Community Paramedicine, The next step?

[JPINFV]

Redacted

 

[ExpatMedic0]

Ok if all the medical students and nurses are done playing grab ***.... :wub:
I have a few questions...

Is anyone aware of anywhere in the U.S. other than Colorado and Minnesota with Community Paramedic pilot programs?

The current training/education for these pilot programs are embarrassing low considering the idea of this concept and what these providers are doing. Here is one such example below. Kind of like an EMT-I type of an idea compared to a Paramedic, only filling a mid level provider role, which is kind of scary.


Phase 1—Foundational Skills (Approx. 100 hours, based on prior experience) Comprehensive didactic instruction in advocacy, outreach and public health, performing community assessments and developing strategies for care and prevention
Phase 2—Clinical Skills (Range of 15 to146 hours, based on prior experience) Supervised training by medical director, nurse practitioner, physician assistant and/or public health provider.


Now compare that with the Masters degree in Australia for the same provider role and title..... Makes me laugh.

 

[Tigger]

Ok if all the medical students and nurses are done playing grab ***.... :wub:
I have a few questions...

Is anyone aware of anywhere in the U.S. other than Colorado and Minnesota with Community Paramedic pilot programs?

The current training/education for these pilot programs are embarrassing low considering the idea of this concept and what these providers are doing. Here is one such example below. Kind of like an EMT-I type of an idea compared to a Paramedic, only filling a mid level provider role, which is kind of scary.

Phase 1—Foundational Skills (Approx. 100 hours, based on prior experience) Comprehensive didactic instruction in advocacy, outreach and public health, performing community assessments and developing strategies for care and prevention
Phase 2—Clinical Skills (Range of 15 to146 hours, based on prior experience) Supervised training by medical director, nurse practitioner, physician assistant and/or public health provider.


Now compare that with the Masters degree in Australia for the same provider role and title..... Makes me laugh.

I am only aware of two in Colorado and there's very limited information in terms of their education. Have you found much in the way of curriculum for Western Eagle County's program or Ute Pass Regional Ambulance's? I know someone at the latter, I'll try and get the scoop on that at some point.

 

[Summit]

I am only aware of two in Colorado and there's very limited information in terms of their education. Have you found much in the way of curriculum for Western Eagle County's program or Ute Pass Regional Ambulance's? I know someone at the latter, I'll try and get the scoop on that at some point.

WECAD is a very small rural service with 4 ambulances. They do not charge for CP visits and it is entirely funded by grants.Their CP course is an online non-credit course taught through the local community college combined with a 32 hour lab and 100 hour clinical.

When you look at their talking points for MDs:
http://www.wecadems.com/documents/MD Talking Points.pdf

You see that CP is aimed squarely at a well established realm of nursing. CP roles are clearly doubling into Community Health Nursing roles, a profession that requires a BSN at minimum.

 

[Tigger]

WECAD is a very small rural service with 4 ambulances. They do not charge for CP visits and it is entirely funded by grants.Their CP course is an online non-credit course taught through the local community college combined with a 32 hour lab and 100 hour clinical.

When you look at their talking points for MDs:
http://www.wecadems.com/documents/MD Talking Points.pdf

You see that CP is aimed squarely at a well established realm of nursing. CP roles are clearly doubling into Community Health Nursing roles, a profession that requires a BSN at minimum.

That seems pretty thin truth be told. Ute Pass's PACT program is even smaller (they run 2-3 ambulances) and while it is respected within the community I cannot imagine the actual education component is significantly longer than WECAD's.

There seems to be a lack of formalized education programs for community paramedics that are of what most of medicine would consider to be of proper depth. While I don't think it's unreasonable to think that many of the public health initiatives championed by community paramedic programs can be learned in a few hundred hours, that is not going to get any respect from the rest of the medical community that did not take this perceived "shortcut" to get to this role.

Also WECAD and Eagle County Ambulance District are in the process of merging, it will be interesting to see if the community paramedic program is maintained, expanded, or scrapped.

 

[usalsfyre]

You see that CP is aimed squarely at a well established realm of nursing. CP roles are clearly doubling into Community Health Nursing roles, a profession that requires a BSN at minimum.

While the shortcut aspect is a legitimate concern, if community health nursing had been adequately filling this niche community paramedicine wouldn't be in existence.

MedStar is showing you can have similar outcomes with community paramedics at lower cost...isn't that the entire argument behind APNs?

