# Community Paramedics revisited



## ExpatMedic0 (Apr 8, 2013)

I found these articles interesting. 

http://bangordailynews.com/2012/03/...irst-in-maine-community-paramedicine-program/

http://www.jems.com/article/administration-and-leadership/how-affordable-care-act-will-change-ems

http://www.jems.com/article/role-ems-community-paramedicine

The part I liked the most was _"Paramedics already holding an associates degree can enroll in the advanced certificate level of the program, which consists of five career courses totaling 16 credits, all but one of which will be offered online. Paramedics who do not have an associates degree will enter the associate in science degree level of the program, taking the same five career courses, as well as an additional 44 credits in math, science and other general education courses."_

It may not be much, but its a start in the right direction. Finally a Paramedic with a degree requirement. I think we are going to see a big changes soon with the introduction of the affordable health care act, community paramedicine pilot programs appearing with degree requirements, and the U.S. meeting with Australian community Paramedic leaders, who have a lot of experience in the area and offer a graduate degree in the subject. *What do you think?*





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*DISCLAIMER: You may remember this topic from a month or two ago. Unfortunately that thread was locked due to bickering. To prevent this thread from being locked and staying on topic, I would appreciate we keep the conversation on topic which is "Community Paramedicine." If anyone wishes to discuss community Nursing in the pre-hospital environment, or other types/levels of providers who provide public health services, please start your own thread. Also, please no degrading any health care professions inside or outside EMS. We are here to discuss Community Paramedicine and show respect for each other.*


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## wanderingmedic (Apr 8, 2013)

ExpatMedic0 said:


> It may not be much, but its a start in the right direction. Finally a Paramedic with a degree requirement. [/B]



Amen. 

Community healthcare is the future, regardless of the exact profession in allied health. With the ACA the emphasis will be removed from individual outcomes to affordable population care. Paramedics already have in infrastructure and logistical ability to deliver care effectively to a large population.

One of the areas I have found that we do not do a good job advocating for our patients is in the area of nutrition, psychiatry, and preventative care. Additional training and scope of practice is a much needed advance for the American EMS system.


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## Obstructions (Apr 9, 2013)

azemtb255 said:


> Amen.
> 
> Community healthcare is the future, regardless of the exact profession in allied health. With the ACA the emphasis will be removed from individual outcomes to affordable population care. Paramedics already have in infrastructure and logistical ability to deliver care effectively to a large population.
> 
> One of the areas I have found that we do not do a good job advocating for our patients is in the area of nutrition, psychiatry, and preventative care. Additional training and scope of practice is a much needed advance for the American EMS system.



Don't get me wrong, I think community healthcare, specifically community paramedicine is a great idea. A lot of money can be made and put where it counts (education, 911 response, actual emergencies, etc). Plus that extra education in basic pathologies and conditions can make a medic even better than before. More opportunities for prehospital providers.

However it got me thinking. I feel like this is similar to the physician vs midlevel provider debate currently raging in medicine. People would fight about our level of training and the variety of procedures we are allowed to perform etc. It also gives the patient (at least I think somewhat) the idea that, "Well, hey. If medic Jerry said I should be okay why should I go visit my doctor anymore? I'm just throwing away money with that $300 a visit charge." It gives them a reason to stay away from definitive care when perhaps maybe they really do need it, but stay at home at receive supplementary care.

Maybe I have a wrong interpretation of the community paramedic, and the role they provide, but wouldn't you agree? I'm curious to see what other people think.


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## Meursault (Apr 9, 2013)

Unfortunately, community health is mostly only considered as a stopgap measure; good for rural populations where we can't schlep everyone into a physician's office or the ED, but automatically inferior to doing that instead. I've had some great interactions with Boston Medical Center's community midlevels, mostly with medically complex poor patients. It's nice to have a health program that isn't dependent entirely on patients taking the initiative. Homebound elderly are the other big population for this, and I suspect a lot of people here have carried someone out of their house and spent an hour with them for their 15-minute physician appointment. 

In deference to the OP, I'll pass over the relative merits of community _paramedicine_. It doesn't matter much anyway, because there's going to be massive resistance to urban community health from physicians, hospitals, and payer inertia.


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## ExpatMedic0 (Apr 11, 2013)

Anyone have any speculation if they think this is something the NREMT could adopt? If they did adopt a community paramedic level, would implementing such a new level pave the way for national degree requirements?


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## Pavehawk (Apr 11, 2013)

ExpatMedic0 said:


> Anyone have any speculation if they think this is something the NREMT could adopt? If they did adopt a community paramedic level, would implementing such a new level pave the way for national degree requirements?



The skills needed for community/primary care paramedics are much more educational based and can vary from state to state depending on enabling statutes and other requirements.

Until there is a national standard for this level NREMT would just be blowing in the wind as it would be hard to test to a standard that is not there.

With that siad I'm sure they would be excited to do it as it will open a new revenue stream with written and psychomotor testing and a new spiffy patch with nominals for your name that will not be worth much to anyone.

I think that a stand alone community paramedic compatency exam, ala FP-C or CCP would make more sense.

As for the education needed, more is almost always better, but we need to hit the happy median between degreed PA/RN providers and field paramedics operating on the fringe of primary care in some fashion. I think this will be an exciting growth area for prehospital care and am looking forward to seeing more.


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## wanderingmedic (Apr 11, 2013)

ExpatMedic0 said:


> Anyone have any speculation if they think this is something the NREMT could adopt? If they did adopt a community paramedic level, would implementing such a new level pave the way for national degree requirements?



I think it would be great if the NR adopted a community medic cert - even better if they created a new level that required a BS and included a slightly more advanced skill set similar to what we see in Europe. 

but I doubt this will ever happen....and if it does....it will not be soon.
large organizations move slowly and are scared to innovate and try new things. Old dogs, new tricks.


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## Simusid (Apr 12, 2013)

How would a Community Paramedic be distinguished from a visiting nurse?
Not trolling.  I seriously am not sure!


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## Summit (Apr 12, 2013)

azemtb255 said:


> I think it would be great if the NR adopted a community medic cert - even better if they created a new level that required a BS and included a slightly more advanced skill set similar to what we see in Europe.
> 
> but I doubt this will ever happen....and if it does....it will not be soon.
> large organizations move slowly and are scared to innovate and try new things. Old dogs, new tricks.



That would be pretty awesome, but I agree with your assesment. If we see a national stabdard BS level medic in my lifetime, I'll be surprised (but happy).



Simusid said:


> How would a Community Paramedic be distinguished from a visiting nurse?
> Not trolling.  I seriously am not sure!



Shhhh! We can't talk about Community Health BSN RNs in this thread or there might be some uncomfortable questoins and debates. The purpose of this thread is discuss this idea of community medics in a vaccum so that it doesn't have to stand up to scrutiny. :unsure::glare::sad:


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## Pavehawk (Apr 12, 2013)

Summit said:


> Shhhh! We can't talk about Community Health BSN RNs in this thread or there might be some uncomfortable questoins and debates. The purpose of this thread is discuss this idea of community medics in a vaccum so that it doesn't have to stand up to scrutiny. :unsure::glare::sad:



The biggest difference in community paramedicne vs BSN/RN community health is the access through the 911 system. While our nurses are making thier scheduled rounds, the paramedcis could respond to sub-acute situations as determined my triage protocols and either treat and release or other interventions including transport (arranged or actual) to non ED providers. RN and medic SHOULD be working together, not at odds with each other.

Community medicine and health care as a whole needs to evolve, I think there is a place for both the community paramedic and the community RN both helping to keep folks who don't need it out of the ED, as well as prehaps prevent some people from ending up in an ED from non-compliance or lack of entry in the system except via ED/911.


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## ExpatMedic0 (Apr 13, 2013)

Yes, I think one reason this whole concept is beginning to boil to the surface in the USA is because there is now a way to profit from it and it has already been used and proved successful in other countries. I have posted community paramedic studies on here in the past, they show %80 reduction in ER admission. 
3 reasons off the top of my head are below

1. The way EMS is being reimburse is changing dramatically with the PPACA.
(see interesting article hereIt will also lead to EMS "checking up" on frequent fliers and recent discharges. 

2. It has already increased Paramedic education. Although Community Paramedcine pilot programs really just started in most areas, Maine has already made it a degree requirement, other state's programs are requiring additional college course work, and its not long before everyone follows suit. Community Paramedicine has advanced education for EMS providers in some states more in a few months than decades of standard U.S. EMS education to date. It is gaining momentum at an alarming rate right now because of the PPACA and other factors that are new, that will increase profits and demands from EMS agency's. If we(EMS) do not move fast enough and do this the right way, we could lose it as an opportunity. 

3. The old way our EMS system works is, if someone ask to go the hospital you have to take them... My friend once took a guy for playing to much xbox because his hand hurt. However... I am thinking with the introduction of this paramedic model, frequent fliers and unnecessary ER admissions would be eliminated, as shown in the study where ER admissions where reduced by %80 because of community Paramedics. We are already responding to these people, they are the majority of our calls and patient, we are already going to there house with all are resources and equipment, now we can just treat and release in some instances. Which is what Paramedics do in most other countries anyway.


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## ExpatMedic0 (Apr 13, 2013)

Here is the latest news of a pilot program in Boise. http://www.ktvb.com/news/Community-paramedic-program-aims-at-cutting-ER-visits-201216211.html


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## akflightmedic (Apr 13, 2013)

I am currently laying the foundation for a program in my area.

This is the future and it will be a reality. For anyone who questions who will pay for it or why...here is the reason.

Reimbursements to hospitals has changed. If they admit a patient 3 x in a 30 day period for a chronic condition, they will no longer be paid for the 2nd visit. There is huge loss of revenue when you extrapolate those numbers.

Collectively, hospitals will love this approach and will help pay for it. The reimbursement system is changing and holding the hospitals accountable for their treatments.

Ideally, a community paramedic is a better approach in the sense that studies have shown repeatedly just visiting your chronic illness patients reduces 911 calls. In our study just being finalized, we excluded drug and alcohol abusers and psych as those are an entirely different issue right now. We focused on diabetics, CHF, HTN, etc...when you visit these people and are educated enough to review their systems and medications, therapies, and perform a basic health screen you will see a positive impact in the sense that 911 call volume goes down, admissions go down and overall patient pro-activeness in their health care improves.

Another benefit aside from reducing strain on area hospitals is it reduces strain on area emergency response systems as well. The IAFF may protest this but we have to not be selfish and wonder what is in it for us, but what is better for humanity. Definitely a shift away from traditional American thought.

With a robust enough program, you may see a truck or two being taken off the streets and those funds being allocated to the Community program. No one likes working themselves out of a job but it is time and necessary.

Typically the paramedic is embedded, he/she has already met or transported these patients. This is how they get on the list for community health checks. Visiting nurses are visiting those who are already in the system one way or another. By utilizing a paramedic or having an in house referral system, in theory there could be no delay in visiting someone. Crew A sees a patient for hypoglycemia today, submits a form and Community Medic B puts them on his list to visit tomorrow. Bam...they are now in the system. The other processes typically take a lot of time and bureaucracy and typically follow repeated hospital admissions, etc.

Would this program eventually grow and become just as cumbersome with paperwork and admission into the system? Possibly but at least we are thinking about it now and trying to find ways to prevent that and keep it to its true form.

Lots more to discuss but thats the overview.


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## AlphaButch (Apr 13, 2013)

Our pilot program (a version of community paramedicine) has actually been met with alot of resistance from hospitals because of the reduction in ER admissions. 

Hopefully, once they've sorted out the reimbursement issues for ACOs, this resistance will change as continuity of care and prevention of hospital admissions will have more focus and affect reimbursement. Should start seeing some effects from the up and coming hospital re-admission penalties soon as well. 

It will make for interesting times.


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## Action942Jackson (Apr 13, 2013)

This is all fine and dandy, but until we see an increase in all of our salaries equivalent to our education.  This topic is dead in the water.  

The few people who will do it regardless of money are worth their weight in gold. But if I were to jump on this bandwagon and obtain my BS in order to do so, there better be a bump in pay.  Because honestly, I didn't get a single cent more for me going and getting my CCEMT-P. 

The moment I see the program running requiring the BS or equivalent with salaries comparable to the amount of education.  I will jump on it.

But this will have a lot of hurdles to overcome.  As this program was originally intended for rural areas without immediate access to definitive care.  And majority of those areas still rely on volunteers.  Not knocking them.  But it's time to wake up and smell the roses.  Pay has got to come in line with required education levels.  

Otherwise, This is the future of EMS.


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## STXmedic (Apr 13, 2013)

Action942Jackson said:


> This is all fine and dandy, but until we see an increase in all of our salaries equivalent to our education.  This topic is dead in the water.



Wait.... So are you advocating we need to be paid less? Because our education is laughable... There are many medics that are far overpaid for the education they posses... :unsure:


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## Action942Jackson (Apr 13, 2013)

PoeticInjustice said:


> Wait.... So are you advocating we need to be paid less? Because our education is laughable... There are many medics that are far overpaid for the education they posses... :unsure:



No, what I am saying is if there is going to be another career path for the career medic (CP) requiring higher education.  Then salaries should be risen to fully compensate based on amount of education for that particular path.


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## usalsfyre (Apr 13, 2013)

Action942Jackson said:


> This is all fine and dandy, but until we see an increase in all of our salaries equivalent to our education.  This topic is dead in the water.



Sorry bubba, that's not how it works. Prove you can rise to that level then we'll talk about pay.

I spent a fair amount of my own money on CCT education. It didn't pay off immediately but I now have the job I do because of it. To take the next step I'll need to get a BS, which will also be out of my pocket...but it'll lead to much greater opportunity.


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## Action942Jackson (Apr 13, 2013)

usalsfyre said:


> Sorry bubba, that's not how it works. Prove you can rise to that level then we'll talk about pay.
> 
> I spent a fair amount of my own money on CCT education. It didn't pay off immediately but I now have the job I do because of it. To take the next step I'll need to get a BS, which will also be out of my pocket...but it'll lead to much greater opportunity.



To whom do you request I prove "my level" to? What level do you speak of? Paragod v. 4.0?     I think you missed the gist of my stuff.  What I was specifically referring to was if this next level of paramedic required a BS degree, it better come with a bump in pay.  There's no way in hell Im paying out the wazoo for BS degree nowadays to get to another level of paramedic with no additional monetary compensation.  I make 37k a year as a medic right now.  9 years in EMS, 7 as a medic.  Ive learned since I paid for my own CCEMT-P, to not do that again.  Do you see doctors choosing another specialty for free or no change in pay? Nope.


