As EMS involvement in MIH-CP has grown, one of the key questions to arise has been what education is required to safely (and legally) deliver MIH-CP care. Educational preparation of CP providers remains extremely diverse. In a recent MIH practices survey conducted by the National Association of EMTs (NAEMT), 26% of respondents reported that their system had no specific educational or experience requirements. Within programs that did require specific training, clinical topics (67%), communications (66%), community services (63%) and patient navigation (60%) were common topics.1 While the national dialog continues, there’s no sign of consensus on the horizon.
Until a national strategy for MIH-CP education exists, each community may need to select or develop their own educational approach. This article describes a proven approach for developing successful and accountable educational programs, and illustrates the use of that approach at American Medical Response (AMR) and Evolution Health (EvH) to develop an MIH-CP educational program that has successfully trained providers from multiple disciplines and credentialed them to practice in six states. Hopefully such a systematic approach will prevent EMS agencies from hastily creating educational programs that meet the urgent need for something but either fail to create safe MIH-CP clinicians, or unnecessarily limit the practice of those clinicians after they enter the workplace.
One of the primary purposes of professional clinical education is to enable learners to achieve the competencies required to safely practice their profession. To meet this purpose, educational tools must be built upon the following two guiding principles:
First, the competencies required for clinical practice must be established and agreed upon. Competencies are things that clinicians must know and be able to do in order to safely practice. We can’t create an education program that prepares clinicians to practice if we don’t understand the competencies of that practice.
Second, the education process itself must be learner-centered. Learner-centered relates to the focus of content and the process for learning. Content needs to be focused on the gap between what learners already can do and what they need to learn to be competent in the new practice.
Taken together these two principles guide development of MIH-CP education in the following ways:
Defining competencies: An educational program of any kind must begin with a clear list of competencies for participating EMS personnel.
Content selection: Developing learning content and activities should be guided by answering the question, “Given my learners’ prior knowledge and experience, will this teaching activity improve their ability to successfully perform the competencies of MIH-CP?” Only include activities for which the answer is “Yes.”
Individual needs: Learning activities need to be tailored to the individual learner, recognizing and honoring each student’s prior experience. Don’t force all MIH-CP learners to participate in content that only some of them require.
Achieving mastery: Successful completion should be defined as demonstrated mastery of the required competencies, and nothing less.
Challenges to Training Development
Developing education for MIH-CP providers is challenging for a number of reasons. First, required competencies vary dramatically among communities, and are sometimes poorly understood within them. Some programs are primarily focused on the needs of EMS/ED “frequent faces,” others concentrate on reducing hospital readmission of specific patient groups, and still others emphasize the unplanned care needs of hospice, mental health or other unique care categories. Within each of those clinical practices, what exactly will EMS providers do? Each brings with it a differing set of competencies.
Learner experience adds to the challenge. The NAEMT survey found that 61% of MIH-CP providers have three or more years of EMS experience.1 These individuals are already educated and licensed/certified to perform within their scope of practice in a specific practice environment, so MIH-CP education will optimally “begin” on top of their existing competency rather than forcing them to consume content they’ve already mastered.
Finally, MIH-CP competencies in many cases require learners to perform “existing” skills in a dramatically different clinical environment. Consider the differences between EMS and MIH-CP practices listed in Table 1 on p. 11. In most MIH-CP systems, EMS professionals are not performing patient care tasks that are dramatically different than those they perform in 9-1-1 or interfacility transport. But the significant differences described in Table 1 require educational preparation that improves critical thinking and collaborative decision-making, encourages patient activation, and improves the ability of clinicians to review and contribute to longitudinal medical records.
For most EMS systems, developing an educational course for MIH-CP will be challenging and time consuming. As a result, some communities may be tempted to borrow or buy existing curricula from established programs; 34% of programs in the NAEMT survey report using a curriculum from another source.1 This strategy can only succeed if the organization’s clinical practice and competencies are extremely well matched to those of the organization that created the training. This mismatch is likely the reason that 61% of respondents in the NAEMT survey reported creating their own training.1
Strategies for Success
In early 2014, AMR and EvH were confronted with a similar challenge. The two organizations were exploring development of MIH-CP programs that combined the home health and physician/nursing/midlevel expertise of EvH with the call-taking, resource matching and EMS provider capability of AMR. We wanted to ensure care providers from all disciplines were adequately prepared for their MIH-CP roles, and unsuccessfully sought a training program that would meet our needs. Here are the steps we followed to develop our MIH program, and the lessons we learned:
1 Identify competencies: We spent almost a month talking to our own clinical leaders and the leaders of successful MIH-CP programs, to identify 12 clinical competencies we felt all MIH clinicians needed to have in order to provide safe and effective care. Examples include “demonstrate knowledge of the continuum of care, patient navigation, preventive care, acute care, chronic care, disease state management and care transitions,” and “value the team-based approach to MIH-CP practice and the importance of the experience of care.”
