient in September 2015. By mid-2017, they’d visited 11 unique patients a total of 221 times. Anecdotal results are especially promising among wound care patients, and patient/family testimonials are very positive.
Medical cost savings and quality of life improvements are more difficult to quantify, since the program is now treating patients whose medical needs were previously unmet or underserved (i.e., they’re now generating treatment costs in instances where, in the past, there weren’t any).
Though we’ve discovered specific examples of missed appointments, patients languishing while waiting for appointments far off the reservation and patients “slipping through the cracks,” we’ve yet to quantify the degree to which medical needs are unmet or underserved.
We’re attempting to estimate the costs of the specialist care and off-reservation/out-of-IHS-network care that patients should’ve been receiving but weren’t, and comparing them to the costs of care under the CHR/CP model.
To date, we don’t have hard numbers, though the impact of patient and family testimonials can’t be underestimated–especially upon members of the Laguna Pueblo Council and CHR, who allocate funding for the program.
Laguna Community Paramedics saw their first patient in September 2015 and by mid-2017, they’d visited 11 unique patients a total of 221 times.
The Program’s Future
As the second year of the program draws to a close, we’re looking to expand both the scope and the number of providers in the program in a thoughtful and deliberate fashion. We’re also looking to align the program more closely with the lights and siren side of Laguna fire Rescue by making it easier for any Laguna Firefighter/EMT to refer a patient with social or chronic medical issues to CHRs for help.
More importantly, although the program enjoys strong financial support from Laguna Pueblo, efforts are underway to access third- party payers to help support the costs of the program for patients who have insurance plans in addition to IHS coverage.
Lessons Learned
The Laguna Community Paramedicine program is an example of a meaningful MIH-CP program that’s been built on a small scale, one skill at a time, to address the specific needs of a community. Targeted special skills training and close collaboration with medical direction is essential, but starting a program doesn’t require semi-independent practitioners or the training to become one.
This “grassroots” approach puts such a program within reach for smaller, more rural departments that may not have the personnel or financial resources to send providers to lengthy general MIH-CP training.
Though other tribal community paramedicine programs will benefit from the CHR infrastructure available in reservation settings, such programs don’t require CHRs, and are conceptually within reach of non-tribal communities as well.
Conclusion
The very first Laguna Community Paramedicine patient is now 91 years old, and is still in the program. She has chronic lower extremity ulcers, and though they look much better than when she entered the program, they’ll probably never completely go away. The team visits her three times a week, and helps take her back and forth to primary care and specialist appointments that are no longer as frequent as before.
It’s clear that the team is treating more than just her wounds: her face brightens when the CPs arrive, and she relishes the personal attention they give to her during treatment. She pays attention to them as well; it’s hard to leave her house without some sort of a snack or other tasty treat. Since her mother lived to 108 and her grandfather to 119, she’ll be on the Laguna Community Paramedicine census for many years to come.
Acknowledgement: The authors would like to thank the Laguna Pueblo Community Health and Wellness Director Ramona Dillard, Fire Chief John Garcia, Community Health Representatives, Public Health Nurses, Community Paramedics, and most of all, the people of Laguna Pueblo for the support of this program.
References
1. Patterson D, Coulthat C, Garberson L, et al. What is the potential of community paramedicine to fill rural health care gaps? J Health Care Poor Underserved. 2016;27(4A):144—158
2. Zygowicz W. Adapt to demand: Littleton, Colo. Fire Rescue is rolling out their take on mobile integrated healthcare. JEMS. 2015;40(5):36—41.
3. Zavadsky M. (August 14, 2017.) How paramedics helped BlueCross BlueShield of New Mexico reduce ED usage, readmissions. JEMS.com. Retrieved Monday, Nov. 20, 2017, from www.jems.com/articles/pt/2017/08/how-paramedics-helped-bluecross- blueshield-of-new-mexico-reduce-er-usage-readmissions.html.
4. Shoup S. Red River Project: Expanded scope program for New Mexico medics. JEMS. 1995;20(12):43—47.
5. Hauswald M, Raynovich W, Brainard A. Expanded emergency medical services: The failure of an experimental community health program. Prehosp Emerg Care. 2005;9(2):250—253.
6. Bennett K, Yuen M, Merrell M. Community paramedicine applied in a rural community. J of Rural Health. March 23, 2017. doi: 10.1111/jrh.12233 [epub ahead of print].