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## Dwindlin (Apr 13, 2013)

Action942Jackson said:


> Do you see doctors choosing another specialty for free or no change in pay? Nope.



Not a great example, we don't generally choose another specialty, not how medical education works.


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## Action942Jackson (Apr 13, 2013)

Ok, correction.  A regular RN, promoting to a highly advanced ICU RN for no change in pay. I tried to avoid bring nurses into this, OP.  He made me.


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## VFlutter (Apr 13, 2013)

Action942Jackson said:


> To whom do you request I prove "my level" to? What level do you speak of? Paragod v. 4.0?     I think you missed the gist of my stuff.  What I was specifically referring to was if this next level of paramedic required a BS degree, it better come with a bump in pay.  There's no way in hell Im paying out the wazoo for BS degree nowadays to get to another level of paramedic with no additional monetary compensation.  I make 37k a year as a medic right now.  9 years in EMS, 7 as a medic.  Ive learned since I paid for my own CCEMT-P, to not do that again.  Do you see doctors choosing another specialty for free or no change in pay? Nope.



Not to derail the thread but there are multiple medical professions that have done what EMS is trying to do. All of these professions have increased educational requirements first without an immediate increase in compensation. For some it took years before there was any tangible benefit for the profession as a whole. A recent example is Physical Therapy which is moving to a doctoral degree even without an expected increase in pay.



Action942Jackson said:


> Ok, correction.  A regular RN, promoting  to a highly advanced ICU RN for no change in pay. I tried to avoid bring  nurses into this, OP.  He made me.



Not a great example either. In many places ICU and floor nurses are paid the same. Even without an increase in pay there are multiple highly qualified individuals competing for ICU spots. Right now I make more than I would in our teaching hospital's CVICU but I would still transfer in a heart beat for the opportunity.

Since you brought up nursing. Google and do some research on the history of the profession and how it evolved from Diploma to AD to BSN.


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## usalsfyre (Apr 13, 2013)

Action942Jackson said:


> Ok, correction.  A regular RN, promoting to a highly advanced ICU RN for no change in pay. I tried to avoid bring nurses into this, OP.  He made me.



Actually...there's often times not a huge difference...

You seem to be bitter about CCEMT-P, have you thought about what it may open up down the road? Again it wasn't an immediate pay off for me, but my income is far greater and hours better because of it 5 years later.


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## Clipper1 (Apr 13, 2013)

Action942Jackson said:


> Ok, correction.  A regular RN, promoting to a highly advanced ICU RN for no change in pay. I tried to avoid bring nurses into this, OP.  He made me.



If an ICU RN goes to home care chances are they will take a significant drop in pay and benefits since they will not be with a hospital even though the degree requirements (usually BSN) will be the same plus the additional certs will be in place. Besides the regular home care certs, they may need to pick up wound care,  asthma and COPD certs which are not cheap. AE-C must be renewed every 7 years at a hefty price and the exam must be retaken.  Just the extra time for all of the equipment in home care is time consuming.  But, some just want to see one patient at a time and have more flexible hours which makes the change worthwhile.  Also, in the hospital, for some RNs to be able to apply for a position in ICU or the ER, they must be an RN 2 level which already gives them a little more pay. 

In some places this Community Paramedic concept has be utilized for many years but not with the title. It has been a light duty position. The Paramedic is restricted from lifting so they ride around in a SUV doing housecalls or giving vaccinations at the clinic or Walgreens.  

As a Community Paramedic, you should do this full time. This should not be just a one day a month thing.  Just like the emergency stuff, it takes time and practice to be good at teaching. You also must be willing to do assessments which are not traditionally in your comfort zone. To be effective in home care, you can not pick and choose what you want to see. 

But, if you are not responding with lights and sirens, intubating, lifting and picking up violent patients, do you really need the extra pay? Since you will be responding in a car or SUV, you will have to call 911 for emergencies.  You will no longer be the guy running in to save the day. You might even get pushed aside by all the FFs and other Paramedics.  If you are focused on Community Paramedic, the skills such as IVs, needle decompression, defibbing and intubation will not be your mainstay. You may get as rusty as if you were on a BLS truck all the time.   The other community health programs for Paramedics failed because the Paramedics did not like the boring stuff and there was a stigma that did go along with it.  EMS is very judgmental just like the tensions between FD vs Private vs Public.


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## Carlos Danger (Apr 14, 2013)

Action942Jackson said:


> This is all fine and dandy, but until we see an increase in all of our salaries equivalent to our education. This topic is dead in the water.
> 
> The few people who will do it regardless of money are worth their weight in gold. But if I were to jump on this bandwagon and obtain my BS in order to do so, there better be a bump in pay. Because honestly, I didn't get a single cent more for me going and getting my CCEMT-P.
> 
> ...



Pay for paramedics currently is in line with required education levels. 

How much money do you expect to make with a two-semester vocational certification?



Action942Jackson said:


> Ok, correction.  *A regular RN, promoting to a highly advanced ICU RN for no change in pay.* I tried to avoid bring nurses into this, OP.  He made me.



Yeah, it doesn't work that way at all.

Pay is based primarily on supply:demand in the labor market. It actually has very little to do with education levels.

The only reason people with more education typically get paid more is because usually, the higher you up in education, the fewer people you have to compete with for jobs, so the demand becomes greater than the supply and the employer pays more because they _have_ to, not because they want to reward you for the years you spent in school.

Case in point: I made several dollars an hour more working as an ICU nurse than I did as a flight nurse for the same hospital, even though the flight nurse role required a lot more experience, training, and responsibility. But because the hospital had an easier time filling flight nurse positions - because everybody wants to fly, and because there aren't nearly as many openings for flight nurses - they didn't have to pay flight nurses as much as they did ICU nurses.

Another example: Average compensation for attorneys has dropped like a rock over the past decade or so. Why is that? Is it because the education required of lawyers has decreased? No, of course not. It's because they number of people graduating with law degrees has gone way up, so the supply of lawyers exceeds the demand. Therefore, those who hire lawyers don't have to pay them as much.

So the point is, a community health paramedic is not necessarily going to make any more money than a 911 paramedic does. It depends on the supply of people willing to take the jobs vs. the demand. Increased education will _probably_ result in higher pay, but not necessarily.


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## Summit (Apr 14, 2013)

Action942Jackson said:


> Ok, correction.  A regular RN, promoting to a highly advanced ICU RN for no change in pay. I tried to avoid bring nurses into this, OP.  He made me.



Most of the time, critical care nurses are nurse IIs with 1-3 years of experience, thus they are making more. Once they get into the ICU, they are undergo additional education and orientation. The education, often including AACN's ECCO program, is anywhere from 6 weeks to 20 weeks while orientation ranges from 10-26 weeks depending on the experience of the nurse. No, RN ever puts ECCO in their post-nominals. There is often a boost in pay and much higher employability when the RN is able to attain their CCRN certification which usually takes 2-3 years, and not all ICU RNs achieve this certification. RNs do put CCRN in their post-nominals.



akflightmedic said:


> By utilizing a paramedic or having an in house referral system, in theory there could be no delay in visiting someone. Crew A sees a patient for hypoglycemia today, submits a form and Community Medic B puts them on his list to visit tomorrow.



One has to ask, since you discussed visiting nurses in your post, why doesn't the EMS system in this model hire Community Nurse B instead of Community Medic B? Profit margins? Couldn't the RN command a higher reimbursement rate? EMS service doesn't want to hire a RN?



Halothane said:


> So the point is, a community health paramedic is not necessarily going to make any more money than a 911 paramedic does. It depends on the supply of people willing to take the jobs vs. the demand. Increased education will _probably_ result in higher pay, but not necessarily.



I disagree... I think it will be paid more, although not a whole lot more. True community medicine is NOT glamorous so few in US EMS will want to pursue it, enough that you'd have to pay more if there was an educational barrier.


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## Summit (Apr 14, 2013)

Clipper1 said:


> As a Community Paramedic, you should do this full time. This should not be just a one day a month thing.  Just like the emergency stuff, it takes time and practice to be good at teaching. You also must be willing to do assessments which are not traditionally in your comfort zone. To be effective in home care, you can not pick and choose what you want to see.
> 
> But, if you are not responding with lights and sirens, intubating, lifting and picking up violent patients, do you really need the extra pay? Since you will be responding in a car or SUV, you will have to call 911 for emergencies.  You will no longer be the guy running in to save the day. You might even get pushed aside by all the FFs and other Paramedics.  If you are focused on Community Paramedic, the skills such as IVs, needle decompression, defibbing and intubation will not be your mainstay. You may get as rusty as if you were on a BLS truck all the time.   The other community health programs for Paramedics failed because the Paramedics did not like the boring stuff and there was a stigma that did go along with it.  EMS is very judgmental just like the tensions between FD vs Private vs Public.



This clearly outlines a major issue of the CP model as far as attracting and retaining CPs.


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## VFlutter (Apr 14, 2013)

Summit said:


> The education, often including AACN's ECCO program, is anywhere from 6 weeks to 20 weeks while orientation ranges from 10-26 weeks depending on the experience of the nurse. No, RN ever puts ECCO in their post-nominals.



I'm not supposed to put ECCO in my post-nominals? Oops. But seriously it took me 5x longer and a lot more work than ACLS which everyone loves to throw in.

For the community paramedic programs out there now is there much interest? Enough applicants to keep the programs open? What are the prerequisites?


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## ExpatMedic0 (Apr 15, 2013)

Chase said:


> For the community paramedic programs out there now is there much interest? Enough applicants to keep the programs open? What are the prerequisites?



Although the concept has been around for a long time in the USA, it just now picked up speed. Which is what makes this topic so exciting in my mind. However, things are largely still being developed and are "pilot programs"

 Maine's education consist of a Paramedic with an AAS or higher degree in Paramedicine, plus  16 credits of "community paramedcine" specific course work on top of the paramedicine degree.
http://bangordailynews.com/2012/03/...irst-in-maine-community-paramedicine-program/

This extra reading may prove interesting for anyone who would like to learn more or to answer some of the above questions of "why" and "how".

http://www.naemt.org/Libraries/Community Paramedicine/2012 NCCCP Consensus Conference Summary.sflb
A complete list of information can be found here http://www.naemt.org/about_ems/CommunityParamedicine.aspx


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## Clipper1 (Apr 15, 2013)

ExpatMedic0 said:


> Maine's education consist of a Paramedic with an AAS or higher degree in Paramedicine, plus  16 credits of "community paramedcine" specific course work on top of the paramedicine degree.
> http://bangordailynews.com/2012/03/...irst-in-maine-community-paramedicine-program/



That is a school in Maine promoting its degree program.  There is not a degree requirement as the article states (and the EMS certifying website).  It just gives the Paramedics attending this program an opportunity to finish their degree at this school.  If there was an actual degree requirement to enter the program, then that might be seen differently.  Paramedics are now trying to do patch work or band aid service covering areas which require a minimum of an Associates for each specialty. That seems like a high expectation to make someone competent in wound care, nursing procedures and assessment, PT, OT and Respiratory Therapy in just 3 months or a few classes. 

Here is another state and another CP program.  It just requires the EMT-P and not all states are equal when it comes to education for Paamedics.

http://www.hennepintech.edu/program/awards/394


This is Colorado.
http://communityparamedic.org/Portals/20/WECAD Community Paramedic Handbook Version 1 4.pdf

More articles on education:
http://www.nosorh.org/events/files/CP_Curriculum_Presentation_9.11.pdf

The positives and negatives are interesting at this link for Nebraska.
http://dhhs.ne.gov/Documents/CommunityParamedicineReport.pdf


For the most part the Paramedic will be following a physician's orders for only a few things.  Wound care alone covers more things which can take several months or even a couple of years of looking and treating many wounds before one is truly competent.  To a diabetic, malnourished and/or paralyzed patient, this is a huge aspect of home care.  For the COPD and Asthma patients, many are mismanaged by the GPs and I doubt if a few hours of training is going to make someone knowledgeable enough to see the treatment plan from the physician is questionable. The same for diabetics, which also include those with COPD, Asthma or other corticosteroid dependent patients, who have a complex medical situation which involves more than just a noncompliance issue.  Paramedics are sometimes taught by their schools or pick it up from their mentors that patients are just bad and noncompliant.  I pointed that out in another discussion.  This sometimes comes from a lack of understanding the complexity of the issues.  When patients must remember 20 medications at several different times during the day, there is room for error. Even health care workers with computers to remind them have a difficult time keeping track of all the medications one patient takes.  Community medicine means you must change your own way of thinking before you can be effective to help others.

The documentation and stricter oversight might turn some off from this.  The overlap of services from other health care providers might be redundant and even contradictory depending on the education of both all involved. This could just add to more confusion for the patient.  But, in some of the licensing and curriculum websites, it did state the Paramedic would not be writing care plans but rather just following orders and making referrals.  The public however might be led to believe much more with all the publicity this is generating to gain funding.  I see it again becoming another us against them whether it is Fire vs EMS or EMS vs PT/OT/RT/RN.


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## ExpatMedic0 (Apr 15, 2013)

It would appear from the end concept (Community Paramedic 4.0) would require a masters degree. However, I am kind of curious about all this so I have emailed the people in the document. I will let you know what they have to say. 

http://ircp.info/Portals/22/Meetings/2012/Presentations/IRCP-2012-8E2-RaynovichRobinson.pdf


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## ExpatMedic0 (Apr 22, 2013)

I was able to reach the guy who started all this in the U.S. We talked a little by email and I got some more information. As you can see from the power point I shared, there is a lot of ideas and concepts they are working with. There are many goals, including increasing education for the role. I was told there has been a huge rebirth and interest in community paramedicine recently. 

If anyone is interested the official international organization for all this, it is the IRCP which can be found here http://www.ircp.info/ all interested paramedics  are welcome to join but there is no official formal membership as of yet.
They are holding an annual meeting with some great topics in England next month, if anyone has time and money that would be interested. I think it will also be a great place for networking, I am going to do my best to be there if I can afford it.

This is what will be covered:
http://aace.org.uk/wp-content/uploads/2013/03/CoP-and-IRCP-Conference-Programme-250313.pdf

Main site to sign up for the meeting is here: http://aace.org.uk/ambulance-leadership-forum/


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## 18G (Apr 22, 2013)

Pennsylvania is in the early stages of exploring Community Paramedicine. 

http://www.communityparamedicineinpa.org/


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## ExpatMedic0 (Apr 22, 2013)

That is great! I think it will be really exciting to watch all these pilot programs develop and grow. Hopefully as they evolve some will achieve what the power point called "community paramedic 4.0" (masters degree)



18G said:


> Pennsylvania is in the early stages of exploring Community Paramedicine.
> 
> http://www.communityparamedicineinpa.org/


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## MountainMedic (May 2, 2013)

BUMP/Time to stir the pot

I don't know where to start. On one hand, I think this is great - EMS has long been the :censored::censored::censored::censored::censored::censored::censored: child of the medical world, and community paramedicine programs provide a path to legitimacy. On the other hand, I feel like the community paramedic position is what this job already is, and that paramedics should be offended that this step is even necessary. Anybody who works in a busy system has done paramedic-initiated refusals, sending patients to urgent cares or PCPs rather than taking them to an ER where they'll wait for hours and cost taxpayers thousands. Ideally, all medics would do this as well as the interventions described below (IMHO). 

