Community Paramedics revisited

[Carlos Danger]

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 actually a really good point.

I can't help but wonder if many of the paramedics pushing for this even know what they are asking for.

 

[Summit]

Brandon: the excitement is in the field, so that is where the EMTs go. Community health is not exciting. There are plenty of home health professionals that don't have EMT or NRP after their name.

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.

I agree with you 100%. I think that lowest-common-denominator is the only way that CP works because otherwise .

However, the natural progression of paramedicine is a system of mostly AEMTs and fewer advanced paramedics that resemble Canadian ACP or Australian/NZ degreed medics.

 

[Wes]

In my ideal world, we'd have educated, not trained, paramedics. And they'd be allowed to use clinical judgment, not protocols.

I think "community paramedic" is another symptom of our lack of a true professional identity. Remember when everyone wanted to be a tactical paramedic, a hazmat paramedic, or a critical care paramedic?

Like I said before, we need to own the realm of emergency healthcare before we try being all things to all people.

In other words, lets keep our focus on providing superior emergency (and let's face it, urgent care) medicine to the out of hospital setting. Perhaps some limited home health care is part of it, but it's not where I think paramedicine should be going.

 

[pcbguy]

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.

Great points. If the CP becomes a mid-level then we defeat the purpose of having it done cheaply by Paramedics. I agree with that.

However, I think that the problem of having money to do it is just as big as the problem of having people to do it. These CPs can and should be educated as a specialty provider to provide home care. The entire program can be geared around this.

Even if the money becomes available(through whatever channels) I still don't believe it's a good idea to pull the mid-levels from the EDs and clinics. Definitely wouldn't be prudent to pull RNs with the RN shortage being what it is.

So even taking away the economics of it, I still think there is not enough availability of staffing to do this. Money is going to have to be made available and some of it can be done by hospitals calculating the time and money saved by not having some of these patients sitting in the ED when they can be managed at home or referred to their pcp.

Again there are so many options for how this could all play out. One thing is for certain, there are going to be changes. The system cannot continue the way it is.

@ Brandon Oto

You're right. I would venture that the majority of providers working in an ED or clinic have no desire to venture outside to do the job in the community. I know several RNs that have repeatedly said "I don't know how you guys do it out there." So utilize the people that are already out there but make sure they know what they are doing. How to do that would be through higher education. Not all will step up or be interested but many will be.


All of the arguments for why a paramedic cannot or would not be willing to do this are null. If a paramedic wishes to become a CP or paramedic practitioner(whatever they will be called) it will be understood, as with any other profession, that this is what you are going to have to do. Dedicating yourself to higher education, helping pts with personal hygiene, and any other duty and role that is required of you. Noone can say that a paramedic won't want to do that. If they want work in this position this is what you will have to do. An RN, LPN, MD or whatever knows what will be required of them and that some of the things they will have to do aren't glamorous but it is their duty to do what is best for the pt.

I would agree that PAs or NPs serving in the role of a community provider would be ideal. But where are we going to get these extra PAs and NPs from? I don't believe there is a surplus of them.

Still loving this thread. Lol

 

[pcbguy]

In my ideal world, we'd have educated, not trained, paramedics. And they'd be allowed to use clinical judgment, not protocols.

I think "community paramedic" is another symptom of our lack of a true professional identity. Remember when everyone wanted to be a tactical paramedic, a hazmat paramedic, or a critical care paramedic?

Like I said before, we need to own the realm of emergency healthcare before we try being all things to all people.

In other words, lets keep our focus on providing superior emergency (and let's face it, urgent care) medicine to the out of hospital setting. Perhaps some limited home health care is part of it, but it's not where I think paramedicine should be going.

I think it might help all the people who don't think this is a good idea if we take the "Paramedic" out of the equation. That seems to be where everyone is hung up thinking that these are going to be paramedics going out doing this.

Maybe we should call it a Community Practitioner. Maybe one of the pre-reqs to get into a Community Practitioner program would be that you have to be a paramedic.

 

[Wes]

So, in other words, creating a new form of home health care provider where the entry is paramedic certification and/or experience? Might just work....

