Successfully Integrating Community Paramedics

This year’s EMS World Expo featured a day-long event to discuss the fast-paced development of the community paramedic (CP) program and the concept of mobile integrated healthcare practice (MIHP). The event provided participants the opportunity to hear from numerous states and providers about the steps taken to implement a successful program. I had the opportunity to discuss state statute requirements and regulatory hurdles that influence the repurposing of an EMS provider as a CP or an MIHP provider. I began my career 25 years ago as a street paramedic; today, I’m a lobbyist for EMS and healthcare. Although I’ve witnessed a lot of changes within EMS during that time, the last few years have brought an unprecedented shift from inpatient to outpatient care, and the development of medical homes and care coordination models. As a result, I believe that successful integration of EMS into the CP and MIHP concept will look very different from location to location. My home state of Minnesota has been on a fast track to reform the healthcare delivery system. Our reform efforts include an array of payment model types and the development of multiple Medicare and Medicaid Accountable Care Organizations (ACOs), in which healthcare providers are at risk for the total cost of caring for their attributed patients. EMS is a critical component of these arrangements. Minnesota is unique in the sense that we have large, nonprofit EMS systems that are integrated into and owned by our healthcare systems. The Mayo Clinic, Allina Health, North Memorial Health Care, HealthEast Care System and Hennepin County Ambulance Service provide the vast majority of the state’s EMS transportation. The importance of state legislation Many around the country have asked why Minnesota law defines community paramedic as a new provider, rather than expanding the existing definition of paramedic as an extender of the ambulance service medical director. In response, I offer a few comments that I hope will demonstrate the importance of describing a practitioner in legal terms, distinct from using an umbrella term such as MIHP. We have maintained a strong EMS presence in Minnesota at both the state legislature and with other healthcare and regulatory agencies. That presence, in turn, has paved the way for us to innovate as an industry within healthcare reform discussions and always have a seat at the table. For years, the Healthcare Committee chairs within the state legislature have reached out to the Minnesota Ambulance Association (MAA) seeking any ideas regarding reform. With our strong relationships within Minnesota’s Office of Rural Health and Primary Care, we have been able to focus on the workforce shortage with regard to access to primary care. The legislature and key state agency leadership have approached our administrators numerous times to focus on a new healthcare practitioner to help “fill the gap” in the healthcare work force shortages. Because Minnesota’s ambulance industry doesn’t compete for emergency ambulance requests for service, as an industry we have been able to sit around the table and discuss the CP concept, presenting our recommendations to the legislature, which were received with warm support. Additionally, we recognized the need, as an industry, to offer a career path to our aging work force of paramedics, who possess invaluable diagnostic and patient care skills. Community paramedic legislation Now to the question of why Minnesota chose to face the uphill battle of taking the legislative route for CP. It’s fair to say that this endeavor was one of the hardest pieces of legislation we have ever moved along through the legislative process, but ultimately, it has been the most rewarding. We held numerous stakeholder meetings and–with the help of smart legislators and advice from the Minnesota Nurses Association and the Minnesota Home Health Association–we developed both the enabling language for CP and a Medicaid payment model. We had numerous discussions with legislative research, our independent EMS board and other trade associations regarding the scope of practice and the Home Healthcare Act. After countless stakeholder discussions, it was clear we needed a strong definition of the community paramedic in law. Everyone involved in the discussion made it clear from the start that we needed to do a few important things to make the new CP practitioner accepted by the healthcare community. These included: “¢ Defne to the legislature the CP concept and what tasks an existing paramedic performs; “¢ Develop an articulate and repeatable message on what a CP is, and what it isn’t; “¢ Employ a defned curriculum, clinicals and testing standard; “¢ Educate the opposition that we were filling a gap, not competing for current home care or nursing jobs; “¢ Be statutorily recognized so we can be paid consistently for our services as a new practitioner; “¢ Have an agency to certify and take any complaints, providing professionalism to the new CP practitioner; and “¢ Provide legal protection for EMS medical directors to provide CP oversight. Once we legitimized the CP in law, the remaining phases of the CP program fell into position at the legislature. During the second year after the initial legislation had passed, additional laws allowed Medical Assistance coverage for CP services at $60 an hour after Centers for Medicare & Medicaid Services (CMS) was approved as part of a State Plan Amendment. The Minnesota Department of Human Services made it clear that we needed a defined CP statute to seek a state plan amendment for CP coverage with CMS. Year three legislation included 12 hours of continuing education in primary care for CP certification, beyond the 48 hours required to maintain an emergency paramedic certification. Final recommendations As an umbrella term, the definition of CP is strong in some states, while MIHP has a stronger presence in others. Minnesota’s CP model clearly has a strong primary care focus intended to address several patient care and workforce needs. As such, we have enjoyed successful implementation of the program. Your EMS service’s level of integration with a healthcare delivery system may decide whether you should explore a CP or MIHP model. It’s imperative that your plan protects you from duplicating services and ensures you are recognized as a part of a coordinated team of healthcare providers. Minnesota accomplished this by clarifying, in law, that all CP visits require a primary care plan and/or enrollment in a medical home. The primary care linkage has proven to be a key to CP functioning in a healthcare coordination system. The climb up the legislative hill to have the CP recognized in law is well worth it–for our patients who require access to properly trained practitioners and for our paramedics who embrace an additional career path option within the EMS field.