1. Antibiotics. Pts with sepsis or meningitis should get 2g IV ceftriaxone or cefotaxime prehospitally. Crossover allergy in PCN-allergic pts is around 5%. This is standard of care in other parts of the world, rural and urban. It's easy and harmless. From a non-emergent perspective, I think medics should have basic antibiotic knowledge and be able to prescribe specific antibiotics for simple infections (skin, bacterial pneumonia and pink eye, otitis media, traveler's diarhea, etc.). Heck, I'd even be game for letting medics leave pts with a couple days' worth of Percocet. 
2. Suturing. Simple lacs in rural environments only. Primary closure should occur in 4-6h. If it takes an hour for a pt to call 911, an hour for EMS to get there, and an hour for the pt to get to the ER, you've almost missed the window. No facial closures or closures of wounds with high probability of infection (e.g. human/cat bites). Keep it simple. Field closure would take ~15 mins. Compared to a 4hr wait in the ER - no-brainer. 
3. FAST exams. The ability to activate an OR (definitively) from the field would kick ***. Studies have shown medics can recognize aortic aneurysms and intraabdominal bleeding very effectively. 
4. Hemostatic resuscitation. The way we treat massive bleeding is kind of appalling. We're WAY behind trauma centers on this one. Read any hemorrhage literature, and you'll quickly learn that the concensus is that massive trauma should only get fluid that a) clots or b) carries oxygen. NS is BAD. Maintain a low MAP with crystalloids and leave it at that. In other words, no more 1-2 L boluses on pts with initial pressures of 80/50. Plenty of systems are looking at prehospital plasma infusion. Google "Mattox" or "Scalea" and "hemostatic resuscitation" for more info, or check out EMcrit. 
5. Labs (iStat). The above could be easily regulated with lab values. If an antibiotic is prescribed, the paramedic could take cultures and bring them back to a lab for followup. If the antibiotic prescribed doesn't match the offending agent, the patient is called for a physician followup. If WBC counts are way off and suggest massive infection or immunosuppression, physician followup. It's relatively cheap and allows followup and ***-coverage. All sepsis and trauma pts get INR and lactate. INR is the single best prognostic indicator of trauma (p value has around 10 zeros or something). 

The paramedic certification is pretty much the only "healthcare professional" designation with ZERO knowledge of antibiotics or labs. It's time we change this. I personally love calls where I can give D50 for hypoglycemia or Benadryl for dystonic reactions and leave the patient feeling better 15 mins after I arrive. Wouldn't it be great to be able to do this with other patients? 

Being a paramedic shouldn't be about rushing in to save the day, it should be about treating patients to the fullest of our abilities rather than carting them off to someone with more medical education, when we ourselves could potentially solve the problem. Extended scope would, above all else, let us start taking pride in our work. 

Sorry for the rant. I'd be interested to see what more qualified folks think - RNs, MDs, PAs, CCP's, etc.


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## Carlos Danger (May 2, 2013)

I definitely agree with this:



MountainMedic said:


> *I feel like the community paramedic position is what this job already is,* and that paramedics should be offended that this step is even necessary. Anybody who works in a busy system has done paramedic-initiated refusals, sending patients to urgent cares or PCPs rather than taking them to an ER where they'll wait for hours and cost taxpayers thousands. Ideally, all medics would do this as well as the interventions described below



Paramedics are not really well educated to do the type of primary care stuff that we typically think about when we discuss "community health", but to me, rather than pointing to the need for an additional certification program, that just strengthens the case for more rigorous basic education. No reason basic primary care can't be part of a basic paramedic program.

As for the specific skills, well, skills are just skills. Some make sense to do in the field and some don't, and there are probably good arguments for an against everything that you listed.


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## MountainMedic (May 3, 2013)

Halothane said:


> I definitely agree with this:
> 
> 
> 
> ...



Agreed. Change my "is" to "should be."


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## ExpatMedic0 (May 3, 2013)

Community Paramedics in the news again, new article related to the use of community paramedics in Western Australia.

http://www.emsworld.com/article/10931616/lessons-from-down-under


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## Arovetli (May 5, 2013)

MountainMedic said:


> BUMP/Time to stir the pot
> 
> 
> So, I've long been opposed to the concept of "community paramedicine" as an extension of EMS and certainly as an extension of the field of Emergency Medicine.
> ...


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## Arovetli (May 5, 2013)

An additional comment,

Alot of this community paramedic stuff is directed to very remote and rural areas, and the pilot test is to use medics as cheap tools to provide care in places where a doc or a midlevel or even a nurse can't be financially enticed to go.

Places where midlevels were designed to go...except that they make more money somewhere else: the urban and suburban. We have always struggled with getting care providers to go places where reimbursement is lacking...or culture is lacking.

Medics have always been used as a cheap source of labor willing to work in terrible conditions, terrible hours, for terrible pay. I don't see community paramedicine improving this, rather I see it taking advantage of it.


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## ExpatMedic0 (May 5, 2013)

You make some very valid points, and although I do not agree with all of them, its not the first time I have seen them. You could be right about every single one of your points, its to early for me to say and I think they are all valid concerns.
This whole concept has just seen a huge revival lately for whatever reason. Personally I think its because of the new health care act and those other articles I posted related to it. 
The ultimate education goal appears to be a masters for community Paramedicine, per the presentation I posted above. I am on my last year of undergrad studies, shopping around for graduate school, including MPH programs. 
I love EMS and I would love to see it grow as a profession. I personally intend on following this concept more. I will post new information on this thread when it becomes available so we can discuss and analyze this concept further and I would welcome you to do the same, even if its information which is not so optimistic ;-) so long as its pertinent.


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## Arovetli (May 5, 2013)

I probably came across a bit more negatively than I intended. I hope EMS grows as a profession and I intend to work towards bettering it, but I find it incredibly irksome that the notion of expanding into rural primary care is the future of the field. Paramedics as a whole struggle with the things they are already tasked to do: intubations, STEMI recognition, triage decisions, etc. Let's put what little money and energy we have into making the EMS system workable, efficient and competent. I support growing the skills and knowledge base of a paramedic, treat and release, alternate destinations, all that stuff.

The concept is not really a revival, decades ago midlevels were created with hopes that they would go to rural boondocks county and provide primary care. What actually happened is they followed the money, like everyone else does, and went where they were paid best, treated best, and could live best. Paramedics are an economic anathema: they will perform advanced skills for poor compensation...and many do it for free. Don't think for a second there is a businessman willing to profit off of the altruism of another, and that is what your going to get with a rural medic. Going to North Dakota and doing teeth cleanings and basic abx rx's and anti-tobacco education for $25/hr isn't going to change life for the other 99% of paramedics getting their butts kicked on the 911 truck. 

If there was any money to be made out here I promise you the powerful nurse lobby or any number of other professions would snatch it up and legislatively lock out medics. EMTs and paramedics have free reign in the prehospital environment because no other profession wants it.

Lets grow EMS in the field it was planted, and work to get it recognized and reimbursed and legislatively protected accordingly. The people supposed to be doing this are failed leadership who invent pyramid scheme training programs so you can have a new provider card in your wallet and they can have your money in their wallet. But that is my cynicism talking again...


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## Arovetli (May 5, 2013)

Oh I would note that all my remarks are addressed to the USA, in other countries this is so much more feasible.

Big money is coming into American EMS by way of Falck, Warburg Pincus, and CDR. These corporate jokesters are not buying up ambulance services because they want supermedics, but because they know they can work you like a beast, pay you very little, and scrape a nice profit margin out of transporting government insured patients.

Just wait 'til the Bentham-esque utilitarianism big money corporations love comes to bear on the EMS system.

Last I checked, Detroit and DC and NO cant afford paramedics and their EMS system is crumbling to dust. Last service I worked at in a major metropolitan area had no trucks with less than 300k miles on 'em. Lets fix that before we go off trying to reinvent ourselves, because that is an attempt to escape the responsibility we have, which is acute and emergent care and transportation.


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## Carlos Danger (May 5, 2013)

Arovetli said:


> I probably came across a bit more negatively than I intended. I hope EMS grows as a profession and I intend to work towards bettering it, but I find it incredibly irksome that the notion of expanding into rural primary care is the future of the field. *Paramedics as a whole struggle with the things they are already tasked to do:* intubations, STEMI recognition, triage decisions, etc. *Let's put what little money and energy we have into making the EMS system workable*, efficient and competent. *I support growing the skills and knowledge base of a paramedic, treat and release, alternate destinations, all that stuff.*
> 
> The concept is not really a revival, decades ago midlevels were created with hopes that they would go to rural boondocks county and provide primary care. What actually happened is they followed the money, like everyone else does, and went where they were paid best, treated best, and could live best. Paramedics are an economic anathema: they will perform advanced skills for poor compensation...and many do it for free. Don't think for a second there is a businessman willing to profit off of the altruism of another, and that is what your going to get with a rural medic. Going to North Dakota and doing teeth cleanings and basic abx rx's and anti-tobacco education for $25/hr isn't going to change life for the other 99% of paramedics getting their butts kicked on the 911 truck.
> 
> ...



I made a very similar case in another thread on this same topic. I think the demand for community health paramedic services as a new, reimbursable paradigm is low and the barriers large, and more importantly, I think there is a heck of a lot we can/should do without going down that path. 

If the government decides to increase funding for community health initiatives, it makes more sense to simply expand the existing infrastructure than it does to invent a whole new provider. We already have NP's, PA's, and CHRN's. The existing entities all have more political pull than EMS, and will quickly snatch up any funding made available. And as a taxpayer who would rather see his tax dollars go towards the actual delivery of care rather than towards funding redundant educational programs, I wouldn't necessarily disagree with that.  

Now, that said.....

One of the big problems with paramedic education is that it is still focused solely on life-threatening emergencies even though those requests make up a very small percentage of what paramedics actually do. For that reason, it makes good sense to me that paramedic education and mindset would shift from its emergency focus to one where the importance of basic non-emergency care is increased. 

I would re-design paramedic education to take a full two years (at least), and the curriculum would spend at least as much time on non-emergency as on emergency care. Paramedics would still learn to do EKG's and ACLS and PALS and airway management, but rather than pretending that's all there is to prehospital care and then having to schlep everyone to the ED whether or not they need it, medics would also be in a much better position to implement protocols that allowed for "treat and release" and for referral to clinics. Asthma attacks, diabetic wake-ups, minor burns, minor lacerations, and drunks would no longer have to receive the same disposition as a STEMI or a stroke. 

And I wouldn't call this a "community health paramedic"; I would just call it a paramedic who is better trained to do what we are already called to do most of the time anyway.

I would much rather see the EMS community get behind the idea of increasing and improving basic educational standards and making them reflect the realities of what paramedics actually do. To me that makes a lot more sense and is a lot more realistic than all the push towards the community health or critical care stuff.


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## Summit (May 5, 2013)

I think Halothane hit the nail pretty square on.


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## Wheel (May 5, 2013)

Halothane said:


> I made a very similar case in another thread on this same topic. I think the demand for community health paramedic services as a new, reimbursable paradigm is low and the barriers large, and more importantly, I think there is a heck of a lot we can/should do without going down that path.
> 
> If the government decides to increase funding for community health initiatives, it makes more sense to simply expand the existing infrastructure than it does to invent a whole new provider. We already have NP's, PA's, and CHRN's. The existing entities all have more political pull than EMS, and will quickly snatch up any funding made available. And as a taxpayer who would rather see his tax dollars go towards the actual delivery of care rather than towards funding redundant educational programs, I wouldn't necessarily disagree with that.
> 
> ...



I very much agree, except for a few things. In my limited experience, people won't use the community health resources we have because it takes too long and they have no idea what is available to them. They call 911 out of convenience. How do we solve that? Patient education and paramedics being able to refer to clinics is a start.

This also means that paramedics are being taken out of service to make referrals (patient education always takes me a while, especially since most patients see ems as a quick way to get a room in my area.) I will have to explain the new function of ems and why I am referring instead of satisfying their impatience with getting a doctors appointment, all while (this is the big one) not being reimbursed. Private companies will not go for that. I know many dont like diabetic wake ups because we spend our time and supplies and aren't likely to get paid. I can't imagine this will be any different. That means that there needs to be a change in ems reimbursement.

I'm all for paramedics being educated about the realities of what they'll face and being prepared to handle it, but there are some huge hurdles with getting that to happen, primarily money.


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## MountainMedic (May 5, 2013)

Clinic referrals and antibiotics would make my day. Cut transports in half. 

I note you have "MD" in your training. I plan to go down the same road in a few years. Ultimately, I think paramedicine needs to progress to the level of nursing so that we're respected as healthcare providers.


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## Carlos Danger (May 5, 2013)

Wheel said:


> I very much agree, except for a few things. In my limited experience, people won't use the community health resources we have because it takes too long and they have no idea what is available to them. They call 911 out of convenience. How do we solve that?



This is exactly why "normal" paramedics need the ability to do non-emergency care, and part of the reason why having dedicated "community health paramedics" is unworkable, IMO:

A patient calls 911 for shortness of breath, just like they do now. A paramedic unit responds emergently, just like they do now. 

Once arriving, they do the same assessment they normally would, including an EKG. Their assessment findings point to pneumonia. Their protocol takes into account the assessment findings, age, co-morbidities, etc and indicates that the patient should be triaged to clinic. They make a quick call to med control, who agrees with their plan. They then make a quick call to dispatch, who gives them a time for a clinic appointment the next day (or a followup home visit with a PA or NP from the home-health car agency). 

The paramedics give a neb treatment and a course of ABX, tell the patient to drink lots of fluids and call back ASAP if they have worsening SOB, talk for a minute about the importance of smoking cessation, and leave the appointment slip with the patient. 

They clear that call and are dispatched to a rollover MVC.  
​


Wheel said:


> This also means that paramedics are being taken out of service to make referrals (patient education always takes me a while, especially since most patients see ems as a quick way to get a room in my area.)



I doubt the scenario I described above would take much more time than driving the patient to the ED and waiting in line, giving report, and getting the patient into a room.