2 Develop specific learning objectives for the competencies: We created over 60 individual objectives for our 12 competencies from both the cognitive and affective domains. Because no practitioners were being trained to perform outside of their scope of practice, there were no psychomotor (skills) objectives. The predominance of higher-level objectives–e.g., recognize, demonstrate, apply, evaluate or distinguish–over lower-level objectives–e.g., know, list or understand–had substantial impact on our instructional design.
3 Identify competency “gaps”: Our clinicians brought significant expertise to the program so we identified very few clinical competency gaps related to assessment or diagnosis. However, virtually all clinicians had significant gaps around systems of care, quality and the triple aim, and team-based care. These “gaps” became the backbone of our program.
4 Clarify which gaps apply to all MIH programs: Like most MIH-CP programs, the exact services to be provided varied among the communities we intended to serve. Accordingly, we developed a core curriculum, which contained objectives that applied to all programs and is required for all clinicians. To avoid mandating training on topics that may not be used, we created specialty courses (e.g., hospice, mental health) for use in communities that offer those programs.
5 Develop an instructional plan: A significant body of knowledge shows that lecture has limited value for adult learners.2 Lectures tend to focus on factual content that can often be better learned through reading. In addition, the high level of our objectives required students to do more than regurgitate facts; they needed to demonstrate application of competencies in realistic patient situations.
Our instructional plan called for a single lecture, approximately two hours long, which communicated the program’s beliefs and expectations and gave students high-level familiarity with the competencies. Pure knowledge-based content was provided through guided discussion of four groups of focused articles that supported the objectives. Every clinician was required to contribute to these discussions to demonstrate their mastery of the objectives.
Participants then applied what they’d learned to their MIH-CP system through a series of case studies. Learners were broken into interdisciplinary groups, each working on a unique case that followed a single patient for several weeks. Groups came back together to share what they learned with the rest of the cohort.
6 Develop a delivery plan: We determined that communities starting MIH-CP programs would initiate training to a small select group of clinicians, and that they might need to “go live” fairly quickly. This made conventionally scheduled classes ineffective. Following our learner-centered principle we created a program that could be started at any time and completed largely online. An introductory “lecture” is offered by webinar every 2—4 weeks, and is always available in recorded form. Articles are posted on an online learning platform, and guided discussion is managed through threaded discussions that encourage interaction among learners. Online platform records verify that each learner posted comments and participated for each article. Case studies are posted online as well, placing students in groups that create and revise care plans for patients over a 1—2 week period. Approximately 40% of case discussions to date have been held online, with the balance done within individual communities.
7 Use clinical credentialing to support quality: Like physicians who are credentialed to perform specific procedures within a hospital, we elected to individually credential each clinician within our MIH-CP systems. Credentialing enables general MIH-CP and specialty care based on each provider’s course completion and the approval of the local MIH-CP medical director. Credentialing is active for two years and requires ongoing assessment of actual patient encounters and continuing education to renew.
8 Measure impact: We measure the impact of our educational model in two distinct ways. First, participants must complete a course completion survey in order to receive their certificate. This feedback has resulted in multiple corrections in our instructional plan and delivery. Over 88% of participants currently report that course content is very or extremely pertinent to their clinical practice, and 73% are very or extremely satisfied with the online format. Second, we collect data on the clinical impact of MIH-CP programs we operate. This measurement provides validation of our clinicians’ ability to meet the required competencies of the MIH-CP program.
Since our first course in October 2014, we’ve enrolled almost 120 physicians, pharmacists, physician assistants, nurse practitioners, paramedics and nurses in our MIH-CP education program. Course dropouts were fairly high in 2014, but have decreased to almost zero in 2015. We’ve so far credentialed 46 practitioners who are successfully practicing in MIH-CP programs based in six states, with 25 additional individuals nearing program completion. We believe this structured approach has created clinicians who meet the MIH-CP competencies we identified, and each can now safely and successfully care for the over 300,000 chronically ill, homebound and medically fragile individuals for whom they are responsible.
Scott Bourn, PhD, RN, EMT-P, is vice president of clinical practices and research at American Medical Response and president of the National Association of EMS Educators.
1. Goodwin J, editor. (2015.) Mobile integrated healthcare and community paramedicine (MIH-CP): Insights on the development and characteristics of these innovative healthcare initiatives based on national survey data. NAEMT. Retrieved July 14, 2015, fromwww.naemt.org/docs/default-source/MIH-CP/naemt-mih-cp-report.pdf.
2. Freeman S, Eddy SL, McDonough M, et al. (2014). Active learning increases student performance in science, engineering, and mathematics. Proc Natl Acad Sci U S A. 2014;111(23):8410—8415.