 

[Brandon O]

I would agree that PAs or NPs serving in the role of a community provider would be ideal. But where are we going to get these extra PAs and NPs from? I don't believe there is a surplus of them.

There may be before too long. Everybody and their mother is getting interested in the midlevel role; if enough programs become available the numbers could become pretty impressive.

 

[Clipper1]

The CP websites are using the UK, Australia and Canada as models but seem to have forgotten the difference in education and each nation's health care system. The UK also takes it a step further to the ECP (Paramedic or nurse) which is more like a PA or NP. If you went by that model then the PA and the NP are what we already have in the US. Thus, some of the comparison makes very little sense.

example
West Eagle County
http://www.naemt.org/Libraries/NAEMT Documents/WECAD Community Paramedic Handbook.sflb

According to the Joint Committee on Rural Emergency Care, the expanded role of EMS personnel has already occurred on a wide scale in countries such as England, Australia and Canada.

Nothing is free as West Eagle County claims. The money for the vehicles, extra equipment, personnel, new uniforms, patches, teachers and the school program accreditation process had to come from somewhere even if it is a "grant". Right now many community colleges are cutting programs just to stay viable. Adding new programs might not be an option even for short cert programs like this. You will then also have extra costs at the state level for certifying and maintaining the records of CPs if there is an additional level added. This can get expensive even just for testing. Additional liability insurance may also need to be considered even by the individual. For municipal agencies they would need to review their state's immunity laws to see if coverage will extend to this area.

There are probably several licensed health care providers who would like to do home health and just have one patient at a time but the responsibility and liability is often a deterrent. I know how difficult it can be caring for patients with multiple medical needs on a daily basis in the hospital with resources readily available. Working "long term" in a patient's own home environment is not that appealing.

 

[Clipper1]

So, in other words, creating a new form of home health care provider where the entry is paramedic certification and/or experience? Might just work....

There is also another alternative which some states are utilizing and that is the HH-PCT. They can do all the basic care needs along with glucose monitoring, wound care, ECGs and phlebotomy. These programs are already in existence and are about 6 months or 600 hours in length. They know what they are getting into since the CNA cert and experience is first required.

 

[pcbguy]

There may be before too long. Everybody and their mother is getting interested in the midlevel role; if enough programs become available the numbers could become pretty impressive.

Someone is going to have to take care of this problem. If the enrollment is up that would be another way to fill the gap. There should be a pre-hospital specialty.


@Clipper1

That sounds interesting also. One of the arguments thought is that paramedic with additional hours isn't enough. Is a CNA with more hours going to be adequate? Not saying it won't just playing off one of the arguments already out there.

 

[Brandon O]

Let's bear in mind that there's no reason the idea of "extending healthcare options into the home" needs to be addressed by a single entity. It seems like it would make sense to have a large toolkit, allowing the system to answer various needs with the appropriate resource.

 

[Clipper1]

There may be before too long. Everybody and their mother is getting interested in the midlevel role; if enough programs become available the numbers could become pretty impressive.

But the educational process is not. Not many want to get a Masters degree just like not many in EMS want an Associates degree. A Paramedic could go on to be a PA. But, they then would not be called a "Paramedic". Being called an "assistant" even a Physician Assistant is not as cool. You would also think with well over 3 million RNs in the US and probably 40% (goal of 80% by 2020) holding BSNs, there would be more NPs. But, out of the percentage which hold Masters, some are MBAs, MSNs (general) and education. So the numbers are there with potential candidates but many will have established other goals or priorities after a Bachelors which might even be family first.

There are PA schools and they are very competitive to get into. But, even with the relatively high number of applicants, I doubt if that number even comes close to those who graduate from an EMT or Paramedic school every month.

 

[Clipper1]

@Clipper1

That sounds interesting also. One of the arguments thought is that paramedic with additional hours isn't enough. Is a CNA with more hours going to be adequate? Not saying it won't just playing off one of the arguments already out there.