Also, if more transports were triaged as non-emergent and fewer patients required transport to the hospital, you'd probably have less pressure to clear quickly.



Wheel said:


> while (this is the big one) not being reimbursed. Private companies will not go for that. I know many dont like diabetic wake ups because we spend our time and supplies and aren't likely to get paid. I can't imagine this will be any different. That means that there needs to be a change in ems reimbursement.



There would certainly have to be a reimbursement structure in place, that is true.

It seems like it would be worth it to the receiving hospitals themselves to help finance a program like this, considering how much money it could save them.


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## Summit (May 5, 2013)

MountainMedic said:


> Stir the pot
> ...
> 1. Antibiotics. Pts with sepsis or meningitis should get 2g IV ceftriaxone or cefotaxime prehospitally. Crossover allergy in PCN-allergic pts is around 5%. This is standard of care in other parts of the world, rural and urban. It's easy and harmless. From a non-emergent perspective, I think medics should have basic antibiotic knowledge and be able to prescribe specific antibiotics for simple infections (skin, bacterial pneumonia and pink eye, otitis media, traveler's diarhea, etc.). Heck, I'd even be game for letting medics leave pts with a couple days' worth of Percocet.
> ...



*Antibiotics and Suturing:*
First you suggest a typical EMS add-on intervention: an intervention with a critical patient that is hard to screw up and may have critical results. These typify EMS protocol based intervention for providers with a low educational floor. Abx for sepsis is not a primary care type of intervention. The whole reason EMS providers can do most of the things they do with so little education is that they are relatively high potential payoff vs a low relative risk (risk of action vs inaction) over relatively short periods of care if protocols are adhered to. At least... that is how it is supposed to be in theory. Thus, some rural services have a specific prehospital abx protocol.

Primary care is not about critical patients and it is much easier to do more harm than good with primary care patients AND POPULATIONS. That is why a much higher standard of education is required. You jump right on in to treat and release via prescriptive authority for abx and schedule II narcotics... ARE YOU NUTS? That isn't something vo-techs CE classes enable, or even associate degreed providers do. It is not something BSN CHRNs do either. Those are skills limited to physicians and midlevels, and in some states Schedule II cannot be prescribed by a midlevel. Paramedics will NEVER receive even limited prescriptive authority until they have masters degrees, and at that point it is still questionable. The same goes for suturing.

*FAST:*
Again, this is not a community health intervention and might hold promise for tele-FAST, but on paramedic judgement alone?? Again, graduate level education should be involved here.

*Hemmorhagic shock resuscitation:* 
Your points are nothing new and a service's failure to get-with-the-data is a system issue stemming from medical direction. It is not a community health issue.

*Labs: *
Paramedics can already draw labs. Justifying an i-Stat though? Debatable... and a lot more educational need here to justify.


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## Arovetli (May 5, 2013)

You guys remember the movie Apollo 13? When they ship is stranded and the engineers sit down at the table with a bunch of junk raided from the janitor's closet and figured out how to limp the astronauts home? This is kinda where we are at. A flimsy system was made out of haste and political pressure, it got catapulted out there and then things started going wrong, and we have no real tools to fix it.

We have created a system where a limited resource is being used and abused because it has been proffered up by our government as an unlimited resource, a sacrifice to appease the masses who demand free. Now, I do hold that it is a public trust, and even probably evolved into a concept of a right, that there be _access to emergency care_. But nowhere in this should we as a society hold that emergency care be free.
Patient education will not fix abuse. Read up on the economic notion of the tragedy of the commons. 
At some point we have to either say pay up and subsidize the whole thing, or start saying no and rationing. That is the epic debate raging in Washington, who knows how it will turn out.

So in the meantime, we are left with limited resources to meet a potentially unlimited demand, creating downward pressure on the labor conditions.

I really do support expanding ems education, but realistically placing it at a two year, associate degree level places the field behind the times. the 4 year degree is standard, and is going to be the only way to achieve respect as a professional, competent, stand-alone healthcare provider. But it is not economically feasible to require this level of education, we cant pay commensurate salaries or provide work conditions to match education.

There is immense downward pressure on the wage earnings of medics, because reimbursements are low AND if insurance is going to ever up reimbursements, the political and consumer pressure is to up them for hospitals and doctors and innovation tech companies, not paramedics.

We are on the losing side of economics.

As far as FAST, field abx, field Rx...the more advanced care you introduce into EMS, the more good stuff we give away for free. It's not going to happen unless the whole healthcare system becomes consolidated under the govt. and taxpayers are willing to foot the bill..which is projected to grow to 40% of GDP..and that is utterly unsustainable.

Lets face reality: Our system needs *ambulance drivers alot more than it needs paramedics*. We need ambulances to provide a logistical purpose of transporting patients at low cost, and we need it badly.  Insisting on paramedics on every firetruck, every ambulance, every call keeps the downward pressure on wages strong.

Paramedics are a specialized resource, and we need to act like it, especially if we want it to get better, increased wages, increased scope of practice.

I'm fine with basic EMT training for ambulance attendants, we need vocational/certificate level educated basic responders, CPR/AED etc. to drive ambulances. Fire departments need Advanced EMT to give be able to justify their existence by saying we have ALS on every truck, and its good to provide that extra level of care.

But getting to the level of a paramedic, where we are doing real EKG interpretation, real invasive stuff, higher level drugs and procedures...it either needs to be done away with (which I oppose) or it needs to break off of the concept on being chained to an ambulance and a fire truck on every 911 call. Because right now, paramedics suck at being paramedics, and that is because too little money, too little education, and too many calls. The police dog gets more mandated training than the paramedic.

But hospitals like transports because they get to bill the patient, doctors like transports because they get to bill the patient, and corporate owned ambulance services like transports because they get to bill the patient. Until it becomes economically/financially/politically disadvantageous to take someone to the hospital, everybody is going to the hospital.

So, give them that. Let there be ambulance drivers, and let there be paramedics. 

Right now an EMS medical director does so at either 1) an academic center affiliated with the service on salary, or 2) a financial loss. There is not even a decent way to reimburse physicians for their time as medical control. Why are we asking a doctor to provide his consultation services at below market or nonexistent rates? And thus few physicians take a hands on role in EMS. EM right now is obsessed with observation medicine, critical care, and ultrasound....nobody really comes after EMS except more as an interest and a hobby and because it is fun. Relying on altruism and hobby enthusiasm is a terrible plan for EMS success.

It is all about the money and politics.

I am sorry for writing a book, kudos if you read it.


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## chaz90 (May 6, 2013)

Arovetli said:


> We have created a system where a limited resource is being used and abused because it has been proffered up by our government as an unlimited resource, a sacrifice to appease the masses who demand free. Now, I do hold that it is a public trust, and even probably evolved into a concept of a right, that there be _access to emergency care_. But nowhere in this should we as a society hold that emergency care be free.
> Patient education will not fix abuse. Read up on the economic notion of the tragedy of the commons.
> At some point we have to either say pay up and subsidize the whole thing, or start saying no and rationing. That is the epic debate raging in Washington, who knows how it will turn out.
> 
> So in the meantime, we are left with limited resources to meet a potentially unlimited demand, creating downward pressure on the labor conditions.



And the people said amen. I have so much more to say on the subject, but it may need to wait as I should probably try to get some sleep.


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## ExpatMedic0 (May 6, 2013)

Some great points guys. I think its also important to remember we are seeing a lot of new pilot projects pop up, and although the focus of many is rural areas its not the only one. I for one am more interested in seeing it intergraded in urban systems. I think of Community Paramedicine not only as a provider level, but also an abstract concept in these early stages. It has picked up a lot of momentum, funding, and interest, only recently. 

Much of what some of you said is true, why not fix what we have which is broken (current Paramedic model and EMS system) before making a new provider. The thing is nothing has done much for that, the NAEMT has proved useless in my eyes for advocating and advancing EMS. The NREMT has been making progress lately, but at to slow of a rate, and we are not reaching objectives from the "EMS Agenda of the future" (if anyone has read it) in timely or effect manner. 

What I see community Paramedicine is, our Hail Mary play. It could cause a domino effect in helping EMS better itself in a rapid manner. Not only through increasing education standards and reimbursement, also by having so much international influence and input with the integration of the IRCP (www.ircp.info/) In the bigger picture of things, it gives me hope. Anyone who has been in this business long enough knows we are the red step children and it takes a lot of optimism to stay in EMS as a career.

Paramedics have been replaced in systems where they proved to be inefficient. They where replaced by EMT's and RN's in two systems that come to mind. If we don't find a way to start advancing our education and then proving our existence with results (I.E. empirical data and peer reviewed professional studies) we will either cease to exists in some areas or will remain a vocational trade and not a profession. We need change and we need it now. CP may not have all the answers, but it seems to be a step in the direction.

Just some food for thought is all


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## ExpatMedic0 (May 6, 2013)

Apologies for the major typos


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## Arovetli (May 6, 2013)

I admire your optimism, and I apologize for being such a negative nellie on this issue.

I agree with you wholeheartedly on the utter abysmyl wretched failure of Our Glorious Leaders to lead.

Ultimately it will fall to power, politics, and money. Resources will go where the money is or where the political pressure is greatest or both. I suppose it is tilting at windmills to criticize ideas which may never be.

I would submit to you a quote from the International Rountdtable on Community Paramedics taken from your link:  "It is also interesting to note that EMS systems were not seen as part of the primary care continuum until most other options were exhausted."

Or in other words: Nobody else was willing do this job, so we dumped it on the medics.


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## ExpatMedic0 (May 6, 2013)

Arovetli said:


> Ultimately it will fall to power, politics, and money. Resources will go where the money is or where the political pressure is greatest or both. I suppose it is tilting at windmills to criticize ideas which may never be.



Yes, should it prove to be successful and a money maker, EMS will most likely have to go to battle with bigger more powerful groups like the IAFF, the ANA, maybe even NP's and PA's. However, the guys in film 300 did a hell of a job fighting a superior force, except for the ending..... :blush:


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## Arovetli (May 6, 2013)

ExpatMedic0 said:


> Yes, should it prove to be successful and a money maker, EMS will most likely have to go to battle with bigger more powerful groups like the IAFF, the ANA, maybe even NP's and PA's. However, the guys in film 300 did a hell of a job fighting a superior force, except for the ending..... :blush:



Friend, I say this with love, but I think people could forget Kilimanjaro and start climbing Mt. Your Optimism. And they would probably never reach the top...

The day I fight a six figures plus a year makin midlevel for an EMS job....

And even the physicians couldn't stop Gen. Mundingers Nurse Army. She's a freakin machine man. Id wager she could make ol Xerxes cry.


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## chaz90 (May 6, 2013)

Mundinger does indeed make me cry, and her actions don't even directly affect me.


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## ExpatMedic0 (May 6, 2013)

Just an update on a related article I found today. "How Minnesota got its community medcs paid"

http://www.emsworld.com/article/10913443/how-minnesota-got-its-community-medics-paid


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## ExpatMedic0 (Jun 4, 2013)

Update today regarding Honolulu's Community Paramedic Program.

http://www.emsworld.com/news/10953691/honolulu-drops-community-paramedic-program


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## pcbguy (Jun 5, 2013)

Arovetli said:


> Friend, I say this with love, but I think people could forget Kilimanjaro and start climbing Mt. Your Optimism. And they would probably never reach the top...
> 
> The day I fight a six figures plus a year makin midlevel for an EMS job....
> 
> And even the physicians couldn't stop Gen. Mundingers Nurse Army. She's a freakin machine man. Id wager she could make ol Xerxes cry.



I'm loving this thread!

You hit on one of the biggest issues. EMS still relies on protocols and medical direction. That isn't a problem is the MDs go along with it. It is beneficial to them so it shouldn't be a tough sell. 

What does everyone think of the ANA pushback though? Do you think there would be much? It would benefit them also as the traffic to the ED would lower. 

I think we are still in the infant stages of EMS and Paramedicine. It's only been around some 40 odd years. I can imagine that nursing had some similar hurdles to jump through when they were in their infancy. On the other hand we have issues today that previous generations never had. 

Just more food for thought. 

This is one of the best threads ever.


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## Arovetli (Jun 5, 2013)

What pushback and how is it beneficial to a physician?

Paramedics will always have protocols and medical oversight. Even physicians, excepting self employed cowboys, themselves have local treatment "protocols" and guidelines and medical oversight and whatever the group or administrators dictate.

Here's why community paramedicine provided by high paid paramedics is dumb: Because. You. Can. Already. Do. It.

It's called getting an education. As a nurse or mid level or physician you can go out and do community care. All the stuff you want you can have now. You could even do house calls if you wanted. But rarely it gets done because there is no money for this, plus a host of other problems.

Instead of getting an education which already exists, or doing the job we have right for once, there exists a desire to stir special sauce into the concept of a paramedic and expecting the world to contort itself to salve the wounds of inadequacy, disrespect, and poor conditions. The irony is this is the same entitled garbage system abusing patients have: expecting something for nothing, ignoring reality, and waiting for Moses to come down off the mountain bearing salvation.

Is there a need for comprehensive community focused medicine? You bet. Could it be provided by a public health trained coordinator? You bet. Public health has already aligned itself as an academic field in this direction.

I don't need someone proficient in difficult airways and pressors and critical care getting paid big bucks to make sure Joe the diabetic is eating properly, granny is taking her meds, or Suzy gets to the local clinic instead of the ER.

In addition to the embarrassing ignorance of the science and technology being researched now and the amount of VC money flying around.

There is a much much greater chance of your iPhone being a "community paramedic" than there is a burnt out uneducated "ambulance driver" reinventing his career by being the doc of the block.


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## pcbguy (Jun 5, 2013)

Arovetli said:


> What pushback and how is it beneficial to a physician?
> 
> Paramedics will always have protocols and medical oversight. Even physicians, excepting self employed cowboys, themselves have local treatment "protocols" and guidelines and medical oversight and whatever the group or administrators dictate.
> 
> ...



I read one of the recent articles from Minnesota that said, "Nursing groups were the biggest early impediment in Minnesota...."

I would imagine this is going to be a normal thing to get pushback from the nursing groups. 

As for how it will benefit MDs, I think the less of the routine you have coming into the ED the more the pts you will have in the ED that actually need to be in the ED. This should free up the physicians for the pts that really need them. Also I read(here I believe) that return trips to the ED for the same problem won't be billable during the same month. I'm sure that was the short of it and there is more to the story but if an ED physician is seeing the same pt for the same thing a week later and can't bill for it, then it would have been beneficial for a CP to have seen that pt. 

