Health care in the United States has been the subject of many debates. While most debates revolve around mandates and issues of personal beliefs, the real problem remains out of the spot light. There is a crisis in the health care system. The aging population is booming, and the general practice health care practitioners are dwindling. Rural areas, across the globe, are most profoundly impacted by the decline of general practice physicians. Chronic diseases are increasing; diabetes affects 25.8 million people in the United States, and is the seventh leading cause of death (Center for Disease Control and Prevention 2011). Chronic diseases are complex and require frequent visits to a physician’s office to monitor lab results and general health.
As early as 1968, a study showing a decrease of 18% in general practice physicians worried the medical community (Fahs and Peterson 1968). General practitioners are normally one of a few specialty programs including, family practice, internal medicine, and pediatric, that focus on being a generalist and can treat a wide variety of problems. In the mid 1960s, the shortage of doctors forced health care professionals to find alternate modes of delivering care. Nursing has been around since the late 19th century and when faced with a shortage of physicians, they expanded their role in health care. The Nurse Practitioner level provider was created and provides care under a physician’s guidance. Most RNP (registered nurse practitioner) graduates have a master’s level education and, increasingly, a doctorate degree. The Physician Assistant model of provider was derived from doctors who created a “fast-track” program similar to medical school. The majority of Physician Assistants hold master degrees, and works under the supervision of a physician. Both Nurse Practitioners and Physician Assistants can specialize in areas of medicine other than general practice. Opportunity to make more money in specialties has taken both professions away from general practice. Retention for Nurse Practitioners in family medicine has decreased by 40% in 2004 (Bowman n.d.).
Financial rewards, higher standard of living, and professional prestige are all reasons cited by medical students for going into specialties other than family practice. As health care costs continue to increase, and the number of people who can no longer afford health insurance increases, the pressure on the Emergency Department and urgent care clinics rise. Many people are using their local emergency physician as a family practitioner. The system is broken, and needs to be repaired. One possible solution which is emerging is the Community Paramedic.
Where did EMS come from?
The National Academy of Sciences Committee on Trauma and Committee on Shock published a paper called Accidental Death and Disability: The Neglected Disease of Modern Society in 1966. This report is known as The White Paper, it outlined recommendations for training emergency care providers to reduce the mortality of motor vehicle accidents. Until this point, ambulances were hearses, operated by funeral companies, which drove patients to the hospital. The ambulance attendants were not trained to provide any medical care, they simply drove the ambulance. The White Paper recommended that trained responders perform life saving actions on the scene, and became the basis for the current Emergency Medical Service system we know today. The Highway Safety Act of 1966 included federal funding for the training of the emergency care providers as recommended by The White Paper.
In 1973, The Public Safety Act (UCS Title 42 Chapter 6A, Subchapter X, Part A) included regulations for the establishment of a national Emergency Medical Service system, and provided for federal funding of EMS systems. Many states established EMS systems and, with federal funds, provided for training the responders. The Omnibus Budget Reconciliation act of 1981 eliminated all federal funds for EMS and put the responsibility on the state governments to provide funds for their EMS system. Today, most of the budget for an EMS service comes from billing patients and insurance companies.
The National Highway Transportation and Safety Administration, the federal agency who oversees EMS, published a paper in 1996 called The EMS Agenda for the Future with the intent to layout a national direction for emergency medical services. The committee recommended some very specific goals for EMS:
- Integration of health services: “EMS delivers treatment as part of, or in combination with, systemic approaches intended to attenuate morbidity and mortality for specific patient subpopulations”.
- EMS should also maintain liaison with other community resources such as, public health, social service agencies, and health care provider networks
- Be proactive in affecting long term health by relaying information regarding potentially unhealthy situations
- Referrals to agencies with vested interest in maintaining the health of their clients
- Continuously engage in injury and illness prevention programs
- Identify community injury and illness problems
- Eliminate patient transport as a criteria for compensating EMS systems
- Expand the role of EMS in public health
- Involve EMS in community health monitoring activities
- Higher lever EMS education associated with academic institutions, facilitating development as a professional discipline
- Institutions of higher learning recognize EMS education as an achievement worthy of academic credit
Although EMS is often seen solely as a public safety agency, the NHTSA Agenda for the Future states, “EMS is a community health resource, able to initiate important follow-up care for patients, whether or not they are transported to a health care facility”.
Until recently, many of these objectives have been overlooked or not integrated in to EMS systems across the country. One program, with international implications, is implementing these recommendations and evolving EMS from a transportation system, into a health care delivery system. This is the Community Paramedic.