The CNA must have a minimum of 75 hours by a Federal requirement for CMS recognition. Most good programs exceed that by double. This teaches basic daily living care. To specialize in home health, about another 100 - 150 hours is required. To be a PCT, you need about 400 - 600 additional hours. If the programs are taught at community colleges they may also require a semester of A&P. Some colleges believe these students will later progress to nursing. The "hours" add up to almost the same as some Paramedic programs but the focus is entirely upon daily care, range of motion and a few diagnostic procedures. The Paramedic programs are for providing emergent care. You are not going to find bowel or bladder care or bathing a total needs patient (who are now in home care) in their curriculum. CNAs and PCTs may also get further training on the job by OTs, PTs, RNs, SLPs and RTs to do more tasks. I know the PTs train all of our CNAs and PCTs on lifting and all the mechanical lifts even if they received the training in school. Many of the more reputable home health agencies will also provide this training.

I believe a more effective way would be for one provider who can meet many essential care needs and still do some test along with ensuring compliance with medications. The patient can also establish a relationship with that provider who will get to know their needs and won't be just a fly by inbetween emergency calls. A PCT would also be more likely to drive a more economical vehicle.

I am not saying a Paramedic can not learn all of this also buthow much of this would they want to know and do. Sometimes it just takes a good HH-CNA or PCT to get the home organized and see the patient can do some cooking or microwaving nutritious food.

 

[pcbguy]

I think that is still a much needed role and that wouldn't be what CPs would do. I don't see them as being so much home health and physical therapy. If that was needed upon visit they could put in an order for a PT or if a home health nurse was needed then that would be ordered.

The pilot programs that are running seem to have a different role than that. But in the long run there is going to have to be some serious discussion on a higher level of what the roles are and if they cross then so be it.

Interesting stuff though. I wonder, reading all this, how much of this is offered in my area. I'm going to have to look into it. I would imagine it is like most of these roles though and there are not enough of them to go around.

 

[Clipper1]

The pilot programs that are running seem to have a different role than that. But in the long run there is going to have to be some serious discussion on a higher level of what the roles are and if they cross then so be it.

I posted the link to Colorado's West Eagle program.

 

[Summit]

First, there is no shortage of RNs or NPs. There is an excess in most markets.

The reason why people don't want to step out of the hospital isn't because hospitals are a warm fuzzy place. It is because clinics, doctors offices, hospitals are EFFICIENT in terms of seeing many patients quickly which means MORE MONEY. Even for RNs, HH is a lower paid field with few exceptions. Why? Because it is less glamorous, less demanding work, and less profitable than hospital nursing. Why would it be different for paramedics? Being a CP is not likely to make more money than a home health RN. If they did, they'd pay a CHRN.

Unless they were a masters degree midlevel... so why don't higher providers do this now?

The reason virtually zero family practice MD/PA/NPs do not do house calls is all about efficiency and money: How many patients can you see when you have EMT/CNA/LPN/CMA/some girl with OJT doing vitals, injections, lab draws, etc and the provider only sees the patient for 10 minutes? If you can see 4 patients an hour, you can bill a lot more than if you can make 1 house call an hour and spend your time driving to see patients instead of them spending their time driving to see you.

So why is a paramedic going to spend the time to go get an undergraduate education and a graduate education to do home health care for less money than if they went the PA/NP route?

Is there an alternative? Let's look at a US home based care model that uses MD/NP/RNs and all the other specialties! I've had first hand experience with this program:

I'll point to a long running viable program with a track record of success (that I bet nobody here has heard of). That is, the VHA Home Based Primary Care (HBPC) program. “HBPC is comprehensive, longitudinal primary care provided by a physician-supervised interdisciplinary team of VHA staff in the homes of veterans with complex, chronic, disabling disease for whom routine clinic-based care is not effective. “ It was started in 1970, originally as a palliative and primary care program. In quickly grew into a proactive community health program for qualified veterans with the goals of increasing care while decreasing cost. Increased care (and qualifications) comes by targeting it at known disadvantaged veteran populations, particularly those who are unable to travel to care. Decreased cost comes through preventative care that has demonstrably decreased both hospital admissions, lengths of stay, acuity, and non-institutionalization in the HBPC patient population.