I know that this entire shift in the way we look at paramedicine is going to have to center around higher education. Also, even though You. Can. Already. Do. It., it's not being done and not on the level that these discussion are going toward. That's why there are these pilot programs that are trying to make advancements and improve a failing system. 

There is a huge need for this and I suspect an even greater one in the near future. I don't think anyone here has insinuated that any burnt out ambulance driver should be considered or even function in the role of a community paramedic. Quite the contrary. All the discussion here has focused on the need for increased education. That will be an absolute. 

There is a need for both the CP and the medic that is efficient in difficult airways and critical care and the street medic. There will be paramedics not interested in furthering their education to become a CP. Just like there re EMTBs that have not interest in becoming paramedics or paramedics that have no interest in becoming critical care paramedics. But there are a lot of us the see the need and would jump at the chance to further our education to become part of a better system of healthcare.

Hope that doesn't sound to cranky. You seem very negative toward the idea of Community Paramedics. I see you are a medic and looks like you are in med school. Don't you think that you would benefit working as a physician in the ED if you could see the pts that needed you and monetarily that you could bill for? I can't imagine the staggering number of frequent fliers that ED physicians have to see that could be handled by a CP.  

This is of course all just my opinion after working at home and overseas and seeing the need for significant change in our system. I worked a service at home that ran 35,000 calls/yr with 8 full time trucks. A community with only 2 EDs that are both overrun everyday with pts that don't necessarily need to be there. I suspect that this is a common occurrence through out this country and the world or this wouldn't be such a hot topic.


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## Arovetli (Jun 5, 2013)

It's not that I am opposed to community oriented care and readjusting the system, I'm just opposed to ignorance, despite how well intentioned it is.


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## pcbguy (Jun 5, 2013)

Arovetli said:


> It's not that I am opposed to community oriented care and readjusting the system, I'm just opposed to ignorance, despite how well intentioned it is.



Can't argue with that. Lets just hope this is all done appropriately with the emphasis being on education needed for paramedics to become CPs. 

Great discussion. I hope more people get involved and would love to hear from some that are actually involved in these pilot programs. Like to hear what their take is on it.


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## Clipper1 (Jun 5, 2013)

Why do you need to invent another title?  If you really wanted to make a difference for the PATIENT you would advance you education to obtain the title of PA, RN, Public Health RN, NP, PT, OT etc.  Right now all of these areas have taken huge cuts in CMS reimbursement and really need support  to get their clinics and home care services back to the patient. Instead of trying to divert funds to your own cause which essentially is nothing more than a band aid and another level of confusion, your own professional associations should be supporting the patient advocacy movements and the established professionals to keep services.  All the other professional associations have banded together to support each other on the behalf of the PATIENTS in legislative issues. It seems EMS has its own agenda and what is best for the patient is not always considered.  So don't expect other associations to abandon the efforts they have put forth over many years and rush to your side for a cert that is so limited.  These patients need professionals who have taken the time to become experts in occupational therapy, physical therapy, diabetes, nutrition, wound care, asthma and COPD education. They need professionals who can do something for them even if it is a little personal hygiene which is "not the job" of a CP.  

Usually RNs have advanced education  and various specialized certs which require a least a couple years of experience working in that specialty along with up to 1000 hours of clinicals.  This might include diabetes, nutrition, wound care or the Asthma or COPD educator certs.  ACLS is great but the object is PREVENTITIVE medicine and not to work a code. Paramedics are trained to work emergencies. Assessing a patient and addressing their daily living needs are very different areas and a very different mindset. Just reading this forum and the many, many negative comments made toward patients who require just a little assistance or who have only the early onset of some major demonstrates the or at least this community is not ready for community health.  Many have written this patients off as BS and a waste of time. You can not just change that attitude with 100 hours of additional training and a new cert.


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## Ecgg (Jun 5, 2013)

Clipper1 said:


> Usually RNs have advanced education  and various specialized certs which require a least a couple years of experience working in that specialty along with up to 1000 hours of clinicals.  This might include diabetes, nutrition, wound care or the Asthma or COPD educator certs.  ACLS is great but the object is PREVENTITIVE medicine and not to work a code. Paramedics are trained to work emergencies. Assessing a patient and addressing their daily living needs are very different areas and a very different mindset. Just reading this forum and the many, many negative comments made toward patients who require just a little assistance or who have only the early onset of some major demonstrates the or at least this community is not ready for community health.  Many have written this patients off as BS and a waste of time. You can not just change that attitude with 100 hours of additional training and a new cert.



Please stop this charade with your superiority over medics.

Before making statements like that you need to clarify that you performed a nursing diagnosis which does not entail a medical diagnosis but adapting the medical diagnosis made by a physician to the patients limitations their condition  may place on them and the nursing interventions along with nurse teachings you will perform.

You practice nursing not medicine, how many medical treatment decisions not nursing care plans but actual medications and procedures had you ordered? How many medical diagnoses have you made? You say running ACLS like it's a joke, how many codes have you ran as a nurse as the team leader?


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## pcbguy (Jun 5, 2013)

Clipper1 said:


> Why do you need to invent another title?  If you really wanted to make a difference for the PATIENT you would advance you education to obtain the title of PA, RN, Public Health RN, NP, PT, OT etc.  Right now all of these areas have taken huge cuts in CMS reimbursement and really need support  to get their clinics and home care services back to the patient. Instead of trying to divert funds to your own cause which essentially is nothing more than a band aid and another level of confusion, your own professional associations should be supporting the patient advocacy movements and the established professionals to keep services.  All the other professional associations have banded together to support each other on the behalf of the PATIENTS in legislative issues. It seems EMS has its own agenda and what is best for the patient is not always considered.  So don't expect other associations to abandon the efforts they have put forth over many years and rush to your side for a cert that is so limited.  These patients need professionals who have taken the time to become experts in occupational therapy, physical therapy, diabetes, nutrition, wound care, asthma and COPD education. They need professionals who can do something for them even if it is a little personal hygiene which is "not the job" of a CP.
> 
> Usually RNs have advanced education  and various specialized certs which require a least a couple years of experience working in that specialty along with up to 1000 hours of clinicals.  This might include diabetes, nutrition, wound care or the Asthma or COPD educator certs.  ACLS is great but the object is PREVENTITIVE medicine and not to work a code. Paramedics are trained to work emergencies. Assessing a patient and addressing their daily living needs are very different areas and a very different mindset. Just reading this forum and the many, many negative comments made toward patients who require just a little assistance or who have only the early onset of some major demonstrates the or at least this community is not ready for community health.  Many have written this patients off as BS and a waste of time. You can not just change that attitude with 100 hours of additional training and a new cert.



I think this is pretty harsh. Where were the previous fields you mentioned in their infancy? They all started somewhere and non of them were designed to be community health or prehospital care. EMS and paramedicine was designed for emergencies and prehospital. I don't see anything wrong with expanding the role to help a stressed system. If those other professions want to do it that's wonderful. But if so then why haven't they? They haven't because of money. Well that's not exactly what's best for the patient either. 

I don't recall anyone stating that these patients are BS. It has been said that they do not need to be at the ED as it is not an emergency. However they do need care to prevent some of their issues from becoming an emergency. 

I have no problem with nurses, NPs or PAs doing community medicine but they aren't doing it. They are also needed at these EDs and clinics. Not out in the community when they are more valuable in the roles they are in. Part of the problem is the stressed workload of the EDs so what sense would it make to take the nurses and mid-levels out of the ED and into the community? Then you still have the few left in the ED to still handle the load of the ED. 

Lets train and educate the people who are already working prehospital and going on these calls. Let's use them since they are already out there. There should be much more education so that they can make educated descisions on which ones can be treated at home vs. a trip to the ED vs. a trip to their pcp.

There's a place and role for everyone and there is still a gap. These programs are attempting to fill that gap. There's a lot of work to be done but these pilot programs are a step in the right direction. Maybe it's not needed in your area but I think it's safe to say that it is in most.


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## VFlutter (Jun 5, 2013)

Ecgg said:


> Please stop this charade with your superiority over medics.
> 
> Before making statements like that you need to clarify that you performed a nursing diagnosis which does not entail a medical diagnosis but adapting the medical diagnosis made by a physician to the patients limitations their condition  may place on them and the nursing interventions along with nurse teachings you will perform.
> 
> You practice nursing not medicine, how many medical treatment decisions not nursing care plans but actual medications and procedures had you ordered? How many medical diagnoses have you made? You say running ACLS like it's a joke, how many codes have you ran as a nurse as the team leader?



First of all if Clipper is who everyone thinks she is then she is not a RN. 

And by the same token you think Paramedics practice medicine? You provide treatment outside your protocols without medical approval? 

By many of yout posts it is painfully apparent that you are ignorant to what nurses do. 

ACLS is a joke...

RNs run codes all the time. It is not uncommon for us to get ROSC before the CCP even arrives. You act like a Medic would be team leader even if there was an MD present. 

A quick example: I pull femoral arterial and venous sheaths after PCI. I have protocols and standing orders. I decide if and what to use for pain and sedation. I decide if I need to re-anesthetize with SubQ lidocaine. I do the entire procedure by myself with assistance from another nurse. If the patient vasovagals I decide what to do. I give atropine when I think it is appropriate. The only time I call a MD is if I want something not in the standing orders or something is going wrong. 

How is this any different then a paramedic?


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## Clipper1 (Jun 5, 2013)

pcbguy said:


> I think this is pretty harsh. Where were the previous fields you mentioned in their infancy? They all started somewhere and non of them were designed to be community health or prehospital care. EMS and paramedicine was designed for emergencies and prehospital. I don't see anything wrong with expanding the role to help a stressed system.




Harsh?  Not at all as harsh as who some have stated here when it is suggested that RNs could work on ambulances.  "No way can an RN work on an ambulance unless they go through the whole Paramedic training and get a Paramedic patch".  A "PHRN" cert with a couple hundred hours of training is not good enough or so some Paramedics have stated. But, per you it is perfectly okay to do a short class of about 100 - 200 hours, get another "cert" and do what those in other professions have trained and worked for over a few years.


A lot of health care professions are still in their infancy.

Nurses also have been in emergency including prehospital medicince for over a century. 

RNs, PTs, OTs and RTs are all geared for getting the patient home.  They are not strengthening and educating the patient just to hang out in the hospital.  OTs and PTs have all been going from the hospital to the home to evaluate the environment and order the appropriate equipment to train the patient and family on before discharge. This is what these professions train for in school. Their whole mission is to get the patient safely home and in an environment which is safe. 

 A large part of the nurse's training, either in school or on the job,  is teaching over and over again. RNs also can take the BSN or MSN after their initial RN license and specialize in community health. They can do the clinicals along with their nursing experience to gain an insight on patient needs.


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## Clipper1 (Jun 5, 2013)

Chase said:


> First of all if Clipper is who everyone thinks she is then she is not a RN.



Whatever....

I am not giving out any more personal information since it is pretty obviously this is an anonymous forum. There are also some here who claim to be Paramedics who seem to have missed a few chapters in their text and passed the test by luck if they really are Paramedics. I have identified myself to a couple of members for educational opportunities since they are here near U-Dub.


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## Aidey (Jun 5, 2013)

Back on topic, now. 

Clipper, if you can't post something constructive, don't post at all. That means contribute to the thread, don't talk down to anyone, and for every negative thing you say, you have to say something positive. If you can't manage that, then don't post.


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## Ecgg (Jun 5, 2013)

Chase said:


> First of all if Clipper is who everyone thinks she is then she is not a RN.
> 
> And by the same token you think Paramedics practice medicine? You provide treatment outside your protocols without medical approval?
> 
> ...



Let us look at nursing theory history

HISTORY

Nightingale (1860): To facilitate "the body’s reparative processes" by manipulating client’s environment
Paplau 1952: Nursing is; therapeutic interpersonal process.
Henderson 1955: The needs often called Henderson’s 14 basic needs
Abdellah 1960: This theory focus on delivering nursing care for the whole person to meet the physical, emotional, intellectual, social, and spiritual needs of the client and family.
Orlando 1962: To Ida Orlando (1960), the client is an individual; with a need; that, when met, diminishes distress, increases adequacy, or enhances well-being.
Johnson’s Theory 1968: Dorothy Johnson’s theory of nursing 1968 focuses on how the client adapts to illness and how actual or potential stress can affect the ability to adapt. The goal of nursing to reduce stress so that; the client can move more easily through recovery.
Rogers 1970: to maintain and promote health, prevent illness, and care for and rehabilitate ill and disabled client through "humanistic science of nursing"
*Orem1971: This is self-care deficit theory. Nursing care becomes necessary when client is unable to fulfill biological, psychological, developmental, or social needs.*
King 1971: To use communication to help client reestablish positive adaptation to environment.
Neuman 1972: Stress reduction is goal of system model of nursing practice.
Roy 1979: This adaptation model is based on the physiological, psychological, sociological and dependence-independence adaptive modes.
Watson’s Theory 1979: Watson’s philosophy of caring 1979 attempts to define the outcome of nursing activity in regard to the; humanistic aspects of life.

Please point out to me where it says your regular nurse can perform a medical diagnosis on a patient with medical problem and subsequently initiate and order treatments and direct patient care?

Additionally nursing diagnosis does not diagnose medical problems it addresses the deficits the medical diagnosis creates. This is not a derogatory statement.

http://www.staff.vu.edu.au/Nursing/Nursing/nursing_diagnosis_made_simple.htm

Through the nursing school nurses are not trained to perform medical diagnosis and prescribe medicine or perform invasive procedures upon their assessment.


Yes, Paramedics function on protocols and so do Physicians. I’ve bet your hospital ED has protocols for physicians for hypertensive crisis, sepsis, CVA, etc. Protocols are guidelines this does not absolve you as a provider from good clinical judgment at all times. 

When you graduated RN school how many medical diagnoses have you made without calling a doctor? How many codes have you ran where you were a team leader and I don’t mean you are a team lead just until the code team arrives?


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## Aidey (Jun 5, 2013)

What did I say about back on topic? The next person that posts about anything but community paramedicine will get my complete and undivided attention.


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## pcbguy (Jun 5, 2013)

Clipper1 said:


> Harsh?  Not at all as harsh as who some have stated here when it is suggested that RNs could work on ambulances.  "No way can an RN work on an ambulance unless they go through the whole Paramedic training and get a Paramedic patch".  A "PHRN" cert with a couple hundred hours of training is not good enough or so some Paramedics have stated. But, per you it is perfectly okay to do a short class of about 100 - 200 hours, get another "cert" and do what those in other professions have trained and worked for over a few years.



Can't find for the life of me where I said that it was okay t do a 100-200 hours course and do what others have done. 

