Community Paramedicine, The next step?

[ExpatMedic0]

Community Paramedics make the clinical decision to treat, release, and refer with out transport. Many of you maybe aware of the "Community Paramedic" concept, which is already being used in Australia, the UK, and even Qatar. It has been slowly surfacing as a concept In the United States the past few years and gaining more ground. So much that the NAEMT has dedicated its own section of there website to it. http://www.naemt.org/about_ems/CommunityParamedicine.aspx

What does this mean for us as Advanced Pre-hospital providers? Will we(EMS) get this right? Could this be the saving grace for those of us who love EMS and want to take the next step while staying a pseudo clinician? Will the new U.S. Patient Protection and Affordable Care Act (PPACA) help us achieve this?

Its a big possibility but there is also the big possibility for this to fail and become just another "badge upgrade class" like PHTLS, AMLS, ACLS, PALS, PEPP, ect ect.

I hope that the U.S. will model its system off other western countries that already use this concept with success.

In the U.S. we are the red head step children of almost everything we are affiliated with such as healthcare and emergency responders. The two do not seem to mix very well, and EMS has an identity crisis regarding the two. However, what if we affiliated with a new allie, Public Health?

We are already on the front line of Public Health, particularly for Health Disparities( I.E. vulnerable populations). Often we maybe the majority of health care contact many of these people receive in some systems.

 

[Veneficus]

I think that "community paramedicine" is the only way forward for EMS in the US.

I think because of its role as the first contact for vulnerable populations it is actually serving the need that PAs and NPs claimed they would be servicing but actually don't.

I do not think the legislation mentioned will help. Mostly because EMS has not advanced itself educationally at the current time to be realistically included.

After many years I am convinced EMS has nothing to do with public safety. It was just a duty grudgingly accepted by public safety agencies. (Both Police and Fire depending on the area)

EMS could serve a very significant public health role. But I think in order to do that it will have to disengage itself from control of Emergency Medicine physicians who have a financial incentive to keep it how it is now.

As for the few US programs today, I think they are testing the water befoe the plunge so to speak. To my knowledge, not one of the places that have instituted it has experienced failure.

As I understand, Wake County is compiling actual statistics on its effectiveness and I hope Mr. Kirkwood will share those with me after they are complete.

 

[Rialaigh]

I think that "community paramedicine" is the only way forward for EMS in the US.

I think because of its role as the first contact for vulnerable populations it is actually serving the need that PAs and NPs claimed they would be servicing but actually don't.

I do not think the legislation mentioned will help. Mostly because EMS has not advanced itself educationally at the current time to be realistically included.

After many years I am convinced EMS has nothing to do with public safety. It was just a duty grudgingly accepted by public safety agencies. (Both Police and Fire depending on the area)

EMS could serve a very significant public health role. But I think in order to do that it will have to disengage itself from control of Emergency Medicine physicians who have a financial incentive to keep it how it is now.

As for the few US programs today, I think they are testing the water befoe the plunge so to speak. To my knowledge, not one of the places that have instituted it has experienced failure.

As I understand, Wake County is compiling actual statistics on its effectiveness and I hope Mr. Kirkwood will share those with me after they are complete.

I am very interested in this and I believe Mr. Kirkwood is excellent at what he does and there will be great success with this program. I live a couple hours south of Wake County and have heard nothing but great things about how progressive and research oriented their service is. They have currently implemented double gloving for CPR and not stopping compressions to shock, you just keep right on pumping. This was tested at great length in cadaver labs and has been implemented and I am hoping they will find some success with this coupled with "pit crew" CPR that they are currently running.

I am very hopeful for this study and if you hear anything please let me know and keep us in the loop

 

[Veneficus]

I am very interested in this and I believe Mr. Kirkwood is excellent at what he does and there will be great success with this program. I live a couple hours south of Wake County and have heard nothing but great things about how progressive and research oriented their service is. They have currently implemented double gloving for CPR and not stopping compressions to shock, you just keep right on pumping. This was tested at great length in cadaver labs and has been implemented and I am hoping they will find some success with this coupled with "pit crew" CPR that they are currently running.

I am very hopeful for this study and if you hear anything please let me know and keep us in the loop

I just spoke with him and he said it is not completed but told me that Medstar in Ft. Worth have some good numbers for their program.

 

[Shishkabob]

I just spoke with him and he said it is not completed but told me that Medstar in Ft. Worth have some good numbers for their program.

Yes we do. If you'd like, I can get you in contact with any number of the people that head it.


We have our APPs (Advanced Practice Paramedics) that were the initial wave of community paramedicine, and recently 'hired' several "CHP" (Community Health Program) Paramedics to auguments the APPs in the normal day-to-day home visits so the APPs can do the more critical calls (Cardiac arrests, etc) and critical care transfers.

Since its inception, MedStar's CHP has saved more than $7.4 million in emergency room charges, and reduced 9-1-1 use by these patients by 86.2 percent in 12 months post-enrollment, saving $1.6 million in EMS charges.

 

[EpiEMS]

Yes we do. If you'd like, I can get you in contact with any number of the people that head it.


We have our APPs (Advanced Practice Paramedics) that were the initial wave of community paramedicine, and recently 'hired' several "CHP" (Community Health Program) Paramedics to auguments the APPs in the normal day-to-day home visits so the APPs can do the more critical calls (Cardiac arrests, etc) and critical care transfers.

