Community Paramedics revisited

[Brandon O]

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.

 

[Arovetli]

@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.

 

[pcbguy]

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.

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.

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.

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.

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

 

[Arovetli]

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.

 

[chaz90]

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.

 

[Arovetli]

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.

 

[chaz90]

Ok, I can buy that.

But none of that means expanding into primary care.

Detach out the bulk and bloat of "EMS", general transporting, 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.

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

 

[Arovetli]

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.

 

[Carlos Danger]

@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.

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.

And I wouldn't call this a "community health paramedic"; I would just call it a paramedic who is better trained to do what they 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.

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.

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.

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.

 

[Summit]

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

 

[Brandon O]

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.

 

[Clipper1]

@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.

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.

 

[Brandon O]

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]

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.

 

[Clipper1]

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.

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.

 

[ExpatMedic0]

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.

 

[Arovetli]

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.

 

[Brandon O]

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?

 

[Arovetli]

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.

 

[ExpatMedic0]

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/