Community Paramedics revisited

[pcbguy]

The other way this could go is that this isn't meant to be a practitioner level at all but rather just something to augment a stressed EMS and ED system. Something to relieve some of the volume.

I think if they go that way with it they are missing the mark and going to have to revisit it again in the future. They should go all the way with it and create a practitioner level for paramedicine.

 

[Arovetli]

so, let me point out one thing that always seems to get ignored in these CP discussions.

Technology.

As Ive said before, millions in cash are being burned up by VC firms to develop anything and everything under the sun. There are apps in development for EKG, Vitals, some lab values, peak flow testing, you name it, to be able to sync up to a smartphone and sent to the land of Oz where the overall health status can be monitored and the patient can be directed to resources as needed. Many good insurance plans already provide a type of community health program, or care coordination program, in exchange for lower rates.

Amazing research is coming out on biomarkers to detect MI and stroke days before they even occur.

As this tech progresses, it will cut into the role that EMS plays for acute medical care of the upper and middle classes. Not to make it a class warfare issue, but again, EMS will be stuck dealing with accidents and the medical urgencies of the poor who do not have access to technological resources.

Decades ago when EMS got kicked off, accidents and trauma and medical emergencies were a very real public health issue and paramedics were a great tool. Now, being fat and the associated diseases are a much greater overall public health crisis. you can bet had Metabolic Syndrome X been identified in the Great White Paper instead of trauma, we would have much different EMS systems....things change...

I believe in EMS. It has accomplished great things, and there is work still to do. Mainly, getting to patients and getting them where they need to go in a prompt manner, supporting life along the way.

Logistics.

There was a huge interventional stroke study that was recently shut down because patients weren't getting to the right place at the right time in order to be enrolled. Was the therapy they were trialing effective? Who knows, and part of the problems lie with getting EMS on board with the goals of the study. One of the biggest challenges I have seen in some emergency medicine research is having poor information provided by EMS crews. Simple things, like wrong GCS's, mess up royally a patients enrollment.

There is so much potential in EMS, as long as it does what it was designed to do, and does it well correctly. Intubation rates, STEMI identifications, performing gcs correctly...all kinds of things like this need to be improved. There IS money coming into EMS. Insurers and large hospital systems are taking notice of how EMS drives admissions and improves outcomes. Things will change, but medics ourselves have to change, and present ourselves as competent, motivated, and professional.

We need real honest discussion on the topic and a real leadership organization, and we need medics and emts who care. Reinventing into a whole new role...that is utterly not needed.

That is why I get so frumpy when I see this the internet blow up with community paramedicine talk, instead of real talk on how to make ourselves better, do the tasks and procedures we have entrusted to us correctly all the time, everywhere and talk on how to work legislatively and with administration to change things so that we get reimbursed via a more workable method.

If a remote area of the country increases the scope of a paramedic to better care in that system, great. Systems are supposed to be responsive to local needs But that happens because the nurses and midlevels and physicians who are trained for that role refuse to go there. So, cheap labor paramedic gets the reins.

If an urban ems systems uses supervisors or crews or hires a coordinator or follow up person or uses alternate destination or treat and release to try and drive down calls and steer resources...great. None of that is suggestive of some kinds of future universe where quasi doctor medics make house calls.

How bout we look at medic 1 or wake or any of the great ems systems, see what they are doing right to improve outcomes...and make those changes what we push for? Or, in other words, do our freakin jobs. There are a million ways to brainstorm improvement. Brainstorming complete overhaul into another field altogether? Nonsense, I say.

 

[Amberlamps916]

It will not work with fire-based EMS. Tell me how OCFA would love that idea.

 

[pcbguy]

Noone is trying to reinvent paramedics. This is an added role. No different than an RN becoming an NP.

There are a lot of paramedics and nurses I've known that I couldn't start an IV to save their own life. There is always room for improvement and this runs from every level from an EMTB through MD. Just because there is room for improvement doesn't mean we shouldn't try to advance our education to a higher level.

We SHOULD, as a whole, start doing what we can do better. But some of us already do it damn well and are proud of what we do. My argument is a push for education. I don't think that street medics should be thrown into a CP role or act as a practitioner. Proper education should be the precursor to the entire program.

 

[ExpatMedic0]

I think some of you think we are trying to "reinvent the wheel" here. That is the not entirely the case. EMS is already broken and inefficient. Reimbursement models stink and the whole thing needs a revamp. We already interact with the target patients and frequent fliers on a routine basis and dump them on the ED. Its a vicious, unproductive, expensive and monotonous cycle.