 

[Veneficus]

What everyuone arguing economics is failing to realize is you can send a specifically trained tech to any condition, in any environment, from surgery to EMS and get results that look good using guidlines.

About 100 years ago, a doctor could become so in the US with an apprenticeship not a formal education. Surgeons didn't always go to medical school.

The reason that such strict criteria for the practice of medicine exists is because of that.

Medical education costs and artificial shortage in doctors is easily remedied by doctors.

This same thing is going to play out with nursing and EMS.

But as I have saidin PM, these band-aid fixes require a dysfunctional system. A system which will not be able to sustain another 100 years.

This rol filling is not optimal, it is simply better than nothing, and since the future of medicine is individualized genetically based treatment, not guidlines and protocols, comparing oneself and results to current guidlines is not going to work forever. It may not even work for the next change of guidelines.

I am of the mind that the only long term viable and portable careers in healthcare is basic nursing and doctors.

I also agree that if EMS is to remain a viable career, it will have to grab hold of community medicine from nursing and they need to start doing that ASAP if they want to succeed.

I also stated and stand by the point, mid level providers are middlemen and do not exist in viable much less economical healthcare systems. When it comes to savings, middlemen will always be cut before those at the top and bottom. IF there is a realistic shift in US medical policy to train an adequete amount of doctors for the population and not based on market manipulation, midlevels will be competing with doctors for jobs, and I am willing to bet I know how that will work out.

As anyone in business can attest, filling a need doesn't mean the need will always exist.

 

[Tigger]

While the shortcut aspect is a legitimate concern, if community health nursing had been adequately filling this niche community paramedicine wouldn't be in existence.

MedStar is showing you can have similar outcomes with community paramedics at lower cost...isn't that the entire argument behind APNs?

While I agree that community paramedics would not exist without community health nursing dropping the ball, it seems to me that nursing in is in a much better position to get it back than EMS is to keep it.

EMS has little lobbying power and the educational differences between a community health RN and community paramedic are significant. The community paramedic model is only sustainable because as you said, it provides similar outcomes at a lower cost.

But what happens when the CP model starts to expand and there is no expansion in education with it. Can the similar outcomes can be maintained at a larger scale?

 

[Summit]

While I agree that community paramedics would not exist without community health nursing dropping the ball, it seems to me that nursing in is in a much better position to get it back than EMS is to keep it.

EMS has little lobbying power and the educational differences between a community health RN and community paramedic are significant. The community paramedic model is only sustainable because as you said, it provides similar outcomes at a lower cost.

But what happens when the CP model starts to expand and there is no expansion in education with it. Can the similar outcomes can be maintained at a larger scale?

Id wager that the shortfall from nursing is a combination of:
1. lack of support from the healthcare system as a whole for preventative care, particularly for undeserved and rural populations
2. a historic lack of qualified BSN RN providers

#2 isn't a problem anymore with the trend towards BSN entry, completion, and graduate education in nursing. Also, there are more and more nurses looking to get outside the acute care and shift work world.

#1 will continue to be a problem for community health nursing and CP. But, if there is money, the RNs will be more successful for the reasons stated.

I wouldn't compare CP to APNs. I'd compare it to a FD takeover of EMS. Picture a fire chief saying, why don't I make all my FFs into medics so I can get medical call revenue while they aren't running fires since fire call volume is steadily decreasing, plus the entry barrier to FD is so low I have are billion applicants, so let's add this paramedic thing as another prereq.

Now picture an EMS service director looking for something their medics can do instead of sitting on a street corner or at the ems/fire station. Why don't we send them to an online class, call them community medics, and increase billable services?

The CH RNs focused on HBPC, HH, on other forms of in-home care do this as their primary profession backed by university level community health courses and an entire curriculum that covers the general, chronic, and all aspect considerations for patient care (not to mention a real pharmacology course). They are not techs dabbling in primary/preventative care inbetween 911 calls.

 

[usalsfyre]

So lesser educated providers who get similar outcomes SHOULDN'T take over a healthcare niche in this case? But they should in others?

I wish y'all would make up your mind...

 

[VFlutter]

So lesser educated providers who get similar outcomes SHOULDN'T take over a healthcare niche in this case? But they should in others?

I wish y'all would make up your mind...

