Pinch Hitting

Doctor shortages in rural America have paramedics stepping up to the plate when needed.

Three years ago Robert's diabetes was so severe doctors planned to amputate his leg. But because Robert lives in Minnesota, one of the first states to launch a community paramedicine program, emergency medical technicians got involved. Three times a week they stopped by to care for his wound, share diabetes management tips and evaluate his overall health.

Today Robert still has his leg and credits the North Memorial Medical Center's community paramedics for saving it.

"He loves us," says Community Paramedic Supervisor Peter Carlson. "He welcomed us from the beginning. He's happy to see us and offers us candy. And we provide care, propping him up literally and figuratively."

Beyond Emergencies

Community paramedicine systems are popping up in Colorado, Maine, Minnesota, Missouri and Nevada to provide health care where few services exist. Often, they save money for patients, hospitals and insurance companies, mostly in avoided costs. A leg amputation, for example, costs around $76,000. That's about what it would cost to fund community paramedic home visits to Robert for 11 years. Minnesota reported that because of the paramedicine program there, Medicaid providers serving 100,000 residents spent $10.5 million less in 2014 than analysts projected they would.

Community paramedicine broadens the role of emergency responders beyond the traditional paramedic training that has existed since the 1970s and that focuses on stabilizing patients as they are transported to hospitals. Community paramedics can perform health assessments, monitor chronic diseases, ensure patients use medication correctly, give vaccinations and follow up after hospital discharges. They are also a great source of information and help educate patients on the care and treatment of their illnesses, injuries and diseases.

"Paramedics are highly trained, highly regarded, trusted health care providers in their respective communities," says Nevada Assemblyman James Oscarson (R), whose bill authorizing and regulating community paramedicine services was signed into law in May. "Community paramedics will have an expanded role in health care, not an expanded scope. Now they can complement the services of the other health care professionals in the health care system."

A Rural Lifeline

Community paramedics usually work in rural and isolated areas where physicians are scarce. Patients are often from underserved populations, meaning they are typically, but not always, low-income, elderly people. In Minnesota, community paramedics are specifically trained to care for patients who visit hospital emergency departments frequently, are at risk of needing nursing home care or are close to being readmitted to a nursing home or hospital.

The growing number of community paramedics reflects a larger demographic shift. Only 15 percent of the country's population lived in rural counties in 2014, according to the Department of Agriculture.

"Thirty years ago there were more health professionals in rural areas, there were more volunteer firefighters and EMTs, and the rural population was younger and healthier," says Gary Wingrove, president of The Paramedic Foundation, using the common abbreviation for emergency medical technicians. Today, there are fewer health facilities, fewer qualified people to work in them and fewer resources to fund them. Increasingly, community paramedics are stepping in to help fill that gap.

The Rural Assistance Center, part of the U.S. Department of Health and Human Services' Rural Initiative, reports that rural Americans suffer from higher rates of chronic illnesses and worse health overall than city dwellers. They are less likely to have employer-provided health care coverage, or to be covered by Medicaid even if they qualify for it. They seek treatment in hospital emergency rooms and call 911 for non-emergency situations-a costly practice. Nearly 80 percent of adults who visited emergency departments did so because they didn't have access to other providers, according to a 2012 report on emergency room use from the Centers for Disease Control and Prevention.

"Basically we are taking the resources that already exist in a community and expanding upon them to offer broader health care coverage," Wingrove says. "The specifics of how these programs operate depend on the communities they serve."

Who Pays?

Providing these services, however, isn't free. Pilot programs have used grant funds from foundations and the federal government to cover costs. Some hospitals that own ambulance services, in places such as North Carolina and Missouri, have started funding programs in hopes that the savings from fewer readmissions will cover the added costs. Elsewhere, local agencies fund emergency medical services for their communities, absorbing the added costs in their budgets with slightly higher fees.

The additional costs come from the advanced training community paramedics must receive and the higher salaries they earn for their education and additional time spent on community services. In advanced training they learn higher level health concepts such as the social determinants of health. When working with an elderly person, for example, community paramedics ask, Does the patient own a car? Can the patient walk? If the answer to both questions is no, how is the patient getting prescriptions? Such determinants can make a difference in a person's health.

Community paramedics with advanced training may earn about 10 percent more than traditional EMTs. But in many cases, employers pay for the additional training without offering greater compensation.

Minnesota created its new community paramedic profession in 2011. To earn a community paramedic certificate, a person must hold an emergency medical technician- paramedic certification, have worked two years as a full-time EMT-P and have graduated from an accredited EMT course.