I actually have been saying this is a call for higher education for Paramedicine.





Clipper1 said:


> RNs, PTs, OTs and RTs are all geared for getting the patient home.  They are not strengthening and educating the patient just to hang out in the hospital.  OTs and PTs have all been going from the hospital to the home to evaluate the environment and order the appropriate equipment to train the patient and family on before discharge. This is what these professions train for in school. Their whole mission is to get the patient safely home and in an environment which is safe.



They are geared for getting the patient home. I haven't seen too many that follow the patient home. The home health care, at least in my area, is very minimal. Also if the RNs, PTs and the others were doing this then why would there be a need for these other programs popping up? Because they are not filling the gap. At least not adequately. There aren't enough RNs, PTs etc... to go around.

The point is that there is a need for this! Otherwise we wouldn't be having this discussion. More importantly the powers that be believe there is a need for this regardless of what we think. The need isn't going to go away. It's going to get worse. 



Clipper1 said:


> A large part of the nurse's training, either in school or on the job,  is teaching over and over again. RNs also can take the BSN or MSN after their initial RN license and specialize in community health. They can do the clinicals along with their nursing experience to gain an insight on patient needs.



RNs haven't been able to take the BSN or MSN for over a century. There was a need for higher education for nurses and they acted by instituting BSN, MSN and now DPN programs in response to that need. 

Now there is a need for Paramedicine to evolve and the education is going to have to evolve with it. That means BSP and MSP courses should start being developed with adequate education and clinical requirements. 

Saying that Paramedics cannot be trained and educated to treat or triage a patient at home and make a determination of care is just as ignorant as saying an RN doesn't have the training or is ill equipped to work on an ambulance.


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## pcbguy (Jun 5, 2013)

Aidey said:


> What did I say about back on topic? The next person that posts about anything but community paramedicine will get my complete and undivided attention.



Sorry. I was typing when you posted this. 

My apologies if I have offended anyone.

I have the utmost respect for RNs, OTs, PTs and everyone in the business.  I will be marrying an DNP soon.


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## Clipper1 (Jun 5, 2013)

All of the references you mentioned also support the evolution of nursing into Public and Community Health. The things mentioned are all essential foundations in the education and training of someone who providing care for the patient and meeting their needs in many aspects and not just the life saving ones. Nursing has also grown as the technology and science has developed. Nursing must care not only for the emergencies or acute situations but also all the long term issues. 



Ecgg said:


> Please point out to me where it says your regular nurse can perform a *medical diagnosis *on a patient with medical problem and subsequently initiate and order treatments and direct patient care?
> 
> Additionally nursing diagnosis does not diagnose medical problems it addresses the deficits the medical diagnosis creates. This is not a derogatory statement.



For legal purposes to satisfy the definition of Medical Diagnosis, Physicians and Physicians Extenders such as NPs and PAs are recognized. A Paramedic can not legally code as a Physician Extender for a medical diagnosis. 

NPs are nurses and they make medical diagnosis.

All licensed professionals involved in initiating treatment or therapy make some type of diagnosis to initate the treatment and plan of care. This does not have to be an emergency situation. Again, this is the difference between the way a Paramedic is trained to recognize situations and that of nurses or any of the allied health professions. It takes alot of training and experience to recognize many, many different aspects of care and anticipate needs than it does to work an emergency long enough to get to a higher level of care.


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## Clipper1 (Jun 5, 2013)

Aidey said:


> What did I say about back on topic? The next person that posts about anything but community paramedicine will get my complete and undivided attention.



Does this mean you are one sided and believe only Paramedics can do community health?   The issue of CPs affects many other professions  and care aspects. The Paramedic is NOT the sole provider of care.

Isolating other professions is exactly why this idea is not being accepted in more realms.  

This must be an interdisciplinary approach for it to be successful. But, because of the way the US health care system is set up, we must make the most of what is available.  Paying out for another layer of service or duplication may not be the best use of resources.


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## Aidey (Jun 5, 2013)

Clipper1 said:


> Does this mean you are one sided and believe only Paramedics can do community health?   The issue of CPs affects many other professions  and care aspects. The Paramedic is NOT the sole provider of care.
> 
> Isolating other professions is exactly why this idea is not being accepted in more realms.
> 
> This must be an interdisciplinary approach for it to be successful. But, because of the way the US health care system is set up, we must make the most of what is available.  Paying out for another layer of service or duplication may not be the best use of resources.



No, it means exactly what it says. Community paramedicine, or get out of the thread. If you want to discuss it from an interdisciplinary perspective, start your own thread.


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## Clipper1 (Jun 5, 2013)

pcbguy said:


> Now there is a need for Paramedicine to evolve and the education is going to have to evolve with it. That means BSP and MSP courses should start being developed with adequate education and clinical requirements.
> 
> Saying that Paramedics cannot be trained and educated to treat or triage a patient at home and make a determination of care is just as ignorant as saying an RN doesn't have the training or is ill equipped to work on an ambulance.



Will the BSP be toward community medicine? Does this mean the 911 or emergency part will not be emphasized? Will only some Paramedics be taught intubation and ACLS while others are on more of a nursing track?  Does this mean you only want to keep the title of Paramedic to avoid getting the title of RN?


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## pcbguy (Jun 5, 2013)

Clipper1 said:


> Will the BSP be toward community medicine? Does this mean the 911 or emergency part will not be emphasized? Will only some Paramedics be taught intubation and ACLS while others are on more of a nursing track?  Does this mean you only want to keep the title of Paramedic to avoid getting the title of RN?



Who knows where this will lead? The way I see it the Paramedic will remain the same and the BSP or the MSP will be more like the NP/PA. A practitioner that can practice out in the community. 

They won't be taught on a nursing model at all. Just like PAs are not. They will both receive all Paramedic level education(ie., intubation, ACLS). 

How about the title of Paramedic Practitioner. Like Nurse Practitioner. Still a nurse right? 

Again there are so many details to be worked out and I am not the person that will be working them out(probably not anyways). Just my thoughts.


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## pcbguy (Jun 5, 2013)

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.


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## Arovetli (Jun 5, 2013)

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.


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## Amberlamps916 (Jun 5, 2013)

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


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## pcbguy (Jun 6, 2013)

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.


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## ExpatMedic0 (Jun 6, 2013)

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.....


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## VFlutter (Jun 6, 2013)

pcbguy said:


> 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.


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## Clipper1 (Jun 6, 2013)

Arovetli said:


> 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.


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## Arovetli (Jun 6, 2013)

@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.


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## pcbguy (Jun 6, 2013)

Arovetli said:


> @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?
> 
> ...



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.


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## Arovetli (Jun 6, 2013)

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.


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## ExpatMedic0 (Jun 6, 2013)

Arovetli said:


> 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 ;-)


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## DPM (Jun 6, 2013)

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)


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## Wes (Jun 7, 2013)

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.


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## ExpatMedic0 (Jun 7, 2013)

Wes said:


> 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.


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## pcbguy (Jun 7, 2013)

Arovetli said:


> 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


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## pcbguy (Jun 7, 2013)

Wes said:


> 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!


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## Summit (Jun 7, 2013)

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.


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## Wes (Jun 7, 2013)

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.


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## Brandon O (Jun 7, 2013)

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.)


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## Clipper1 (Jun 7, 2013)

pcbguy said:


> @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.


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## Carlos Danger (Jun 7, 2013)

Clipper1 said:


> 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.


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## Summit (Jun 7, 2013)

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.



Wes said:


> 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.


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## Wes (Jun 7, 2013)

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.


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## pcbguy (Jun 7, 2013)

Summit said:


> 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.
> 
> ...



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


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## pcbguy (Jun 7, 2013)

Wes said:


> 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?
> 
> ...




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.


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## Wes (Jun 7, 2013)

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....


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## Brandon O (Jun 7, 2013)

pcbguy said:


> 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.


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## Clipper1 (Jun 7, 2013)

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.


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## Clipper1 (Jun 7, 2013)

Wes said:


> 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.


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## pcbguy (Jun 7, 2013)

Brandon Oto said:


> 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.


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## Brandon O (Jun 7, 2013)

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.


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## Clipper1 (Jun 7, 2013)

Brandon Oto said:


> 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.


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## Clipper1 (Jun 7, 2013)

pcbguy said:


> @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.


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## pcbguy (Jun 7, 2013)

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.


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## Clipper1 (Jun 7, 2013)

pcbguy said:


> 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.


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## Summit (Jun 7, 2013)

*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:*



			
				Summit said:
			
		

> 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?



pcbguy said:


> @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.


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## Arovetli (Jun 8, 2013)

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.


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## Clipper1 (Jun 8, 2013)

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/


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## pcbguy (Jun 8, 2013)

Summit said:


> *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


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## pcbguy (Jun 8, 2013)

@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!


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## Brandon O (Jun 8, 2013)

I agree that part of this system will probably involve the system determining what resources a patient requires requires based on their complaint, rather than the current (highly unusual) situation where we have very few choices on the provider side.

In other words, patient calls and says he wants an ambulance because his prescription ran out. Nope, we'll send over a livery car to bring you to the pharmacy. But I want an ambulance! Tough.

That will be supported, in principle, by the new payment model where an ACO receives a fixed block of money, with no incentive to provide higher-level service (in fact disincentive, because they won't be reimbursed for it), but with rewards for keeping people healthy. If all the stars align then those two factors should provide counterbalancing motivation to get people the appropriate care, no more and no less.

Maybe.


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## Arovetli (Jun 8, 2013)

@clipper

Good ideas. None of which require an emergency medicine trained paramedic. Yes, we need to improve resources in the community, fire houses are strategically placed, not a bad idea to attach an area with care coordinators and a midlevel. Community oriented healthcaring is a great idea. But it doesn't need a cross trained emergency/primary care paramedic. If they want to hire medics to work as techs in this program, like MD offices and ERs and urgent cares already do, no problem.

No one is opposing community health or a community health midlevel. I oppose taking paramedics and training them to do emergency/critical care medicine, and then placing them in primary care.

There is a reason why a family medicine doctor isn't the best at difficult airways and an ER physician isn't the best at managing chronic complaints. Yet you people are telling me if we load Paul Bunyan and his ox into an ambulance, that both are suddenly going to happen.

@pcb

UF sounds like they have a good program. Treat and release/alternate destination. Good stuff. That is an entire world of difference than assuming a primary care responsibility and doing follow ups and ongoing management. That is where I'm going to take issue. 

However there are no resources for poor and uninsured and everyone else on nights and weekends. For a long time doctors pretended they were wizards locked away in Castle Hospital and patients near and far should trek to see them, and bask in the glory of their doctorness.

We have created the situation where the emergency system safety net is the de facto primary care program. Bad idea, needs a' fixin. But long term, that doesn't need a paramedic cross trained in emergency medicine and primary care.

Look, you like working prehospital and you don't want to be in an ER and you don't want a clinic, I understand that sentiment. But nobody is presently willing to give money for what you want.

I want to sing. Nobody will pay me to do it. I could be a singer, but I would go broke and die hungry, in a subway, with my guitar.

I can't force someone to pay me to sing. And I can't use the government to pass a law that forces people to pay me to sing. And I can't force the government to take a rich mans money and give it to me to sing. We don't always get what we want. 

You have to sell a product people want to buy. Otherwise you better enjoy giving it away for free, and earn your living elsewhere.

As to your riddle: it is not at all an assumption. You can already be a midlevel. But your not. Because its not to your liking. Because you'd have to work somewhere you don't want. Because. Because. Me. Me. It's all about me. (No personal attack, just a general comment towards the movement)

Forcing the world to reinvent itself around the desires of a few paramedics...strange philosophy. Meanwhile, in the rest of America, we have really big acute care problems that the EMERGENCY medical services should be taking a role in addressing.

I'm not saying you can't pass organic chemistry, I'm saying your presently not willing to do what it takes to succeed in a midlevel role, and are upset that the world doesn't contort more to your liking. And that that is not a mindset of success.

If its more money for EMS, there's ways to work towards that that don't involve inventing a new healthcare provider.

If folks really have a burning passion for community health, become a PA, work three days in a clinic, and spend the rest of your time volunteering in the community.

If you want to perform emergency/critical care medicine in the streets and out of hospital environments, become a paramedic. It's shocking (pun) that the person entrusted with performing advanced life saving medical procedures and emergent medical decision making is learning how to do this in the community college across the hall from the hairdressing school.

And lets get about working to incorporate some internal medicine/general medicine into the curriculum, and improving training with more OR, ICU, and physician-assisted education. And start researching for ourselves. Improving the education, lobbying for revenue considerations, yada yada.

And why in the heck to we need an emergency technician on every ambulance that does basic transports? Seriously, an ambulance and an attendant with first aid/cpr will do.


As far as using the people we have already, because the people we have already aren't really doing the best job at the tasks they are already assigned. I'd rather spend the resources getting them up to par, and then setting the bar high for out if hospital EMERGENT care.


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## pcbguy (Jun 8, 2013)

Arovetli said:


> UF sounds like they have a good program. Treat and release/alternate destination. Good stuff. That is an entire world of difference than assuming a primary care responsibility and doing follow ups and ongoing management. That is where I'm going to take issue.



I have to say I like their model. Alot of this talk has been about moving to a higher education/masters level for paramedics. As much as I like this I do believe what the UF area is doing along with Wake County EMS is probably going to be more likely. 


Look, you like working prehospital and you don't want to be in an ER and you don't want a clinic, I understand that sentiment. But nobody is presently willing to give money for what you want.



Arovetli said:


> I want to sing. Nobody will pay me to do it. I could be a singer, but I would go broke and die hungry, in a subway, with my guitar.



We can take up a collection to get you to sing. I'd be willing to go in on it. Lol. 



Arovetli said:


> As to your riddle: it is not at all an assumption. You can already be a midlevel. But your not. Because its not to your liking. Because you'd have to work somewhere you don't want. Because. Because. Me. Me. It's all about me.
> 
> I'm not saying you can't pass organic chemistry, I'm saying your presently not willing to do what it takes to succeed in a midlevel role, and are upset that the world doesn't contort more to your liking.



You said we didn't want to work hard for this. I believe that if this develops that a masters degree in paramedicine would follow similarly to what a PA program does and therefore we would be working hard for it. Not looking for any handouts and don't expect it to be made easy. Not that we aren't willing to go with one of the existing mid-level roles. PA is usually a natural progression for paramedics that want to go further.  But some of us might not want to be one of the existing mid-levels. I go back and forth on it. But as a paramedic if I had the option of a paramedic practitioner over a PA, I would go the paramedic practitioner route. 