Furthermore, its time for EMS to advance, this could be our hail Mary play that could push things forward and lay down the foundation for something on a grander scale to fulfill an entire full-spectrum of pre-hospital care. I think most of us concur that EMS education needs to come to a higher level, maybe this could help push that forward, along with many, many other things. It has the possibility.....

 

[VFlutter]

Noone is trying to reinvent paramedics. This is an added role. No different than an RN becoming an NP.

It is a great concept if the educational requirements are similar. Maybe I am just pessimistic but I do not think there will be many people willing to put in the 6 years of college education to get there when most will not even complete 2.

I totally agree that a Community Paramedic in a Mid-Level role could save EMS and advance it to the level of other healthcare professions. But realistically I am not sure if it will get there.

 

[Clipper1]

If a remote area of the country increases the scope of a paramedic to better care in that system, great. Systems are supposed to be responsive to local needs But that happens because the nurses and midlevels and physicians who are trained for that role refuse to go there. So, cheap labor paramedic gets the reins.

Nobody is "refusing" to go there. The resources are just not available. It is also not cheap for a Physician to set up an office. This is why telemedicine has become increasing popular. If the home health agencies can not get the contracts in an area or be able to work out a deal with the county health office, you won't have nurses. If the tax cuts close out reach clinics, the NPs and PAs disappear. This has been the case in many areas which has lead to some of situations in depressed or rural regions.

If you have CPs in an area you will still have the same issues. CPs can not perform all the duties of RNs, RTs, SWs, CMs, PTs and OTs. Nor can they get the equipment needed easily in these areas because of the lack of available vendors.

We have sent patients back to Montana and the CMs have struggled to find adequate DME agencies to fulfill the needs of patients who have complex medical care requirements. What do you think a CP can do for these patients without resources available? It doesn't matter how many times your call your MD to inform them of what is needed. What do you think your liability will be if you accept a patient and can not provide adequate care for them? Some of the issues faced are much more than just an occasional home visit.

Yeah Aidey will probably think this is negative also but unfortunately there is no easy solution or much positive to say about the US health care system when it comes to long term care. This is a highly specialized area and it will take much more than a CP whose primary training is in the emergency acute situation. Just putting band aids on a situation or bypassing and undermining the efforts of other groups who want the clinics and professionals put back in place won't help much either. The main selling point by FDs and EMS is "cheaper" alternative. This is coming from the FDs and EMS agencies. Read the articles from Maine, Colorado and Minnesota. This is like a bidding war for the lowest. The other associations and agencies are not promoting "cheap labor" because they know the cost of providing all the services to meet a patient's needs.

 

[Arovetli]

@clipper:

Yes, that is what refuses to go means. They could technically go, but at a giant loss. I don't blame them, I wouldnt go either.

@pcbguy:

Your saying we need to invent mid level paramedic position? Why do this? If you want to be an emergency medicine or community health mid level, go to college, go to PA school. Practice where you can get paid and where you are happy. I'm saying the route already exists. Financing speweth forth from Student Loan Mountain. Go get the education. Go. What makes you think having an advanced paramedic masters program is going to motivate someone to attend graduate school, when already they can attend graduate school and make six figures quite conformably?

That was/is the point of pa programs. Military medics and technicians and allied health and paramedics to have a program to advance. The educational program is there, yet everyone whines about no opportunities. Go figure. Bachelors programs have come and gone and some are here and there, but no one is jumping wholesale to attend. How are you going to get people to go? Insurance doesn't automatically reimburse higher for a bachelors prepared provider. Go establish repoire with your local universities and pa programs to help develop connections between EMS and the PA profession. Hell, the NAEMT should do this but...riiiiight...

I would note that I think there is room for PA programs to foster an internal track in emergency/critical care medicine.

@expat:

The whole system is broken. I concur with what you say.

Advance to what?

Directing patients to appropriate resources, treat and releasing (for minor issues) screening and developing heuristics and decision tools for prehospital use. Fixing reimbursements. Bachelors programs. I support paramedics doing all of this and will happily work towards it both scientifically and legislatively.

These are things we already can and should do.

Community paramedicine seems like some frankenstein-esque nonsense someone cobbled together from 1955 physician house calls and a JEMS article about increased scope remote medics.