Minnesota reimburses community paramedic services through Medicaid. It was the first state to use a Medicaid payment and delivery system that shares savings and risks directly with provider organizations. To qualify for Medicaid reimbursement, the services must be ordered by the recipient's primary care provider and include monitoring blood pressure, assessing fall risk, setting up medication profiles and delivery, and coordinating care, referrals and follow-up.

Nurses, Doctors Have Concerns

Nurses and home health care groups throughout the country have expressed concerns that the expanded paramedic role infringes on the duties of their respective professions.

The American Nurses Association initially lobbied against Minnesota's program because of the overlapping patient care responsibilities. The nurses argued that since patient-centered care coordination is a core professional standard for registered nurses, they are the best prepared to treat underserved, rural patients.

The nurses' association listed a set of principles for the community paramedicine industry to adopt and follow in order to gain its support. They included establishing minimum standards of education, clarifying roles between community paramedics and nurses and fostering interdisciplinary cooperation through appropriate regulatory models.

Minnesota community paramedic leaders agreed and still adhere to the nurses' principles.

Colorado Senator Leroy Garcia (D) works as a paramedic and as an emergency medical services instructor at his local community college. As in Minnesota, paramedics in his community work with primary care doctors to care for residents in need.

Paramedics are involved from the minute a person dials 911. Current law allows them, in certain situations, to treat callers with a simple medication and a professional's reassurance that the patients will be fine until they can visit the doctor. Paramedics can even help set up the appointments.

"We can provide people the care they need without the expense and inconvenience of going to a hospital. They can recover comfortably at home, and it's a more personal connection," he says.

Garcia plans to draftlegislation to develop the community paramedicine profession further in Colorado. The success of these programs hinges on the ability to tailor them to a community's needs, he says. The needs of a Vail ski resort community, for example, are very different from those of a small agricultural area.

"That is one of the challenges in creating legislation," Garcia says. "You don't want it to be so specific that it is limiting. You want it to be adaptive. This is a dynamic profession that needs to have some flexibility, especially as it develops."

Multifaceted Approach

In Nevada, where Oscarson's community paramedicine bill was recently signed into law, the program's multifaceted health care approach is designed to address rural and urban populations in very different ways. The bill:

* Allows licensed ambulance, air ambulance or firefighting agencies and certified personnel to qualify for an endorsement on their permits to provide community paramedicine services.

* Enables legislators to review how Nevada community paramedicine programs are addressing health care gaps in rural and urban locations throughout the state.

* Requires paramedicine departments to submit quarterly reports to the state outlining the services they provided and the estimated health and economic benefits of those services. Nevada's health department will summarize the reports and submit them to the Legislature and the Legislative Committee on Health Care.

Oscarson hopes the data collected will result in a compelling argument for a state reimbursement component for community paramedicine in the future. Currently, community paramedics are paid by their governing agency, Oscarson says. In turn, those agencies submit data to regulatory bodies, such as the Nevada Division of Public and Behavioral Health emergency medical services office, with the objective of demonstrating cost savings.

"Agencies do this because it is the right thing to do as health care delivery changes based on the Patient Protection and Affordable Care Act of 2010," Oscarson says. The idea is to not put an hourly, monthly price on community paramedicine, but to determine a value based on savings in order to eventually pursue a reimbursement system.

"Community paramedicine and EMS as a whole are gaining a seat at the health care table," Oscarson says. "These programs have the ability to improve health care for the future because they navigate patients to the appropriate resource at the appropriate time, rather than to the highest cost entry point of the health care system-the emergency room."

Typical Training Requirements

A high school diploma or equivalent and CPR certification are prerequisites for most emergency medical technician and paramedic training programs. Most licensing requirements, which vary by state, require the following:

EMT

Skills include determining a patient's condition, handling trauma and cardiac emergencies, clearing obstructed airways and using field equipment. Courses include about 150 hours of specialized instruction. Some instruction may take place in a hospital or ambulance setting.

Advanced EMT

Programs typically require about 300 hours of instruction, based on the scope of practice. At this level, students must complete more advanced requirements, such as using complex airway devices and administering intravenous fluids and some medications.

Paramedic

Paramedics earn the highest level of education, completing EMT and Advanced EMT training along with courses in advanced medical skills. Paramedics' scope of practice may include stitching wounds or administering IV medications. Programs typically are offered at community colleges and technical schools and require about 1,200 hours of instruction, which may result in an associate degree.

Sources: U.S. Department of Labor's Bureau of Labor Statistics and the National Registry of Emergency Medical Technicians.

"Community paramedics will have an expanded role in health care, not an expanded scope."

Nevada Assemblyman James Oscarson

"We can provide people the care they need without the expense and inconvenience of going to a hospital."

Colorado Senator Leroy Garcia

Michelle Ancell is a freelance writer based in Denver.