The HBPC program is actually multi-discipline with RN/NP initial assessments, physician referral, RN/NP follow up (depending on disposition), and referral to RD, psychology, and PT/OT as necessary. This program is aimed at preventing exacerbations of chronic conditions through monitoring, education, assessment, medication refills, all of which could lead to 911 calls and in-patient stays, or institutionalization in a ALF/LTC. The program has demonstrated better outcomes for the veterans served by it and a cost savings to the VA institution. The only thing stopping a similar model from being applied to the general public is a lack of will.

The HBPC program pays its providers the same as hospital providers on the basis that the system saves money. This shows that if you pay appropriately, then the existing providers CAN AND WILL do the job in the relaxed environment of a patients home (compared to a bustling hospital). If the reimbursement system favors a HBPC system economically, then other providers already exist to step in. I go back to my point that the CP program is only sustainable as a short add-on alphabet soup class with little to no increase in pay over a normal paramedic. Any more school and the providers won't do it with no increase in pay and there will be a shortage of CPs. Increase the pay, and plenty of existing providers will do it, who cares if it is outside the hospital?

@Clipper1

That sounds interesting also. One of the arguments thought is that paramedic with additional hours isn't enough. Is a CNA with more hours going to be adequate? Not saying it won't just playing off one of the arguments already out there.

CNA is usually less hours than EMT. It is a prereq 1. to get basic skills out of the way 2. to give people a taste for the work that many find distasteful before committing to a program as long as current paramedic programs. They aren't decision making educated providers. They are specialized technicians just like paramedics, except they are specialized in home care, not emergency medicine.

 

[Arovetli]

Another point: CP advocates here are presuming patients everywhere WANT healthcare delivered to them by a mastermedic or whatever the hell you want. Please, design a study sampling patients to see if they are responsive to this. I'm genuinely curious. I'm not talking about remoteskitville, I mean Detroit, Cincy, and all our other decayed burned out wrecked ghetto palace cities.

For all the decades we've had midlevels, there's still a bucketload of folks who don't want that...they want the doctor.

And with reimbursements moving towards patient satisfaction, the customer is going to increasingly become always right.

Realistically, who is your target patient population? The poor? Of course we need to care for the poor, but c'mon, hitching yourself to the low class isn't a ticket to high class. Your not going to make alot if money caring for the poor.

Here's a hypothetical. All the psych and mentally distressed/ill patients in the world get abducted by aliens. How many of our problems change? A good bit, I'd say. Less calls, less tying up an ER bed...so why don't we create a Psychiatric Paramedic Practitioner? It is, indeed a specialty separate from EM and PC. Or...how bout we actually solve the mental health crisis, or at least give them some kind of care that doesn't involve 72 hours of haldol and sandwiches, followed by a boot out to the street.

So, I ask you. If not for the poor or the mentally distressed...what use is a national community paramedic?


Everyone supporting CP, riddle me this: why are you not already a midlevel or working towards it? And why do you expect that a degree in community paramedicine will be different from a master in physician assistant studies? Your still going to have to have an undergraduate science foundation, didactic year and a clinical year. I can't imagine the curriculum being much different. And if it was...well, now everybody will continue to find you inferior in education.

And here's the biggest question of them all: do you really want to change the healthcare system or do you want a cooler job, more money and responsibility and more respect, and not have to work as hard to achieve it?

Seems to me there is a whole lot of "I want the world to conform to me" going on.

 

[Clipper1]

It seems the way the CP programs are set up now is a physician will make the referral for the CP to follow his or her patient and write orders or a script to be followed by the Paramedics. This basically implies this patient is being followed by a Physician and probably is on some health insurance plan like Medicare or even a private insurance. The Physicians who are participating in these programs might find this very convenient to avoid being called by the patient. Depending on the program the Physician is probably billing each time the Paramedics call.

There are some really great mobile services out there in the major cities but there are not enough because of funding cuts. But, they do see many people and do make a difference.

