A Nurse`s View of Community Paramedicine

From the July issue of Integrated Healthcare Delivery.

Anne Robinson-Montera, RN, BSN, received her BSN from Bethel College in Newton, KS. She has 17 years of nursing experience in public health, labor and delivery, neonatal, pediatrics, patient safety / quality assurance, and EMS coordination in urban and rural hospitals, clinic and community settings. In her current role as a public health nurse consultant, she works in grant coordination and implementation for various projects in Colorado and across the nation.

Anne is also the co-creator and public health partner for the first national Community Paramedic Pilot Program in rural Eagle, CO. Her job is to assist local and state community paramedic programs through different stages of program development, including statewide stakeholder engagement, to local agency implementation. She has also been a leader in developing the community paramedic curriculum, serves as the college instructor for the second edition of the curriculum in Colorado, and leads a team of educators and experts in developing the 3.0 version of the community paramedic curriculum.

In May 2011, she received the Colorado Nightingale Luminary Award for Innovation for my work on the Colorado Community Paramedic Program.

IHD Associate Editor Teresa McCallion recently spoke with Anne about community paramedicine and how EMS and nurses can work together.

Q: How does the Colorado Community Paramedic Program work?

A: The five-year pilot project was launched in 2010 as a collaborative effort between Eagle County’s Public Health Department and the Western Eagle County Ambulance District (WECAD) to provide better, more cost-effective access to essential healthcare services. As part of the community paramedic model, patients are referred to emergency medical services (EMS) personnel by their primary care physician to receive services in the home, including hospital discharge follow-up, blood draws, medication reconciliation and wound care. The program, the first of its kind in the state, initially served individuals within the WECAD district, which encompasses 1,100 square miles in western Eagle County and eastern Garfield County. Since then, the ambulance districts merged, creating Eagle County Paramedic Services and allowing all residents and visitors of Eagle County to receive access to the program. Read more at https://eaglecountyparamedics.com.

It made sense for the rural area because many of the most vulnerable patients live miles away from the hospital, where it can be difficult or costly for them to find transportation for regular visits or routine checkups.

The program is required to hold a home care license with the state. We were able to obtain a conditional license, but it’s rare that states require that. Part of the difference is that, in Colorado, EMS agencies are licensed at the county level, not state.

There currently is no community paramedic designation in our state laws, so we are preparing to introduce a bill in the next legislative session to make that change. We are continuing to build partnerships and look forward to full support in the 2015 session.

Q: In your opinion, why is there animosity between nurses and community paramedic programs?

A: In those instances where there is friction, it often comes down to a lack of understanding. Most healthcare professionals in general and nurses in particular don’t understand how EMS works in the first place. Five years ago, when I worked in public health, I had to ask, “What’s the difference between an EMT (emergency medical technician) and a paramedic?” I did ride-alongs to see how EMS managed patients and learned that both EMTs and paramedics respond to medical and traumatic emergencies in the prehospital setting. However, there is a big difference in amount of education and scope of practice. An EMT is trained to provide basic-level life support. Although it can differ state to state, EMTs can perform CPR, administer glucose, assist with inhalers, perform spinal immobilization, apply splints and take vital signs. Paramedics receive considerably more education in order to provide advanced-life support care, including advance airway management, endotracheal intubation, IV fluid therapy, surgical airways and administer an array of critical care medications. Both providers are required to maintain their skills through on-going training and drills.

Part of the confusion arises because the naming conventions and scope of practice are inconsistent throughout the country. EMS grew organically in the 1970’s to address specific community needs. A number of professional EMS groups are working to come up with a consistent name. That will help. Other parts of the world, including Canada and Australia, have decided to call all EMS providers paramedics—similar to calling a nurse a nurse. Within that designation, there are variations depending on the level of education and scope of practice.

Q: How do nursing and EMS overcome these misunderstandings and ensure teamwork?

A: When EMS is asking for a seat at the table, nursing is asking if they even need a seat at the table. That’s not helpful. On the other hand, EMS is building community paramedic programs within their own silos thinking that if they can make the program work, everyone will be okay with it. It doesn’t work that way and the programs inevitably fail.

When initiating a community paramedic program, stakeholder engagement is key. Engage the nurses from the beginning. Meet them face-to-face. That means at the local and state level. Even if the local stakeholders are onboard, a program can still be killed if the state nursing and state hospital administrators are not included early on in the project design.