A Hail Mary play for what? It's still a good entry level technician job. Should it be a more professional clinician role? Sure, there is room to grow. But still It is what it is, and will be. If you don't want to occupy a low rung, you move up. There are no surgical techs clamoring to be first assist. Because they have their role, and if they want to get to close, well, they go through any number of routes to further their skills. That's about as much sense as community paramedicine makes to me. Perhaps I misunderstand.

@everyone:

Alot of the issues faced are healthcare systems issues. Access to care is difficult, especially after hours/weekends. There is little avenue for the poor and uninsured. Mental health resources are abysmal.

These are healthcare system problems, not EMS problems. We just got all the issues dumped in our laps. It's an opportunity to take a role with physicians and nurses and others to craft a beneficial system for all, not an opportunity to salvage some wreckage and twist it into some kind of savior just for us.

If we organized, networked, advocated, and lead; getting the mentally ill in programs where they weren't solely reliant upon the emergency system, getting the poor access to care, perhaps we could have some influence in the reform process. And perhaps then we could have more time to focus on being a great emergency system.

 

[pcbguy]

@pcbguy:

Your saying we need to invent mid level paramedic position? Why do this? If you want to be an emergency medicine or community health mid level, go to college, go to PA school. Practice where you can get paid and where you are happy. I'm saying the route already exists. Financing speweth forth from Student Loan Mountain. Go get the education. Go. What makes you think having an advanced paramedic masters program is going to motivate someone to attend graduate school, when already they can attend graduate school and make six figures quite conformably?

That was/is the point of pa programs. Military medics and technicians and allied health and paramedics to have a program to advance. The educational program is there, yet everyone whines about no opportunities. Go figure. Bachelors programs have come and gone and some are here and there, but no one is jumping wholesale to attend. How are you going to get people to go? Insurance doesn't automatically reimburse higher for a bachelors prepared provider. Go establish repoire with your local universities and pa programs to help develop connections between EMS and the PA profession. Hell, the NAEMT should do this but...riiiiight...

I would note that I think there is room for PA programs to foster an internal track in emergency/critical care medicine.

Why then was it okay for nursing to develop a mid-level position? If they wanted to do more they should have attended PA or medical school.

The point is that there is a giant gap that a pre-hospital mid-level could fill. Maybe the answer is for a PA specialty in prehospital emergency/critical care as you said. But I don't see where that is happening. What is happening is that these CP programs are going to develop and hopefully the education along with it. I don't see how they could without it. I don't think the answer is to give a street paramedic a couple of hundred more hours of didactic and clinical hours and send them out to do what the CP role should be.

@Clipper1

To say that a CP cannot preform the duties of an RN is a bit short sighted. We don't know how the CP program will develop. If it develops the way it should, it will include significantly more education and if and when this becomes wide-spread then I believe the CP will be trained for a variety of roles. But without knowing the end outcome I don't think you can accurately say they won't be able to perform any particular duty or skill.

 

[Arovetli]

Because in decades ago men weren't going to be caught dead in no gaylord focker nurse job. Don't neglect all that nonsense had a role shaping things.

And because nursing is its own field and has predated about every other medical professional. They developed a formal mid level pathway and a PA pathway was developed for those of other backgrounds...or those who wanted the whole medical model/nursing model difference. And it's accepted more in the sub specialties.

And because what happened decades ago in a different time is not necessarily how it should go now. If there wasn't a terrible war with fast tracked docs and military medics, likely there would be no PA programs.

Heck, community/rural/primary care was and is a big reason these programs exist.

I agree it's silly to have so many different levels and doctoral degree creep has gotten out of hand for everyone.

Having mid level assistant doctor, and mid level doctor nurse, and midlevel Community Paramedic...is pretty silly when you think about it.

At least to me.

I'd focus my time on getting funding and resources established so the midlevels we have can actually go do this stuff.

Ill put my money where my mouth is, and out of good sport, If community paramedicine exists as you all are preaching, and it becomes widespread in at least 50 percent of the states, I will buy everyone who is posting in the thread a round.

 

[ExpatMedic0]

Ill put my money where my mouth is, and out of good sport, If community paramedicine exists as you all are preaching, and it becomes widespread in at least 50 percent of the states, I will buy everyone who is posting in the thread a round.

You got yourself a deal. Be careful though, I have been here since 2005 and I am not going anywhere anytime soon ;-)

 

[DPM]

Getting in on this for some free booze... ahem.