Go for it. I wish all the community paramedics the best of luck. I do no predict outcomes will be any better than they are now and most likely be worse. There are just too many aspects to community care to learn in a 200 hour course.

I have no doubt that paramedics could eventually fill this role however it will not be as easy as some are suggesting and it will definitely require an increase in education including humanities and Gen. Ed.

There is a differene between lesser educated and under educated. Most, not all, paramedics are undereducated for the jobs they perform now let alone stepping into advanced roles.

 

[Wheel]

Hopefully the CP concept will lead to more education. I think it would be great if an organization (let's take med star as an example) would flesh this idea out. I think it would be great if they would pay for their paramedics to finish the bachelors from uthscsa and an internship both in the field and also other areas (wound care, family practice, er, urgent care clinic.) Then they could make the case that their education was comparable and outcomes similar. That plus their ability to be dispatched to frequent fliers/primary care 911 calls might allow them to make a case for reimbursement.

I'm just thinking aloud here. Might this be an opportunity for ems to push itself into something that meets a need and to make a reason for increased education and subsequently reimbursement?

 

[ExpatMedic0]

Regarding some of the previous post.

I think this particular (theoretical)mid level provider would not take jobs from M.D.'s. I think one purpose of this provider would be to save money, cut down on unnecessary hospital visits or M.D. contacts in the first place. Lets face it, an M.D. is not going to be making house calls as a full time job in rural areas or areas of health disparities which will result is no real reimbursement. Also think of all the unnecessary and overcrowded ED's.

It should also be noted I think a mid level provider such as a community paramedic would actually be taking the crap work many do not want which is also not worth very much money. Much of the work would simply be deciding if someone needs to go see a Doctor or not.

Any mid level provider that is arguing for full autonomy like a Doctor needs to STFU and become a Doctor, problem solved. Nursing, PA, and Paramedic are all built to assist, provide an extension, or work below Doctors in one way or another. Not to practice medicine independently as a fully autonomous provider.

Also this is a "Pre-hospital" environment which I see as EMS's sandbox and as a result, a Paramedic's sandbox if U.S. EMS can get its stuff together, like every other country using this right now.

 

[ExpatMedic0]

Also I would like mention this is all ready the future of EMS in the USA.

I would like to quote 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"

source: http://www.ircp.info/Portals/22/Future/FinalEducationAgenda.pdf

 

[Summit]

Also this is a "Pre-hospital" environment which I see as EMS's sandbox and as a result, a Paramedic's sandbox if U.S. EMS can get its stuff together, like every other country using this right now.

Paramedics date to the early 1970s. EMERGENCY prehospital medicine is EMS's sandbox in the US. Preventative and home care in the US is the realm of RNs (and in the past, MDs) and increasingly, telemedicine (which is awesome and managed by physicians, midlevels, and RNs).

Community Nursing in the USA dates back to 1877. Community paramedics to what, the 2000s?

Paramedics are not going to take the role as a positive development in the US unless their educational minimums advance drastically (to where most of the regular posters on this forum want them to be).

I predict that community paramedics will continue to develop in small programs in rural areas where the ALS services have very light call volume. I do not think it will happen in urban areas unless there is and education revolution in EMS. In the urban and suburban environments where EMS has a higher call volume and BSN RNs are plentiful, how does it make economical sense to dispatch two paramedics in an ambulance when you could dispatch one better educated and focused CHRN in a compact car?

 

[ExpatMedic0]

how does it make economical sense to dispatch two paramedics in an ambulance when you could dispatch one better educated and focused CHRN in a compact car?

I am going to be careful how I answer this because if we are going to get into another career penile measuring contest, I would prefer to be in another thread

IMO I think a Paramedic with years of field experience and a college degree in a related field that is relevant would be a better fit.

One of the main goals of this is not only to provide a level of care that otherwise not be there, along with public health but to mainly reduce ED visits. A seasoned Paramedic is already trained and experienced in recognizing and treating emergencies. All Paramedics are also trained to operate alone outside of a hospital or clinical environment.
However most importantly, we are all ready responding to many of these calls. Just being forced to transport in many cases when its not necessary. Community Paramedics have been shown to reduce ED visits by over %40 http://ircp.info/Portals/22/Downloads/Expanded Role/NAEMSE Community Paramedic Article.pdf
Regardless of what healthcare system your using, that saves money.. It also allows Doctors at the hospital to treat more important patients and matters. Some(not all) Paramedics are more than prepared to meet the needs of the community if there given the right tools and education to do so. In fact, IMO there Ideal for this.