It may take some time. You have to educate people first. One helpful document is the recently released Guiding Principle published by the American Nurses Association called Essential Principles for Utilization of Community Paramedics. See www.emsworld.com/11499425.

Once you have a nurse champion, you have entrée into the rest of the healthcare system and a better understanding of how it works.

Don’t forget to embrace the rest of the EMS community as well, including those within your own EMS service. Bring them in on the plan. It’s not for everybody, but everybody needs to understand what it is.

Q: You mentioned interdisciplinary team work. How does that work in the community paramedic model?

A: This is probably the biggest challenge for the nursing profession. Everyone is concerned about overlapping roles as if that is a bad thing. There are going to be overlapping roles. Instead of fighting that, we should be working together to achieve an interdisciplinary concept. Some functions need to work with nursing.

When an EMS agency is considering a community paramedic program, the first step must be to conduct a needs assessment or gap analysis to determine if there is an actual need for the program. If so, how would it work in their community? Where are the gaps in service and how would a community paramedic fill those gaps? Approach the nurses with a plan to help provide a recognized need goes a long way to getting their approval. They might even appreciate the help.

The community paramedic programs that have not succeeded are the ones that have taken a cookie-cutter approach. You can’t transplant a successful program from elsewhere. The community’s needs may not be the same.

Give it time to be successful. The overriding consideration must be patient outcomes and patient safety. Don’t let anyone push to ramp up a program just to have one.

Q: What are the primary concerns the nursing profession has regarding community paramedics?

A: A significant concern is that community paramedics don’t have the appropriate education and training to do this work. While, education programs have been growing in size and number, they need to look similar to national standards for critical care paramedics, flight paramedics and technical paramedics. (See the Board for Critical Care Transport Paramedic Certification at www.bcctpc.org.) At the national level, the Paramedic Foundation is taking the lead. See www.paramedicfoundation.org.

In our program, we learned that this was a top priority and worked to evolve a curriculum that is based in a college or university. Some paramedics don’t have a college degree. We determined that this college level course is necessary for the type of critical thinking needed for a community paramedic. Where a paramedic needs to know how to respond to a particular illness or trauma—stabilize, treat and transport the patient—a community paramedic must ensure an appropriate support system once the patient has returned home, review medication, understand why the patient became ill or injured in the first place and look for ways to prevent future hospitalizations.

In order to get the respect and buy-in from nursing those education pieces need to be in place. Frankly, I think we are going to change the industry. The paramedic course of the future is going to evolve because of community paramedic programs.

Q: Are there other concerns?

A: Patient record-keeping is a challenge. EMS has been limited by system design. Because they are only reimbursed for each transport, they record each transport as a separate patient encounter. When they see a patient five times in one month, there are five separate patient care records. When a hospital or physician sees a patient five times, each visit gets added to a single patient record.

The ultimate goal is patient safety. But it’s going to take a change in the reimbursement model for EMS to make significant changes in record keeping.

Q: What about other data collected?

A: The way EMS has tended to collect data is to document performance indicators, such as whether or not aspirin was given to a patient with chest pain, rather than track patient outcomes. In Colorado, we recently published 18 months of patient data on the community paramedics program. It is closer to the type of information that needs to be gathered by all of EMS. For example, did community paramedics affect change, including avoiding a hospital readmission? We need to prove that what we are collecting is the right thing so we can standardize it.

Q: What role do physicians play in community paramedic programs?

A: Our push is to ensure that the medical directors who oversee these programs have some experience or background in primary care or public health. Typically, medical directors for an EMS agency are emergency department physicians. Because of the clinical component of their education, the community paramedics will need this added experience from the medical directors. The American College of Emergency Physicians (ACEP) is in support of this effort and recommends co-medical direction. This is going to push the envelope to require some medical directors be more hands-on involved.

Q: What will community paramedicine look like in the future?

A: Like EMS, that will depend on the community it serves. Regardless of the EMS delivery system—fire-based, hospital-based, third party, privately-owned, volunteer—all EMS agencies will need to consider these recommendations to launch a successful program. Ultimately, the programs that work alongside the rest of the healthcare community will succeed. Healthcare is going to filter them.

Q: Looking back on the last five years of the community paramedics program in Colorado, do you have any advice for others looking to start a similar program?

A: Innovation is hard. It’s tough to have people coming at you. My advice is to stay strong. Don’t take the easy way out. In the end, the right way will be the standard. The challenge is getting there.

Teresa McCallion, EMT-B, is the managing editor of Integrated Healthcare Delivery.