Bringing the health care to the patient
Alaska has one of the earliest, and most successful, models of providing health care to an underserved population. The Alaska Community Health Aid Program (CHAP) was first developed in the 1950s in response to a tuberculosis epidemic in rural Alaska. The community health aides are trained to deliver vaccination, suture wounds, provide preventative screening and are expanding to provide dental care, behavioral and elder care to rural Alaska. The federal government began providing funds for the CHA program in 1968. Today there are five hundred and fifty CHA practitioners serving native and rural area.
The first example of an EMS system providing preventative and non-emergent care was in Taos County, New Mexico. The Red River Project ran from 1995-2000. Taos County is a popular place for tourists during peak times. The community did not have a physician practicing in the area, and the closest hospital is one hour away by ground transportation. The leaders decided to utilize the paramedics for the needs of the community. Paramedics would provide wound care (suturing), long term diabetes care, chronic health surveillance and treat upper respiratory infections with antibiotics. By using the treat at home method of care, the ambulance service was able to reduce transport to the hospital from 78% down to 11% (Wingrove and S. n.d.). It’s hard to imagine why a successful project failed, but they cite a few reasons, a physician assistant and nurse practitioner both started practicing in the county, reducing the need for paramedics to provide the service. They study says that the attrition rate for the paramedics was very high, making it difficult to maintain the level of service requested by the county. The final reason for closing the program was a lack of community awareness of the services provided by the paramedics. The Red River Project may not have been successful, but it still provides valuable data for advancing community paramedicine. The project suffered from poor public awareness and alternate family practice options arriving in the county.
The Canadian Province of Nova Scotia developed a community paramedic program which serves as a template for many similar programs being developed in North America. Born out of necessity, the communities of Long and Brier Islands had only one doctor who retired in 2000. The closest hospital was fifty minutes away, and required two ferries to get to the hospital. There was no ambulance stationed on the islands prior to the doctor retiring. The first phase of the program implemented was to have a paramedic and an ambulance on the island for emergency response. During the second phase, the paramedics provided flu shots, blood pressure checks and health clinics for the residents. The third and final phase was adding a Nurse Practitioner to the staff, allowing paramedics to expand their role, provide wound care and become involved in preventative education, such as fall prevention. A community liaison committee made recommendations to increase the role of the paramedics by adding blood draws, congestive heart failure assessments, administration of antibiotics, urine analysis, diabetes assessment, and medication compliance. The island residents could access the community paramedics in three ways. First was the patient or the family of a patient could request a visit from the community paramedics, a family physician could request the service as a follow up, or the nurse practitioner could refer patients directly to the service. The community paramedic program reduced visits to the emergency department by 23% (Community Paramedic, Program, Programming and Rural Health Delivery: A Nova Scotia Success Story n.d.), saving the residents from two hour round trip rides for minor procedures. The community paramedic program on Long and Brier Islands is so successful Nova Scotia is implementing the program in other counties in the province.
Wake County EMS in North Carolina uses a similar program, called Advanced Practice Paramedic (APP) that started operation in January of 2009. Within any EMS system, certain portions of the population require the services of the paramedics more; those people are called super users. The APP program was a response to super users who did not need transportation to an emergency room, but could benefit from alternate treatment modalities. The Advanced Practice Paramedics focus is to minimize or reduce medical crisis for people with specific medical conditions. Currently they are focused on diabetes, hypertension (high blood pressure), congestive heart failure, fall risks, substance abuse and children with asthma. Advanced Practice Paramedics can schedule meetings with patients to help them with medication compliance, or assess their needs. The Wake County EMS system also uses the APP in an emergency role, providing a higher level of care and extra hands on scene. The APP can arrange for transportation to alternate facilities, and in some cases even arrange admission to those facilities for behavioral or substance abuse problems.
The National Health Service (NHS) in the United Kingdom is also developing a program for paramedics trained beyond emergency care. The NHS Specialist Paramedic has been in service in the North East Ambulance Trust since 2006. As of September 2009, there were 720 Specialist Paramedics in England. The Specialist Paramedics are very successful at finding appropriate care pathways other than the emergency department. They have reduced the number of patient transports to the emergency departments by 50% – 66% (Association of Ambulance Chief Executives (GB) 2011). The Association of Ambulance Chief Executives published a report in June 2011 recommending that the clinical training for Specialist Paramedics be designed around the needs of the community served. They also recommended that more ambulance clinicians take routine assessments of patients in their homes, in partnership with the primary care team.
Fort Worth, Texas’s Area Metropolitan Ambulance Authority (MedStar) has a very successful Advanced Paramedic Program in place. Started in 2009, the Advanced Practice Paramedics identify super users of the 911 system, as well as congestive heart failure patients. The program has reduced the average monthly call volume from 342.3 to 143.3 (Agency for Healthcare Research Quality 2012). They have also saved the patients over $900,000 by not transporting them to the emergency department. The burden on the emergency room has also been eased by freeing up more than 14,000 bed hours, to be used by true emergencies (Agency for Healthcare Research Quality 2012).
