Community Paramedics revisited

[Action942Jackson]

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.

 

[VFlutter]

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.

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.

 

[usalsfyre]

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.

 

[Clipper1]

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.

 

[Carlos Danger]

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.

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?

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.

 

[Summit]

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.

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?

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.

 

[Summit]

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.

 

[VFlutter]

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?

 

[ExpatMedic0]

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

 

[Clipper1]

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.

 

[ExpatMedic0]

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

 

[ExpatMedic0]

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/

 

[18G]

Pennsylvania is in the early stages of exploring Community Paramedicine.

http://www.communityparamedicineinpa.org/

 

[ExpatMedic0]

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)

Pennsylvania is in the early stages of exploring Community Paramedicine.

http://www.communityparamedicineinpa.org/

 

[MountainMedic]

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.

 

[Carlos Danger]

I definitely agree with this:

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.

 

[MountainMedic]

I definitely agree with this:



Paramedics are not really well education 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.

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

 

[ExpatMedic0]

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

 

[Arovetli]

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.

There is no viable funding. A nurse or a PA can already work as a "community paramedic", and perform all the things you outline above. The market can only support a few of these, because there is not great demand and there is not great reimbursement. Generally these field NP/PAs cater to high income patients on a cash pay or private insurance reimbursement, or are employed directly by an insurer or HMO to reduce overall cost.

The only way this is working is if healthcare becomes massively consolidated under a single payer and you are in a system where all providers are under the same financial umbrella.

In some markets this type of service may work, and paramedics have always been and were designed to be flexible to meet the needs of their practice area. Education levels definitely need to improve and the systems need to retooled. None of this is going to happen without financial incentive.

If you guys want to do community medicine....why not enroll in RN/NP/PA/MPH programs and go do it? The educational pathway exists...the demand and finances don't, but get the advanced license and shape your practice more to your liking.

EMS needs to improve, but it needs to focus on what it was designed for, and that is out of hospital acute care. There is a million ways to improve this without branching into primary care.

Now, there is a need for out of hospital primary care as well, but as I said these are served by others.

I would also note that technology is increasing at an astounding rate and will be the driving force in improving medicine. You should check out the stuff Phillips/GE is doing. Alot of this "community paramedicine" can and will be performed by technology instead of humans.

 

[Arovetli]

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.