What's the protocol and SoP difference between the two? Are CHPs APPs with a focus on more GP-type medicine?

 

[Shishkabob]

To be honest, the CHP-medics are brand new as we just hired a couple from within and I don't know much more beyond what was included in the internal job posting.



Our current protocols are split in to levels 1-6, each level a corresponding provider level. (Protocols are changing this month, doing away with the levels)

1: EMT
2: Intermediate
3: Paramedic (New to the system, can't have their own truck, basically an intermediate with a few more things)
4: Lead Paramedic (Has their own truck, full working Paramedic, most Paramedics are this level)
5: Paramedic (Has a few more things such as RSI)
6: APP, Advanced Practice Paramedic. They have even more open to them.



Without knowing for sure, I'm betting the CHPs are still level 4 or 5, but they are used for the general home visits and checking out the patients. I don't believe they have the refusal capability of the APPs, and doubt they have the advanced protocols, otherwise they'd be the APPs instead of a separate branch.

 

[EpiEMS]

What patient population is the target for the CHP program?

 

[Shishkabob]

Depends, really. CHFers are a big part, followed by psych and general system abusers (terms not mutually exclusive)

This is a good link to read up on the basics that was put in for a government grant.
http://www.innovations.ahrq.gov/content.aspx?id=3343&tab=1



I actually referred someone a couple weeks ago because I transported them several times in several weeks and saw their call log was basically every couple of days, always complaining about the same thing. They got enrolled and we've transported them a lot less, but they are a difficult case because they are non-complaint with discharge orders, and call back because they keep doing the same thing, causing the same complaint... Simple fix they refuse to do.

 

[EpiEMS]

Linuss, that's a fascinating program. Sounds like it does an excellent job (especially compared to the baseline).

 

[ExpatMedic0]

Linus what area of Texas? Is there any kind of degree requirement or specialized training for this pilot program?

 

[Shishkabob]

Fort Worth, Texas (North part of Texas, next to Dallas)


The last job opening stated having gone through a CCT class and 2 years as a Lead Paramedic with MedStar. They then do a 16 day program going further in-depth with the CHP and critical care.

 

[ExpatMedic0]

Nice, Texas has the "licensed Paramedic" level which requires an AAS or above right? I am really surprised they are not requiring that. 1 step at a time I suppose.

Fort Worth, Texas (North part of Texas, next to Dallas)


The last job opening stated having gone through a CCT class and 2 years as a Lead Paramedic with MedStar. They then do a 16 day program going further in-depth with the CHP and critical care.

 

[Shishkabob]

Yes, Texas' LP is either an AS in EMS or a bachelors in anything. It was initially intended to replace some nursing sports in trauma rooms but you can guess the hissy-fit the nurses threw around. As such, LPs haven't really taken off like it should have, but it's still going.


Most of the APPs I know have an AAS at minimum... some are going to medical school as we speak.



Doesn't hurt that our medical director started as a Paramedic here, got his RN, then got his DO and is back.

 

[EpiEMS]

A tad off topic...Do LPs make more than EMT-Ps in Texas?

 

[Shishkabob]

A tad off topic...Do LPs make more than EMT-Ps in Texas?

Not at any employer I've ever seen, which is partially why there hasn't been a big influx. What comes first, education or pay? You'll have someone on both sides arguing their side.



Without an immediate incentive of increased pay, I don't see why most people would push for it. (Right or wrong or indifferent)

 

[Summit]

Lerner B, Shah MN, Fernandez AR (2008). Do EMS Providers Think They Should Participate in Disease Prevention?
Poster presentation at 2008 annual meeting of the National Association of EMS Physicians.
The objective of this study is to determine EMS providers’ opinions regarding participation in disease prevention initiatives. Eighty-one percent (95% CI: 80.5 -81.6) of EMS providers re-registering in 2006 believed that they should participate in disease prevention programs and 28.8% (95% CI: 28.2-29.5) of respondents reported actually having provided prevention services. Those who had a graduate degree were the most likely to have provided prevention services (40%, p<0.001), as were those who had worked in EMS for more than 21 years (41%, p<0.001).

As a side note, community health nursing is one of the few nursing specialties that absolutely requires a BSN minimum.

 

[Veneficus]

Lerner B, Shah MN, Fernandez AR (2008). Do EMS Providers Think They Should Participate in Disease Prevention?
Poster presentation at 2008 annual meeting of the National Association of EMS Physicians.
The objective of this study is to determine EMS providers’ opinions regarding participation in disease prevention initiatives. Eighty-one percent (95% CI: 80.5 -81.6) of EMS providers re-registering in 2006 believed that they should participate in disease prevention programs and 28.8% (95% CI: 28.2-29.5) of respondents reported actually having provided prevention services. Those who had a graduate degree were the most likely to have provided prevention services (40%, p<0.001), as were those who had worked in EMS for more than 21 years (41%, p<0.001).

As a side note, community health nursing is one of the few nursing specialties that absolutely requires a BSN minimum.

I'm a 41%er!!!

 

[Shishkabob]

No, you're just old.

 

[Veneficus]

No, you're just old.

I managed to live this long, so don't mess with me