Arovetli said:


> And lets get about working to incorporate some internal medicine/general medicine into the curriculum, and improving training with more OR, ICU, and physician-assisted education. And start researching for ourselves. Improving the education, lobbying for revenue considerations, yada yada.



I agree the basic paramedic curriculum needs to be expanded. 



Arovetli said:


> As far as using the people we have already, because the people we have already aren't really doing the best job at the tasks they are already assigned. I'd rather spend the resources getting them up to par, and then setting the bar high for out if hospital EMERGENT care.



I think it's the ones that are up to par that are going to be the game changers and pioneers of this movement. Just like with any other field there are always going to be those that just want to do the bare minimum and those that want to be the best they can be. It's those that push things forward for change. 

Now.....about you singing. How about a youtube video? Lol


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## Arovetli (Jun 8, 2013)

What educational difference are you expecting between a PA and a Paramedic Practitioner? You still need a foundation in science and medicine. And AFAIK PA do have at least some elective rotation time built in for you to study what you please. PAs can work in all fields from cardiothoracics to sleep medicine to hypertension clinics. Why give up the portability afforded by that program? I'd rather be a prehospital PA than a paramedic practitioner. 

So you touched on what really sets me off when you said the gamechangers are those at the top, already up to par.

Why aren't these people focused on getting everyone else up on the mountain with them? Creating new roles just for the best, serves only their interests. It does nothing for the rest of the field. 

Maybe you could FOIA the NSA into releasing a copy of my singing. I'm sure they have a recording of it somewhere...for national security purposes of course.


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## chaz90 (Jun 8, 2013)

Arovetli said:


> So you touched on what really sets me off when you said the gamechangers are those at the top, already up to par.
> 
> Why aren't these people focused on getting everyone else up on the mountain with them? Creating new roles just for the best, serves only their interests. It does nothing for the rest of the field.



Ignorance and mediocrity are tolerated far too often in many systems and for many people. For those that are happy providing the bare minimum service and taxi ride, there is no bringing them up to par. Perhaps some of them can be rehabilitated if we can show them good reason why our current model is failing, but the majority see no problem with today's practices and don't want to change. It's easier to complain about 911 abuse or low pay then make concerted efforts to enhance your skills or knowledge. I think a lot of this debate comes from a disagreement in trickle down improvement vs. building from the ground up. IMO, our foundation is too rotten to build upon and requires some kind of revamping. Taking the current group of EMS providers that excel at what they do (and they do exist!) and creating a new purpose built role for them provides the best opportunity to improve EMS over a period of time. Right now, we lose our best and brightest to attrition and other careers because there is no meaningful way to advance in decision making, scope, and applying education. Giving the quality providers that want to advance and still love EMS a way to move forward without changing careers seems to me to be the way of the future.


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## Arovetli (Jun 8, 2013)

Ok, I can buy that.

But none of that means expanding into primary care.

Detach out the bulk and bloat of "EMS", general transporting, have real mental and poor health resources available, and let paramedics become proficient at medical decision making, advanced skills, drugs, and procedures. I'm all for developing EMS.

Instead of jettisoning the whole emergent care notion, or pretending fairy tale god mothers wand will allow you to do both emergency and primary care well...and focus on being expert out of hospital acute care clinicians.


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## chaz90 (Jun 8, 2013)

Arovetli said:


> Ok, I can buy that.
> 
> But none of that means expanding into primary care.
> 
> ...



And I agree with that 100%. Having come to a rare internet agreement with someone, I believe I can happily leave this thread alone.


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## Arovetli (Jun 8, 2013)

chaz90 said:


> And I agree with that 100%. Having come to a rare internet agreement with someone, I believe I can happily leave this thread alone.



Behold ye, the power of my persuasion.


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## Carlos Danger (Jun 8, 2013)

Arovetli said:


> @clipper
> 
> Good ideas. None of which require an emergency medicine trained paramedic. Yes, we need to improve resources in the community, fire houses are strategically placed, not a bad idea to attach an area with care coordinators and a midlevel. Community oriented healthcaring is a great idea. But it doesn't need a cross trained emergency/primary care paramedic. If they want to hire medics to work as techs in this program, like MD offices and ERs and urgent cares already do, no problem.
> 
> ...



Excellent post. 

Dovetails nicely with some things I wrote earlier in this thread:



> One of the big problems with paramedic education is that it is still focused solely on life-threatening emergencies even though those requests make up a very small percentage of what paramedics actually do. For that reason, it makes good sense to me that paramedic education and mindset would shift from its emergency focus to one where the importance of basic non-emergency care is increased.
> 
> I would re-design paramedic education to take a full two years (at least), and the curriculum would spend at least as much time on non-emergency as on emergency care. Paramedics would still learn to do EKG's and ACLS and PALS and airway management, but rather than pretending that's all there is to prehospital care and then having to schlep everyone to the ED whether or not they need it, medics would also be in a much better position to implement protocols that allowed for "treat and release" and for referral to clinics. Asthma attacks, diabetic wake-ups, minor burns, minor lacerations, and drunks would no longer have to receive the same disposition as a STEMI or a stroke.
> 
> ...





> A patient calls 911 for shortness of breath, just like they do now. A paramedic unit responds emergently, just like they do now.
> 
> Once arriving, they do the same assessment they normally would, including an EKG. Their assessment findings point to pneumonia. Their protocol takes into account the assessment findings, age, co-morbidities, etc and indicates that the patient should be triaged to clinic. They make a quick call to med control, who agrees with their plan. They then make a quick call to dispatch, who gives them a time for a clinic appointment the next day, or a followup home visit with a PA or NP from the home-health care agency.
> 
> ...



I, too, think the idea of a PA-level "paramedic practitioner" is redundant, inefficient, and unnecessary.

The idea of specialty trained RN or NP's / PA's making house calls to follow up after the type of scenario that I described above makes good sense to me, but that requires nothing more than expansion and better coordination of resources that currently exist....no need to invent an entirely new practitioner from the ground up.


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## Summit (Jun 8, 2013)

I came back to post, but halothane and alvoreti already said everything on my mind!


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## Brandon O (Jun 8, 2013)

I think the key point about training and levels of care is that whomever is making the initial contact and assessment needs to have enough education to be able to rule out critical conditions and down-triage with high specificity. This probably means great EMD and tort reform along with it, but it also means providers who can build a more reliable differential than most current paramedics.

Remember, deciding sick/not sick (in the gray areas, not the obvious cases) comprises most of emergency medicine nowadays -- even in the ED, and they have a lot more resources than we do in the field.


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## Clipper1 (Jun 8, 2013)

pcbguy said:


> @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!



The referral is in the systems trialing the CP program. The physicians may have something to gain. 

I also believe it is a failing of the hospital system to not have assessed the patient's need for special equipment and housing situation prior to discharge.  After a patient has been discharged is not the time since some of the preventative measures take time to implement. 




Brandon Oto said:


> I think the key point about training and levels of care is that whomever is making the initial contact and assessment needs to have enough education to be able to *rule out critical conditions and down-triage with high specificity.* This probably means great EMD and tort reform along with it, but it also means providers who can build a more reliable differential than most current paramedics.
> 
> Remember, *deciding sick/not sick (in the gray areas, not the obvious cases) *comprises most of emergency medicine nowadays -- even in the ED, and they have a lot more resources than we do in the field.



This is where the EMS training needs a total reform if it wants to participate in community medicine.  It is not about seeking out emergencies but rather preventing them.  If there is an emergent situation, fail unless it is related to something totally different or an expected exacerbation.

The focus of doing follow up should be based on what CMS measures for post discharge and readmission within 30 days.

CMS measures for 
AMI, heart failure, and pneumonia, THA
and/or TKA, PCI, the end-of-life measure focused on cancer patients. Post op patients are also part of what CMS monitors. 

The "critical" part has supposedly been treated by the hospital admission. Now it is time to maintain and prevent new infections and complications which lead to readmission.

Unfortunately, many who are most at risk do not have a regular primary and may continue to go unchecked or not be worthy of the CP program. Right now the new CP programs are looking for results.  Their patients might be chosen for them based on a higher probability of success rather than actual need. Some patients will continue to be written off as a repeater based on their chronic illness and socioeconomic status.

Yes you might have to think like other health care providers who make a plan of care from the bottom up meeting the most simplest non critical needs as well as the emergent.


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## Brandon O (Jun 9, 2013)

You're right, of course, but just as there will be unavoidable readmissions, there will also be patients with "new" complaints who weren't recently in care. The system should have a way of appropriately triaging them to the right resources and right destination, otherwise you're still sending a huge slice of people to the "default" of the ED who don't need to be there.


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## pcbguy (Jun 9, 2013)

I think that's what a lot of this is going to come down to. The ability of the paramedic to make determination on whether a patient needs to go to the ED and if not can their complaint be resolved on scene or do they need to go to a clinic.


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## Clipper1 (Jun 9, 2013)

Brandon Oto said:


> You're right, of course, but just as there will be unavoidable readmissions, there will also be patients with "new" complaints who weren't recently in care. The system should have a way of appropriately triaging them to the right resources and right destination, otherwise you're still sending a huge slice of people to the "default" of the ED who don't need to be there.







pcbguy said:


> I think that's what a lot of this is going to come down to. The ability of the paramedic to make determination on whether a patient needs to go to the ED and if not can their complaint be resolved on scene or do they need to go to a clinic.



I think some of you might be missing what the intent of these programs are right now which is why I posted the handbook for Colorado. You can also find similar material for Maine and Minnesota online.

According to the programs which already exist, you will not be doing anything new. The problems have been identified by the Physician, hospital and other care providers at the hospitals and maybe come clinics. The Physician will write specific instructions for why he or she wants you to follow this patient. Your role might be to check out the safety of the home and to do some vitals.  You may already know the patient was recently released after have CHF or some other exacerbation. The Physician will probably list the medications and would like you to see the patient is following his or her instructions. You might need to see if the patient is eating and if their glucose is being regulated.  Many patients with chronic lung disease will also have steroid induced diabetes. After a hospital stay with a hefty course of steroids on top of what they had normally been taking, other problems might occur as their dose pack is tapered.  There should be no mysteries and you will have the Physician to contact for all questions. The patient should also still have the ability to contact the Physician if he or she believes you are advising them wrong. Chances are all the education was done at the hospital and it will be your responsibility to reinforce the instructions and not change the game plan.  If this person returns back to the hospital within 3 or even 30 days, the charts will definitely be scrutinized since CMS will come back on the hospital and the doctor. You might be free from penalties but that does not mean you will not have to answer especially if you did not follow up as the Physician and hospital wanted you to.


You will be reporting back to the Physician's office or some other appointed person like a SW or CM who will then be making the appropriate referrals based on insurance. I doubt if any Paramedic wants to assume the responsibility of insurance and DME arrangements.   

Right now the CP will not be acting like a Physician Extender but rather someone who is given a plan of care with the expectations it will be carried out.  If you are intent on having the services similar to a Physician Extender then that is who should be doing the assessments rather than a band aid which just adds another inbetween level.


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## ExpatMedic0 (Jun 9, 2013)

pcbguy said:


> I think that's what a lot of this is going to come down to. The ability of the paramedic to make determination on whether a patient needs to go to the ED and if not can their complaint be resolved on scene or do they need to go to a clinic.



Yes indeed, and part of that can be fixed with out the concept of a community paramedic I believe. I also agree with many of you that we need to fix the "Emergency" part of pre-hospital care. I would be a fool if I did not acknowledge many of the valid arguments and points made by the "nay sayers". You can call me an optimist, naive, or whatever you like.... Just don't call me late for dinner! Wait what? Anyway.....:unsure: I am not ready to nail community paramedicine to a cross and set it ablaze just yet. Also, implying community paramedicine is only an egocentric attempt for my own(or CP stakeholders) benefit is a little rash....

Remember in these early stages, the term/concept "community paramedic" is being thrown around a lot, but its important to remember this is still a "concept". 

Also in the pilot projects which where successful the community paramedic projects reduced ED admits by up to %80. Their are peer reviewed empirical research studies showing stats like this. Feel free to look at them and post results here. You can say what you like, but it appears to work, which is why there is such an interest in it.  So why I am excited about CP, its not only to serve my own self interest. 

 Many countries already have community paramedic concepts that seem to be working great. They go by many titles such as Extended Care Paramedics and Emergency Care Practitioners in countries like the UK and Australia. A similar concept is even being introduced in the middle east in places like Qatar. 

I really wish I had the time to devote to this thread or even this forum this week, but with 18 credits worth of finals plus the CCEMT-P upcoming, my activity level is gonna be a little less.


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## Arovetli (Jun 9, 2013)

ExpatMedic0 said:


> Many countries already have community paramedic concepts that seem to be working great.



Why has it suddenly become popular (all over the place) to throw the "just look at other countries" argument around. Jeez, if you want to live in that, go get all you want, but please people, stop pretending you can copy and paste one piece of another country and integrate it here post haste. 

It's ludicrous. 

Look, like it or not, there is a large part of this country that wants to be left the hell alone and can arrange their affairs accordingly. 

And you have people waiting on Moses, Jesus, the rich, Obama, who the hell ever, to take care of them and give them things.

The ones that fall in between, that suffer unfairly, I genuinely feel sorry for. And I do have compassion towards all men, but all men can't be equal in all things.

It bothers me that I am overweight and children starve in foreign lands.

But...it's a harsh reality. In order for me..for us..to have, someone has to go without.

This is a fundamental divide. And it ain't going nowhere. 

All these programs and system redesign are counting on being bankrolled or ar least strong arm manipulated by Uncle Sam who took by force this money from someone else. Just...keep in mind the fact that you have to bury a steak knife in the side of one man in order to feed another.

Limited resources and human nature. It is what it is.

Alot of the CP talk has ventures into the realm of caring for poor populations. Social welfare is noble, but it is not necessary the burden of medicine alone. 

I don't know how I feel about re engineering the safety net to be the take care of everyone net.

At some point, the threads begin to fray.

So I ask, who is going to pay for all this community paramedicine? An ACO under the guise of keeping more money to themselves? I really doubt there going to offer up big cash for another midlevel/quasi midlevel/whatever, when they could probably OJT a CNA to do it all.

Sorry for the political/socioeconomic twist, but you have to fund the dream. And I don't know how you can keep voting a largesse out of the printing press. A lot of the countries your envying are able to do what they do because we do what we do.

And if we are venturing down the road of designing a hyperpaternalistic federal healthcare system, we would be better of appointing Bloomberg as the Health Czar, putting you in prison if you didn't eat paleo, and requiring televisions to be powered by pedaling an exercise bike.


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## Brandon O (Jun 9, 2013)

ExpatMedic0 said:


> Also in the pilot projects which where successful the community paramedic projects reduced ED admits by up to %80.