In order for this succeed like it is in all the other modern countries in the world... Its going to take a more advanced understanding of disease process, A&P, and public health than a certified Paramedic. These issues have already been addressed and inter-graded into the curriculum for many of the community Paramedic degrees/programs outside the USA.

And although certainly not the majority at this time, there are plenty of degree baring Paramedics in the USA (more than enough to conduct pilot programs at this time) who already posses many of those qualities. In addition to that if you gave them recognition of prior learning through field experience, I believe many of them are highly capable with a simple upgrade of public health and disease process.
However I would like to see a more formal curriculum develop in the states specific to the community paramedic which also meets the needs I mentioned above. The link I posted to the aussie community paramedic degree would be something to go off of.

 

[Summit]

IMO I think a Paramedic with years of field experience and a college degree in a related field that is relevant would be a better fit.

The argument could be made for that in combination with sufficient education in community health, but the current programs do NOT require any of these things. So, saying that is little different than wishing for a BS or MS minimum for paramedics.

One of the main goals of this is not only to provide a level of care that otherwise not be there, along with public health

Thus my statement that CP programs will probably continue to exist in small rural districts.

A seasoned Paramedic is already trained and experienced in recognizing and treating emergencies. All Paramedics are also trained to operate alone outside of a hospital or clinical environment.

Working alone outside the hospital is exactly where the CHRN is educated and trained to practice. They are also trained to recognize emergencies and respond appropriately (possibly calling 911).

However most importantly, we are all ready responding to many of these calls. Just being forced to transport in many cases when its not necessary.

Sounds like a great reason to have a CHRN in a fly car.

Paramedics are more than prepared to meet the needs of the community if there given the right tools and education to do so. In fact, IMO there Ideal for this.

That is a huge IF that simply isn't happening. They are NOT ideal for this because their education is NOT ideal for community health.

In order for this succeed like it is in all the other modern countries in the world... Its going to take a more advanced understanding of disease process, A&P, and public health than a certified Paramedic. These issues have already been addressed and inter-graded into the curriculum for many of the community Paramedic degrees/programs outside the USA.

I agree... but that is not how it works here, nor how it will work anytime soon (I say that with great sadness).

Wishfull thinking about what paramedicine should be is not a valid reason for paramedicine to prematurely take on roles that would be appropriate ONLY AFTER the progression becomes reality.

 

[Shishkabob]

Thus my statement that CP programs will probably continue to exist in small rural districts.

Or the 16th biggest city in the US (Or #9 based on population of service area)


MedStar Making House Calls

 

[ExpatMedic0]

I think what is important to remember here is that no program really exists yet. There are 1 or 2 experimental pilot programs in the states right now that are in the VERY early stages of researching this further. ( that I am aware of)

This already exists and is in practice in England, Aus, Canada, so on and so forth. There are 20+ universities in the United States pumping out Bachelor degree baring Paramedics with education to do this, they just need a little more information on disease process and public health. They in no way represent the majority of certified Paramedics in the USA but neither does community Paramedicine.


If we want to talk about nursing and CHRN's maybe allnurses.com would be a good resource. If we could stay on topic it might help this thread provide further information for those of us who interested community PARAMEDICINE

 

[Summit]

There are 20+ universities in the United States pumping out Bachelor degree baring Paramedics

That makes up, what, 1% of US programs?

If we want to talk about nursing and CHRN's maybe allnurses.com would be a good resource. If we could stay on topic it might help this thread provide further information for those of us who interested community PARAMEDICINE

Discussing CHRNs is absolutely appropriate in a discussion about paramedicine expanding into an area that has been the realm of CHRNs for a very long time. I don't see why it would be a bad idea to have a CHRN work for an EMS system as a colleauge of the providers and resource of the EMS system function in that PH/CH role. Afterall, if since you mentioned many other nations using baccalaureate equivelent and masters prepared providers in a community health role, it is worth noting that many countries use EMS providers while others use nurses including prehospital specialized nurses.

ETA: I guess what I am saying is that you've come up with all of these changes that you (and I) think paramedics need to make in their educational system to properly fill a role, but the changes haven't occured. The role can be filled by an CHRNs produced by the current system, so WHY NOT incorporate BSN RNs in that sub-role within the EMS system?