Also, there is a similar system where I come from with Emergency Care Practitioners. They are MSc trained (Paramedic in the UK is nearly all BSc now) with an expanded scope. They have more drugs and assessment tools, and the theory is that they will manage the non-acute cases with the aim of avoiding an ER visit. Instead of an ALS ambulance taking you to the busy ER, the ECP will see you at home, start a long term treatment plan (which can include ordering X-rays, starting anti-biotics etc) then arrange for a GP visit, Dr's office visit, home nurse visit for you. This frees up ER beds as well as ALS units. The ECPs can deal with a lot of the Alpha and Omega calls per EMD, while also responding to the Echo calls as an extra set of hands with extra skills (e.g. Thrombolytics)

 

[Wes]

Am I the only one who sees a disconnect when you have the same person dealing with the two extremes of our patient population? It would seem that the skill sets/interventions/mindsets for dealing with the critically, acutely ill patient are by no means the same as dealing with low acuity patients.

While I'd love to see community paramedicine and critical care paramedicine both take their rightful place, I worry that we, as EMS, still haven't proven ourselves capable of providing competent BLS and ALS care as it is. In other words, let's be the best EMTs and paramedics before we go looking for more to do -- or screw up.

 

[ExpatMedic0]

Am I the only one who sees a disconnect when you have the same person dealing with the two extremes of our patient population? It would seem that the skill sets/interventions/mindsets for dealing with the critically, acutely ill patient are by no means the same as dealing with low acuity patients.

While I'd love to see community paramedicine and critical care paramedicine both take their rightful place, I worry that we, as EMS, still haven't proven ourselves capable of providing competent BLS and ALS care as it is. In other words, let's be the best EMTs and paramedics before we go looking for more to do -- or screw up.

I hear ya Wes, and I know a couple other people are singing this tune as well. The problem is this.... EMS and Paramedicine has had well over 40 years to improve. It needs change in order to initiate change, the UK and Australia are primarily Bachelors degree Paramedics now and also offer masters and PhD in the subject... Somehow we(the USA) never evolved and there are a lot of arguments and reasons why that is.... most of them come down to reimbursement and our current health care polices.

EMS is full of "Transactional leaders". These good ol boys promote stability,and that is exactly what we have to much of in the American EMS system. To much stability and not enough change. Medcine and technology change, so EMS needs to also. On the other hand, Transformational leaders create change with things like this community paramedic concept, I am not saying its perfect... but its an outside the box idea we can try and it might just work. As long as it raises enough eye brows and stirs the pot, it may, if we are lucky, promote change. That change may trickle all the way down the entire system.

 

[pcbguy]

I'd focus my time on getting funding and resources established so the midlevels we have can actually go do this stuff.

Ill put my money where my mouth is, and out of good sport, If community paramedicine exists as you all are preaching, and it becomes widespread in at least 50 percent of the states, I will buy everyone who is posting in the thread a round.

Even if we had the money available to fund PAs and NPs going out, there isn't enough of them. They are needed where they are. If you take them out of the EDs and Clinics then you haven't really fixed the problem. The ED will have less providers and still be overloaded.

And I'll take you up on that drink. If it doesn't happen, I'll buy! Lol

 

[pcbguy]

Am I the only one who sees a disconnect when you have the same person dealing with the two extremes of our patient population? It would seem that the skill sets/interventions/mindsets for dealing with the critically, acutely ill patient are by no means the same as dealing with low acuity patients.

While I'd love to see community paramedicine and critical care paramedicine both take their rightful place, I worry that we, as EMS, still haven't proven ourselves capable of providing competent BLS and ALS care as it is. In other words, let's be the best EMTs and paramedics before we go looking for more to do -- or screw up.

Even though these are being called Community "Paramedics" I think there is some confusion. Noone is suggesting that we take paramedics off the street and throw them into a new role. These CPs would be a new level of care. They could still respond to emergencies if needed but would have to have ample training and education to enable them to take care of "low acuity patients."

Some of us have proven that we provide excellent BLS and ALS care. Don't reduce us to the lowest common denominator. There is always room for improvement and some that need to work on their BLS skills. It's always going to be that way and not just for EMS, but for all levels or health care(RNs, Mid-levels and MDs). Just because some people have poor BLS skills shouldn't hamper others from expanding their role and pushing for the advancement of our field. The ones that need to work on their BLS/ALS skills just won't be coming along until a time when they are capable of doing so.



@ExpatMedic0:

Well said!! It's outside the box and hopefully will stir things up enough to invoke a change.

Thanks!

 

[Summit]

Avoreti has been repeatedly hitting the nail on the head... with a jackhammer.