Several other states, countries, and provinces are starting programs designed to bring the care to the patient using paramedics. The state of Maine just passed a bill, which was signed by the governor, allowing up to 12 community paramedic pilot programs in the state.
The major issue in every aspect of health care is reimbursement and community paramedic programs are no different. The traditional reimbursement model in EMS is bill for transport, if the patient was not transported to the emergency department, then the EMS agency cannot bill the insurance. Two important strides forward have been made in recent months. Minnesota House of Representatives passed an amendment to statute 2010 256B.0625. The bill, H2060, will allow community paramedic programs to bill insurance companies for services rendered. This is a large step forward for funding community paramedic programs and state level recognition that a community paramedic is a health care provider.
Western Eagles County EMS, in Colorado has formulated a different method. Their community paramedic program is registered with the state as a home health agency, allowing them to bill for services rendered, just like visiting nurses and other home health agencies.
Nursing organizations and physician assistants might feel like the community paramedic program overlaps with services they already provide. The goal of community paramedic is not to take jobs away from these professionals, rather to supplement those services and work with general practitioners, especially in the public health sector to provide health care services to those in need.
Where do we go from here?
The EMS agenda for the future provides a framework for the direction in which EMS systems should be heading. The community paramedic concept achieves many of the goals set forth by the EMS agenda for the future.
Educational standards for EMS professionals in the United States vary widely between states, counties and even the cities. A unification of the educational standards should also be implemented. The United Kingdom, Australia, and Canada all require paramedics programs to be through the university. Paramedics are one of the most respected professions in United Kingdom and Australia, and among the least respected in the United States. I propose the United States take similar actions and have paramedic programs be an associate level degree, and the community paramedic level be a bachelor level degree. Most certificate paramedic programs are 1,100 to 1,500 hours in length, about 35 to 44 credit hours. An associate degree is normally 62 to 66 credit hours (Hseih 2012), by finishing a paramedic program you are two thirds of the way through an associate degree. By raising the educational standards for paramedics and providing an additional four year degree option with a community paramedic program the career options for EMS personnel will not stagnate, as they are currently.
Workers in the EMS career field suffer high attrition rates. Burn-out is very common in EMS with the average paramedic remaining in this career for only five years. Licensed paramedics have very few career options in the current EMS system. With no clear career path, paramedic retention can be difficult causing workers wishing to forward their education going on to nursing programs, while others leave the medical field all together. Licensed paramedics have very few career options in the current EMS system. A community paramedic level of licensure will enhance the career options for senior paramedics and those who wish to advance their medical knowledge, without having to leave the EMS field.
Many people debate whether EMS is health care or just public safety, like fire departments and police departments. I believe that Emergency Medical Service systems are both public safety and public health, and should exist as an entity in both. Preventative programs like Child Safety Seat inspections, blood pressure checks, blood glucose monitoring, fall prevention and community CPR classes can all be done immediately, with no need for increasing scope of practice. These programs can be implemented tomorrow by any service willing to shift their focus from transportation to health education. Many EMS agencies are already providing service similar to public health departments, but many are not operating in cooperation with their department of public health.
EMS chiefs and medical directors are hesitant to increase the scope of practice for the paramedic. The Community Paramedic program is not intended to make drastic increases in the scope of practice, but rather to increase the role of the paramedic within the community. With additional education, the community paramedic can evaluate existing conditions, advise patients on possible medication interaction issues and provide preventative screenings using skills that are already available to the paramedic. As you saw above, some programs have decided to increase the scope of practice to include wound treatment, suturing and antibiotic prescription. EMS agencies should survey their population and, in conjunction with the department of public health, identify areas where high risk patients could benefit from preventative interventions. . By expanding the role of paramedics in to public health, they can affect positive outcomes on the populations they serve. Community Paramedicine should be the vision for tomorrow, not ten years from now, but tomorrow.
Paramedics are underutilized, highly skilled, health care professionals. Raising the educational standards to the university level, can help ensure that everyone gets the same education and provide a pathway to career advancement within EMS. The gap between the aging population, and decline in general practitioners will only increase. Community Paramedic will fill this void, by extending the physician services to the door step of those in need.
Agency for Healthcare Research Quality. Innovations Exchange. January 18, 2012. http://innovations.ahrq.gov/content.aspx?id=3343 (accessed April 2012).
Alaska CHAP. Alaska Community Health Aide. http://www.akchap.org/html/home-page.html (accessed April 2012).