I haven't seen numbers quite this high anywhere -- are you saying these communities had an 80% relative reduction in overall ED visits (or hospital admissions)? If so, that's quite remarkable. Where is that figure from?


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## Arovetli (Jun 9, 2013)

Brandon Oto said:


> I haven't seen numbers quite this high anywhere -- are you saying these communities had an 80% relative reduction in overall ED visits (or hospital admissions)? If so, that's quite remarkable. Where is that figure from?



I would be interested in legitimate sources. I searched the literature, the best I can find is this review:

http://www.ncbi.nlm.nih.gov/m/pubmed/23734989/?i=1&from=community paramedic

And out of all this literature, only one randomized controlled trial was found. Of course, designing methodology for this type of study would be...a bit challenging to say the least.

And while we can make slight inferences perhaps from Britland and Canada, I'm not at all convinced the results can be readily transposed to the states.


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## ExpatMedic0 (Jun 10, 2013)

here a couple stats off the top of my head, Ill have to find that %80 one and post it here later. Although I will admit, I can't remember if it is overall admissions to the ED or "target populations", which it may very well be. 

The Community Referrals by Emergency Medical Services program in Toronto reduced emergency medical calls by 73.8% in the target population. (NHRA, pg.8)

MedStar in Fort Worth accomplished a $13.5 million reduction in costs and charges over a 2 year period, reduced 911 call volume in a target population by 58%, and reduce emergency department bed occupancy by 14,334 hours. (NHRA, pg.8)
 source:
https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=2&ved=0CDQQFjAB&url=http%3A%2F%2Fwww.ruralhealthweb.org%2Findex.cfm%3Fobjectid%3D24480DBA-3048-651A-FE808A7FF0AC5CFE&ei=3Ja1UZDMDu2O4gSzooGABA&usg=AFQjCNHBlvV13VnsJuVRf9qzZlsQQ9Sbdw&sig2=Riw0RrdJXD-J7OV0Nazmxg&bvm=bv.47534661,d.bGE

Also,

According to the National Highway Traffic Safety Administration (NHTSA), the Health Resources
and Services Administration (HRSA) the National Association of EMS Physicians (NAEMSP) and National
Association of State EMS Directors (NASEMSD).

"Emergency Medical Services (EMS) of the future will be community-based health management
that is fully integrated with the overall health care system. It will have the ability to identify and
modify illness and injury risks, provide acute illness and injury care and follow-up, and
contribute to treatment of chronic conditions and community health monitoring. This new entity
will be developed from redistribution of existing health care resources and will be integrated with
other health care providers and public health and public safety agencies. It will improve
community health and result in a more appropriate use"

ALSO check these links, esp the first one:
http://www.communityparamedics.com/information.html

http://www.ircp.info/

http://www.communityparamedic.org/


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## Wes (Jun 10, 2013)

http://www.theage.com.au/victoria/doctors-raise-doubts-on-ambulance-plan-20130610-2o05b.html

Interesting article from Australia raising some doubts/concerns.


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## Arovetli (Jun 10, 2013)

Ok so there seems to be a disconnect between some visions of community paramedicine and the present reality of these programs in the US is. 

Lets take the Medstar program for example.

I don't know much about it except from what I have read, so don't hold me as an expert as to the nuts and bolts of the operation.

First of all as to the statistics, they are irrelevant in this case. All I can gather is they are based on 21 patients which grossly abuse the system, and that providing some sort of special attention to these patients the number of EMS calls they place decreases.

This fails to provide us data about the big picture, or any reason to assume EMS or paramedics played a role in achieving the results, we can just infer that providing ongoing attention to system "abusers" or frequent flyers reduces the amount of times they call.

More of a case for reducing frequent flyers than a case for paramedics gaining a higher level of medical prowess.

And it seems their community health program is really one of nursing, follow up, social work, patient education, and direction to appropriate resources...none of which requires a paramedic or requires any additional advanced knowledge or skill of the paramedic.

I'm all for that type of program, but absolutely nothing at all indicates advanced scope or pay for paramedics.

About every service I've worked for would have a supervisor or a paramedic or the police go talk to a frequent flyer and get them educated on resources and a plan for them to get healthcare that didn't involve 911. We just never called in community health.

This is where alot of confusion comes in to play, because there are folks who genuinely believe this will lead to a midlevel role, increased pay, increased scope, save EMS...nonsense. This is the type of stuff we should do already. We all educate diabetics on their conditions, and how to care for their disease so as to avoid having to activate EMS for a wake up. Directing them to a physician or scheduling an appointment for them is logical. Having someone follow up the next day or week is great.

But none if that really requires a paramedic, it's just medics are familiar with the streets. And it certainly doesn't require advancing the skillset or education of paramedics into degree programs.

It's just smart business and good patient care.

One of the big problems we face is that there is just not alot of places to direct these patients to go, because the ER is about the only place that tolerates difficult patients, and sees the uninsured.

Again, that's a healthcare system problem, not really and EMS problem.
 And honestly, it's a fundamental problem to societies: how to care for poor and difficult populations.
We're not locking the lepers outside the gates, but I doubt we will be able to rig up a system where advanced level clinicians roam about the streets seeking whom they might heal.


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## Wes (Jun 10, 2013)

So, is community paramedicine midlevel practice, a method of home health care, a means to divert "frequent fliers" and system abusers, a method to reduce ER visits, or a way to "treat and street" patients?

Honestly, I'm not sure anyone knows.


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## Arovetli (Jun 10, 2013)

Wes said:


> So, is community paramedicine midlevel practice, a method of home health care, a means to divert "frequent fliers" and system abusers, a method to reduce ER visits, or a way to "treat and street" patients?
> 
> Honestly, I'm not sure anyone knows.



It is a band aid over a bleeding artery.

How to fix the underlying problem extends far beyond EMS.


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## Wes (Jun 10, 2013)

Agreed.   A few years back here in Austin, the children's hospital moved out of the city/county hospital/trauma center.   I thought the smartest thing would be to turn the children's ER into an urgent care/fast track for non-acute patients.   It was turned into more ER beds.  Surprise.  The ER is still full.

IMHO, we need to have the ERs perform screening exams for non-critical patients and then have someplace to send them.  But that would involve the welfare/public health system having hours other than 9-5 Monday - Friday.


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## Arovetli (Jun 10, 2013)

Well, they used to do the MSE and send them on their way. That method was much more common. But all the hospitals I know just try to keep them now, because if they are insured there's some money to be made, and if they are not, there are some government subsidies, or at least writing off the care helps the tax situation, or keeps donor money coming in.

You know, for way to long we have all been trying to erect barriers to the hospital because the sign above the door says Emergency on it. But patients keep coming, because honestly it's the smartest place to go. They are familiar with the brand. It's easier to sell the brand of a hospital system than it is to market and brand an individual physician, especially for primary care. Good doctors staff the hospitals, There's access to scanners, labs, diagnostics, beds if you need to stay, a cafeteria...it's a one stop health shop.

It really makes sense, and it is what consumers and patients want, to center care around the hospitals in conjunction with community follow up.

We, the medical profession, are the ones clinging to the past by insisting everyone form a relationship with a physician and go to his office and let him guide your care. Things change and it's time for us to change as well.

The first place a patient should go is a satellite facility in the community affiliated with the health system, like an urgent care or primary clinic, open 24 hours a day, and they can begin to triage and coordinate care, as well as direct the community health programs. 

Emergencies and acute cases can bypass or be sent out from the community clinics into the main receiving hospital and be handled accordingly.


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## Meursault (Jun 10, 2013)

Arovetli said:


> They are familiar with the brand. It's easier to sell the brand of a hospital system than it is to market and brand an individual physician, especially for primary care. Good doctors staff the hospitals, There's access to scanners, labs, diagnostics, beds if you need to stay, a cafeteria...it's a one stop health shop.
> 
> It really makes sense, and it is what consumers and patients want, to center care around the hospitals in conjunction with community follow up.


It's somewhat of a digression, but where did that brand come from? Who manages that brand, even to the point of doing customer satisfaction surveys every single day to make sure their underlings are keeping the brand's value up?
The suits are going to fight tooth and nail against anything that diminishes their market share. I suspect this means community health needs to work for them if it's going to have any success. We get the brand and a tiny straw to sip from the vast river of money; they get to follow customers home and bring them back. The only things we'd have to give up are independence and cost-effectiveness. All the health professions already made that trade.


Arovetli said:


> It really makes sense, and it is what consumers and patients want, to center care around the hospitals in conjunction with community follow up.


And now we see the perniciousness of the brand. The healthy customers, the ones our new masters are interested in, don't want to sit at home and wait. They want to go sit in that lovely glass and brushed steel waiting room for a few minutes, then be ushered back into an equally nice room with a more comfortable chair, where their problems will be fixed. 
And if they're an equal distance from some strip-mall urgent care that probably doesn't even have an MRI machine and its parent, Big Teaching Hospital, which one are they going to go to? 
But what about the sick customers, whom we're probably more interested in anyway? A lot of them don't see themselves as sick. They saw all the ads too, or their loving children did. And if they really are, better go to Big Teaching Hospital so we're sure that they'll have everything in case we need it. Our insurance should cover it.
And the rest? Oh, now we're back to taking care of poor people no one cares about. Except now our job is to keep costs down and keep them out of the hospital, and if we come across a potential good customer, to bring that person right in.


Arovetli said:


> the underlying problem extends far beyond EMS.


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## Carlos Danger (Jun 10, 2013)

Wes said:


> So, is community paramedicine midlevel practice, a method of home health care, a means to divert "frequent fliers" and system abusers, a method to reduce ER visits, or a way to "treat and street" patients?



These are good questions. It seems it would be sensible to define the need before trying to design a system or decide who is best equipped to meet that need.

It appears to me that community health paramedicine as a concept is more a way for paramedicine to try to adapt and reinvent itself ithan it is a response to an actual need.

I'm not saying that there is currently no need for additional community health nursing services, or that the need won't grow in the future, or that EMS should have no part in meeting that need. It's just that, even after all this discussion, I still haven't seen any justification for the type of massive new shift in the EMS paradigm that some are promoting. 

We already have community health nurses. We already have PA's and NP's. 

Do we need the midlevels out in the community more? Yeah, maybe. 

Do we need the current home-healthcare infrastructure to expand? Yeah, it sounds like it.

Do we need the current home-healthcare infrastructure working more closely with EMS to identify patients and provide follow-up at home? Yeah, sounds like a great idea to me.

Do we need paramedics to have the education and authority to do more non-acute assessments, treat-and-release, patient education, referrals, giving out short-term scripts pending a clinic or home health appointment? Absolutely - see my last post in this thread for my vision on that.

But again, do we really need "paramedic practitioners" and all the expensive new educational infrastructure, experimentation, legal battles, and bureaucracy that will come with inventing an entire new profession? Do we need EMS to take over home care? Do most paramedics even really know what they are getting into in asking, essentially, to work as a nurse in people's homes? 

I hate to be negative about this, but I just don't see the need or the practicality.


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## Arovetli (Jun 10, 2013)

Meursault said:


> It's somewhat of a digression, but where did that brand come from? Who manages that brand, even to the point of doing customer satisfaction surveys every single day to make sure their underlings are keeping the brand's value up?
> The suits are going to fight tooth and nail against anything that diminishes their market share. I suspect this means community health needs to work for them if it's going to have any success. We get the brand and a tiny straw to sip from the vast river of money; they get to follow customers home and bring them back. The only things we'd have to give up are independence and cost-effectiveness. All the health professions already made that trade.
> 
> And now we see the perniciousness of the brand. The healthy customers, the ones our new masters are interested in, don't want to sit at home and wait. They want to go sit in that lovely glass and brushed steel waiting room for a few minutes, then be ushered back into an equally nice room with a more comfortable chair, where their problems will be fixed.
> ...



I think we are making the same point. Consumer/patient preference for going to the hospital or at least remaining affiliated with one clinic/doctor affiliated with their choice of health system, and favoring a one stop shop approach.

I don't think no one cares about the poor, I just think it's unwise to tip the whole system on its head to care for them and i dont favor that level of government intervention and the centralized planning that accompanies it. We have to figure out a viable way to pay for it, and encourage personal responsibility. No small task.

I favor a come one, come all approach.  Come on in the hospital system if you want, but I wish the emergency room and the emergency system wasn't the sole point of entry, and EMS wasn't the primary method of moving patients around. And patients have to pay their bills or at least in some minimal manner have responsibility for themselves and the cost of their care.


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## ExpatMedic0 (Jun 12, 2013)

CP concept in the news again, this time in Santa Monica. Al though, in this case, its really just letting  Paramedics decide rather or not someone should go to the ED. 

http://abclocal.go.com/kabc/story?section=news/health&id=9127766


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## Wes (Jun 12, 2013)

With the current educational standards and our limited knowledge of medicine outside of the acute care setting, paramedic initiated refusals are little more than full employment for lawyers.   

I'm putting down a down payment on my BMW 635 now.


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## Arovetli (Jun 13, 2013)

While y'all already know where I stand on Paramedics providing community health...I did stumble across this grant:

http://www.grants.gov/search/search...0ZhJSlMJDw!-1552203449?oppId=235732&mode=VIEW

I know we have discussed ACA and federal funding, and while this type of program isn't specifically for EMS or paramedics, it's not too much of a stretch to think an EMS agency could somehow finagle their way into this or another similar type of grant program.

I don't agree with EMS doing it, but in fairness I thought I should post it as it shows the type of grant money being thrown at community/home health.


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## ExpatMedic0 (Jun 18, 2013)

Latest news article on Community Paramedics "Indianapolis EMS Reaches Community with CORE Care Team"

http://www.emsworld.com/news/10963425/indianapolis-ems-community-paramedicine


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## AlphaButch (Jun 18, 2013)

Wes said:


> So, is community paramedicine midlevel practice, a method of home health care, a means to divert "frequent fliers" and system abusers, a method to reduce ER visits, or a way to "treat and street" patients?
> 
> Honestly, I'm not sure anyone knows.



Our pilot is already doing all of these. The didactic training takes approximately 3 months for Medic/RNs and 6-8 months for Medics (more for certain specialty trained units). Along with clinical time before being approved by the MD staff.

First stage of the pilot (18 days) allowed us to prevent 49 out of 50 ER trips in the pilot's 10 mile zone (3 sent to urgent care, 47 treat/release, 1 still had to go to the ER). It's slow going though as there isn't any grant funding available at the moment, so it's all done using private funding. The system as it stands is profitable, however the initial capital outlay was immense (mostly for training development). Our second stage which is starting soon implements our reduction of RTA side of the program.


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