My outlook is this: Primary care is not the natural progression for paramedicine. CP is not a progression of paramaedicine. It is a dual purposing to fill a perceived hole. "I can do ACLS and arrange medication refills," is not really a big selling point because you don't need the same provider to do both. You can have the low acuity served by a provider focused on that population and they can summon the emergency technician if need be. The only selling point for crosstraining the emergency specialist is paradox. The excess of these specialists with low utilization rates is, in many markets, a function of the Fire/EMS systems that are least likely to be successful. The argument is that there is slack time these providers can use to focus on community health and they'll do it cheap. Fire fighters are not interested, for the vast majority.

If you make it a masters degree midlevel, then you've defeated the economic argument versus using existing educational and professional providers in that specialty role. This applies downstream too: Bachelors level the economics disappear too. Only when you have vo-ed and AAS degree paramedics with three weekend CP add-on courses and low utilization rates such as found in low call-volume-rural-EMS and 6-medic-engine urban Fire/EMS systems is it an economic argument of "we'll do it cheaper, because what else are we doing," a model that might survive beyond grand funded CP programs.

Doing it better costs more if the market will pay, those providers exist already whether they have PA-C, NP, MD, RN, whatever after their name.

 

[Wes]

I'm not advocating lowest common denominator. I've worked in some exceptionally aggressive systems where high level care was the standard. I also realize that the standards in those systems are, unfortunately, the exception rather than the rule.

All I am trying to say is that home health doesn't seem to be a natural progression for paramedicine. Lets continue to advance in the acute/emergency setting before we try to be all things for all people.

 

[Brandon O]

I think one of the arguments for using EMS personnel is that they're comfortable, capable, and willing to work in the field -- something that may not be true of the average hospital- or office-based provider. It's a certain ability and mindset that's certainly not untrainable, but is a large part of the skillset that defines our role and is probably necessary if you're going to extend the community paramedicine concept to an all-comers scope.

Not everybody can provide effective care while balancing the drug box on a birdcage and talking over the gunshots outside. (So to speak.)

 

[Clipper1]

@Clipper1

To say that a CP cannot preform the duties of an RN is a bit short sighted. We don't know how the CP program will develop. If it develops the way it should, it will include significantly more education and if and when this becomes wide-spread then I believe the CP will be trained for a variety of roles. But without knowing the end outcome I don't think you can accurately say they won't be able to perform any particular duty or skill.

I think some of the duties the RN does is the reason why you become an EMT or Paramedic.

When you do home health you can not always ignore a patient's request for personal hygiene. Assisting a quad with a BM or coaching a BM protocol is not something more Paramedics have ever done or want to do. Checking scrotums for breakdown on corticosteroid dependent or diabetic patients is not something most would want to do. Skin integrity assessments is even in a CNA's skill set even if it is the licensed who must document and initiate treatment. But, prevention is everyone's responsibility. You can not always just focus on one or two specific areas. This is why a home health professional has a broad range of experience and skills. PTs, OTs and even some RTs are actually well versed in personal hygiene skillsets including a complex bowel program for a quadriplegic or stroke patient. They are also very educated on wound care. If the patient gets other complications which could easily have been prevented on your watch, who's responsibility was it? You may not always be able to say "I'll get your nurse" and leave when you are in a person's home. The whole concept is to prevent things from happening so a wound RN or hospitalization is needed.

The CP has been trialed several times over the past 30 years. It has been used as a light duty alternative and for PR stunts. A few EMS agencies were involved in clinic vaccinations. Unfortunately many of these programs just got groans from Paramedics who were assigned to low acuity tasks. These are the same tasks which Paramedics complain about if they become nursing students. If community medicine is done right, it is far from light duty. Many home health professionals are stressed for time because on patient took longer due to an unscheduled situation which was recognized and had to be addressed. If you are also doing emergency calls inbetween, you might not get back to something which should not wait another day or until next week. At least when it was called "welfare checks" the expectations and responsibilities were different. But, once you start holding yourself out as a specialist with title, you could be held accountable for a lot more than you expected even though the agencies with the CP currently have their guidelines written to where it is a "call the doctor or nurse" thing to limit the responsibility. I am using Colorado and Maine as a reference. This was also brought up by Minnesota when asked by other professionals already doing home health. Those who have been in the business do know how involved it can be.

I think some of the mobile units which have staffed an NP or PA along with another professional and maybe a couple of techs have been the most successful. They can serve not only a single patient but also be available in a community or several communities on a regular basis. That is where the funding should be directed if the states can not get the neighborhood clinics back.