Association of Ambulance Chief Executives (GB). “Taking Healthcare to the Patient 2: A Review of 6 years’ Progress and Recommendations for the Future.” International Roundtable on Community Paramedicine. June 2011. http://www.ircp.info/Portals/22/Future/Taking%20Healthcare%20to%20the%20Patient%202.pdf (accessed March 2012).
Bowman, R. MD. Why Nurse Practitioners Are No Longer Primary Care Solutiuons. http://www.ruralmedicaleducation.org/basichealthaccess/Why_NP_Primary_Care_Solution.htm (accessed April 2012).
Center for Disease Control and Prevention. National Diabetes Statistics. 2011. http://diabetes.niddk.nih.gov/dm/pubs/statistics/index.aspx#fast (accessed April 2012).
“Community Paramedic, Program, Programming and Rural Health Delivery: A Nova Scotia Success Story.” International Roundtable on Community Paramedicine. http://www.ircp.info/Portals/22/Downloads/Expanded%20Role/Feb%2020%20NS%20Presentation.pdf (accessed 2012).
Fahs, I.J., and L.O. Peterson. “The Decline of General Practice.” Pub Med. April 1968. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1891041/?page=4 (accessed April 2012).
Hseih, A. Why a degree is a must for today’s paramedic. April 10, 2012. http://www.ems1.com/ems-products/education/articles/1269674-Why-a-degree-is-a-must-for-todays-paramedic/ (accessed April 2012).
Joint Committee on Rural Emergency Care (JCREC). “State Perspectives Discussion Paper on Development of Community Paramedic Programs.” National Organization of State Offices of Rural Health. December 2010. http://www.nosorh.org/resources/files/community_paramedic_programs.pdf (accessed March 2012).
Lynds, J. New Community Paramedic Law Looks to Improve Health Care, Cut Costs. April 05, 2012. http://bangordailynews.com/2012/04/05/news/aroostook/new-community-paramedicine-law-looks-to-improve-health-care-cut-costs/ (accessed April 2012).
McGinnis, K. “Rural and Frontier EMS Agenda for the Future.” International Roundtable on Community Paramedicine. 2004. http://ircp.info/Portals/22/Future/RF%20EMS%20Agenda%20for%20the%20Future.pdf (accessed March 2012).
Misner, D. “Community Paramedicine: A Part of an Integrated Health Care System.” International Roundtable on Community Paramedicine. http://www.ircp.info/Portals/22/Downloads/Expanded%20Role/Community%20Paramedicine.pdf (accessed March 2012).
National Highway Traffic Safety Administration. “EMS Agenda for the Future.” August 1996. http://www.nhtsa.gov/people/injury/ems/agenda/emsman.html (accessed March 2012).
O’Mera, et al. “The Rural and Regional Paramedic: Moving Beyond Emergency Response.” International Roundtable on Community Paramedicine. March 2006. http://www.ircp.info/Portals/22/Downloads/Expanded%20Role/The%20Rural%20and%20Regional%20Paramedic%20Moving%20Beyond%20Emergency%20Response.pdf (accessed March 2012).
Pearce, C., and K. Hegarty. “The Decision to Enter General Practice.” Austrailian Family Physician 13, no. 12 (2002).
Rowley, T. “Solving the Paramedic Paradox.” Rural Health News 8, no. 3 (2001).
Shaddock, D. “Toronto Emergency Medical Services Community Medicine Program.” International Roundtable on Community Paramedicine. http://www.ircp.info/Portals/22/Downloads/Expanded%20Role/Shaddock-Toronto.pdf (accessed March 2012).
Wake County EMS Advanced Practice Paramedic. http://www.wakegov.com/ems/staff/app.htm (accessed April 2012).
Wang, H. “Community Paramedicine.” International Roundtable on Community Paramedicine. January 2011. http://www.ircp.info/Portals/22/Downloads/Research/Community%20Paramedicine%20Summary%20of%20Evidence%20-%20Hui%20Wang%20%202011%20January%2028.pdf (accessed March 2012).
Wingrove, G., and Laine S. “Community Paramedicine: A New Expanded EMS Model.” International Roundtable on Community Paramedicine. http://www.ircp.info/Portals/22/Downloads/Expanded%20Role/NAEMSE%20Community%20Paramedic%20Article.pdf (accessed March 2012).
Wright, D. “Expanding Ambulance Care for the Elderly: An Investigation into Models of Extended Care Paramedic Programs in Canada and the United Kingdom.” International Roundtable on Community Paramedicine. August 2008. http://www.ircp.info/Portals/22/Downloads/Expanded%20Role/Doug%20Wright%20Churchill%20research.pdf (accessed March 2012).