NY
http://www.projectrenewal.org/outreach.html

LA
http://www.wellchild.org/2012.10.17_Release_Mobile_Medical_Unit.pdf

Tampa
http://www.tampabay.com/news/health...nit-brings-the-doctor-to-the-homeless/1211449

Seattle
http://www.kingcounty.gov/healthservices/health/personal/mobilemed.aspx

Dallas
http://www.parklandhospital.com/medical_services/outreach/homeless_outreach.html

San Mateo

http://www.sanmateomedicalcenter.org/content/mobilehealthclinic.htm

Texas Children's
http://www.texaschildrens.org/Locate/In-the-Community/Mobile-Clinic-Outreach-Program/

Boston
http://commonhealth.wbur.org/2013/01/mobile-health-clinic-saves-money


General article about the different mobile units

http://www.nhchc.org/wp-content/uploads/2012/02/mobilehealth.pdf

In California they are putting an NP and a care coordinator at some of the fire stations. This is a great idea.

http://itup.org/blog/2011/12/07/cre...y-converting-fire-stations-to-health-portals/

 

[pcbguy]

First, there is no shortage of RNs or NPs. There is an excess in most markets.

Not sure what market you are in but I've personally seen a shortage in most. You can do a search for nursing travel jobs and find where hospitals are paying damn good money for a nurse to come to work from another state. My girlfriend works in the ICU and just took a contract in the ED at the same hospital she works because they are so short handed. She has worked many travel assignments where they were desperate for help.

I'm sure there are alot of politics behind travel nursing but without getting into that its safe to say that more are needed. More quality ones especially.

We can, and have, spent all day say "they should ...." or "they could ...." But regardless of who should be doing this or who could be doing this, it's not being done. If it was these programs wouldn't be needed. They are being developed out of necessity.

Here is another pointed out to me this morning. It's about UF and their critical care program. But it also says on page 2:

"We have a lot more people using EMS as their primary care provider. No one has a family practitioner anymore," Hillhouse said. "People go to either an urgent care, or straight to a hospital. A lot of people don't have cars. Those people call 911, and they get a paramedic."

Instead of taking them to the ER, paramedics would be licensed to diagnose and determine, for example, if someone needs antibiotics, Hillhouse continued.

"We can get out and evaluate them and determine if it's something they do not necessarily need to see an ER doctor for," Hillhouse said, adding that they would be equipped for live consultations with doctors from the Alachua County Health Department for help in making those decisions.

http://www.gainesville.com/article/20130606/ARTICLES/130609730?p=1&tc=pg

Now this does bring up something a little different than the direction we have been talking about this. UF is using a critical care program to do what we have been talking about. Not the higher education we have been talking about but it makes my point that there is a need for this in most places.

@Arovetli

I read somewhere that patients dont dictate their treatment, they dictate their symptoms. That's an argument for another time but one could argue that they don't want medics responding in an ambulance either. Maybe they want MDs. Thats not up to them. That is the way the system is setup. I'm betting they would rather have a CP or Paramedic Practitioner come see them then nothing or having to sit and wait in an ED. Also they may still get to see the MD if needed.

I really would like to see the system changed. As for why more of us don't go to PA school..... Like I said before I like working pre-hospital. Don't see many PAs pre-hospital. I don't want to be in a clinic or ED. There are plenty of people that do. I would love the education and it seems that in the near future that I can combine my desire to work in the pre-hospital environment with the education that I want.

Riddle me this: Why do you assume that if we want more responsibility and respect that we aren't willing to work hard to get it? If this becomes a practitioner level program(Big IF) then why would you think we are just looking to skate through it and be lazy about it? Pretty big assumption to make.

We are conforming to the need. These programs that are popping up are proof that we are. We see a need and we are coming up with ways to fill it. It might not be the ideal way but it's something and better than waiting on something to happen. How long do you think it would take the government to 1. admit theres a problem, 2. discuss it for a while, 3. come up with a decisions to make more mid-levels available(as an example), 4. figure out a way to fund it, 5. put it into action.

Why not figure out a way to use the people that are already out there and having encounters with these patients?

Damn sorry about being so long winded. It seems alot was posted while I was sleeping. Lol

 

[pcbguy]

@Clipper1

I like that the MD refers them CP to visit the pt. There are so many ways this all could play out.

Thanks for the links!