Lack of access to primary health care has been well documented as a contributor to problems ranging from poor health to a misuse of EMS. In rural Eagle County, Colo., the problem had reached epidemic proportions: A 2005 community health assessment found 46 percent of residents of the Western Eagle County Ambulance District were uninsured, compared to about 17 percent throughout the rest of Colorado. About 38 percent had problems accessing medical care, while 80 percent of all emergency room visits were for primary care issues.
Though many of Eagle County’s 55,000 residents are employed, many work at restaurants and ski resorts and in other service industries that do not offer affordable health insurance. Nor are most workers eligible for Medicare or Medicaid, says Christopher Montera, chief of Western Eagle County Ambulance District.
Montera was determined to help find a solution. For the past 15 months, he’s worked closely with the Eagle County Public Heath Department to develop what experts are calling one of the nation’s most promising community paramedicine programs. Through the program, specially trained paramedics are sent by physicians into patients’ homes to provide such care as making sure they are taking their medications properly, helping with blood sugar monitoring and administering vaccinations.
Community paramedics also work as prevention specialists, helping with elderly falls prevention, connecting residents with social services, making sure they have a safe home environment with heat and sufficient food, as well as making sure they have a primary care doctor and regular source of medical care, or medical home, for future primary care needs.
Launched as a five-year pilot program and paid for by $500,000 in grants from the Colorado Department of Health and other sources, the Ambulance District’s new community paramedics began seeing patients in September and hope to see as many as 1,500 patients a year. “We are not only looking at this as what’s right for patients, but as being part of the solution for health care in the future,” Montera says. “One of our big tenets is that everything we are doing is 100 percent physician-ordered. We are becoming the eyes and the ears of the physician in the home.”
Beyond 911 and into communities
Western Eagle County Ambulance District’s community paramedicine program is the latest in a long line of attempts to move paramedics beyond just responding to 911 calls. Over the past three decades, efforts to establish community paramedicine programs, sometimes referred to as advanced practice paramedicine, have proceeded in fits and starts.
One of the best known was the Red River Project in New Mexico. Hailed in the ’90s as the future of EMS, the program had fizzled by 2000 after a report by researchers from the University of New Mexico School of Medicine found that it was not working as intended, says William Raynovich, a professor of EMS at Creighton University in Omaha, Neb., and a co-author of the report. Among the concerns: physicians saying they were asked by paramedics to prescribe medications for patients they had not examined; charts that showed paramedics providing “substandard” care and violating medical protocols; and paramedics driving patients lengthy distances instead of to local clinics.
Though many factors were to blame, Raynovich says, poor oversight—not to mention a lack of community and public health department buy-in—contributed. “This was the great hope for community paramedics—the pilot, premier, gold-standard program to be the model for other programs,” he says. “Its failure set back community paramedicine for several years as people went back to the drawing board.”
Among those who went back to the drawing board was Gary Wingrove, president of the National EMS Management Association. In 2004, the National Rural Health Association’s Rural and Frontier EMS Agenda for the Future called for better integration of EMS into the rural health care delivery system. Around the same time, an ambulance service in Nova Scotia that had launched a community paramedicine program to serve residents of Long and Brier, a remote island with a population of 1,200, reached out to Wingrove and others for ideas. Those discussions led to the formation of the International Roundtable for Community Medicine, which held its first meeting in 2005 in Nova Scotia.
Among the Roundtable’s goals was figuring out what it would take for community paramedicine to be successful, Wingrove says. One conclusion was that community paramedicine should not attempt to expand paramedics’ scope of practice, a move that would almost surely be met with resistance from the wider medical community. Instead, it was suggested that community paramedics should use existing skills more fully, such as assuming the role of patient educator, prevention specialist or disease management coordinator.
For example, since paramedics were already trained to give injections, why not also have them do immunizations? Or, since paramedics could already administer medications intravenously, why not add antibiotics to that, per doctor’s orders?
Another issue was determining what types of communities are best suited for community paramedicine. According to Wingrove, community paramedicine programs will only work in rural or frontier communities that lack well-resourced public health departments and other medical services, such as after-hours urgent care clinics. Elsewhere, “you immediately become a competitor to everybody and you are almost sure to fail,” he says. “If the full array of services are available, you are duplicating efforts. If you have a home health agency, there is already a home health nurse. If there is a well-resourced public health department, they are already doing community immunizations and maybe even home health care visits. If people have ready access to urgent care, then there is less need for the after-hours care community paramedics could provide.”
While certain elements of community paramedicine can be incorporated into EMS in more urban areas, it can only work with the full cooperation of the public health department and would likely resemble some of the community outreach efforts urban and suburban departments already engage in, Wingrove adds.
The Roundtable also developed a curriculum for community paramedics that it offers free to colleges and universities, with the goal being that a degree in community paramedicine would one day be offered alongside other allied health field degrees, such as respiratory therapy and other medical technician-type jobs.
In Eagle County, Montera partnered with Colorado Mountain College to offer the curriculum, which includes more than 100 hours of coursework in internal medicine, pediatrics, primary care and public health, in addition to 100 hours of clinical time. A dozen paramedics went through the program; two were chosen to become the county’s first community paramedics.
Public health participation is key
Montera got the idea to start a community paramedicine program after hearing Wingrove speak about the topic at EMS Expo in 2008. He immediately began working to bring the public health department and the state office of rural health on board.
With their assistance, Montera began to approach physicians, including finding an indigent care clinic that would be willing to become the medical home for people without other options. While initially, all patients will be referred from the primary care setting, eventually, community paramedics will also take referrals from hospitals. To build rapport with doctors, community paramedics will spend one day a month in primary care clinics, which has the added benefit of increasing the paramedics’ clinical experience. After seeing patients, paramedics will report back to physicians regarding what services were provided, as well as what needs to be taken care of by the physician, such as medication adjustments or follow-up appointments.
While many referrals will come from elderly patients, many of Western Eagle County’s residents have young children. The community health assessment found 54 percent of third graders had cavities and 23 percent had untreated tooth decay, so community paramedics have been trained to do a basic dental exam and apply a fluoride varnish to the teeth, taking over a program that public health nurses were unable to keep up with.
At the outset, all services will be provided for free, though the Ambulance District will need an additional $1 million in grants to fund the first three years of the program. Montera is confident they will get it; several health care foundations have already expressed an interest in being involved.
Of course, significant obstacles remain, including the reimbursement system, which continues to pay EMS only for transporting patients. Western Eagle County Ambulance District has hired a researcher who will gather data in the hopes of proving that community paramedicine can improve patient outcomes and reduce costs. The research will eventually be used to make a case to the state and federal government and private insurers that community paramedicine is worth reimbursing.
There is already some evidence it can, Wingrove says. In Nova Scotia, a five-year review found a 40 percent decrease in ambulance transports to an emergency room and a 28 percent decrease in visits to the island’s sole clinic, which is staffed by a nurse practitioner, he says.
Given the health care crisis and rising health care costs, community paramedicine’s time may finally have come. “What I often say is EMS is one of the last health care entities that provides health care at the bedside,” Montera says. “What we want to do is take that from acute care to non-acute care and become an organization that is integrated into the community and involved in community health.”
