Community Paramedic Lessons From Maine

Maine Gov. Paul LePage signed a law in 2012 to implement a dozen community paramedicine programs that initially were designed to improve healthcare access in the rural areas of the state. Maine also became the first state with a state-level CP coordinator, Kevin McGinnis.

McGinnis, who is credited with coining the term community paramedicine (CP), serves as the CP chief for North East Mobile Health Services and CP program manager for the National Association of State EMS Officials. He says there were CP-like programs in existence prior to him coining the phrase in 2001, but the concept really moved forward with the 2004 release of the Rural and Frontier Emergency Medical Services Agenda for the Future.

“A lot of people read it and wanted to try it or expand what they were doing,” McGinnis says. “In 2008 we started seeing CP programs appearing by that name. In Maine we started to move toward the CP model in about 2009, with discussions about using EMS folks to work in emergency rooms. That was a practice to one degree or another around Maine prior to 2009, although they were doing nonclinical work and weren’t considered community paramedics per se. But that planted the seed in Maine.”

Maine EMS spent a year putting together some grant funds to create the CP coordinator role (a role McGinnis held for its first two years). Today he reports that several communities have been highly successful, and some are doing hundreds of calls a year.

“That parallels what’s going on in the country,” McGinnis says. “Some places have firm establishment of CP within the health system and health financing system (how to pay for the program), and many other states are farther behind.”

Surprises Along the Way

Initially, McGinnis says, they thought mostly rural communities would be interested in a CP program.

“Man, were we ever wrong about our assumptions about CP,” McGinnis says. “We thought this was going to be a mainly rural service, because it was originally rooted in the needs of rural communities. CP sought to ensure that paramedics or other advanced life support practitioners would be in rural areas when you have your major medical emergency. Those citizens are far away from most healthcare practitioners, and having some sort of primary healthcare would help people stay healthy and detect problems before they grow into major problems. We put a paramedic in a rural community so not only are they available for emergency calls, but every day they’ll do primary care types of things. It may be preventive things or for patients who have come out of a hospital stay and are at risk for readmission. That was the whole idea behind it.”

McGinnis says the CP program is indeed working in rural areas, but the surprising part is that it also has been successful in urban and suburban areas.

“The urban/suburban patient interaction volume is higher than the rural volume because there are simply more patients,” McGinnis says. “Urban programs have more different patients—for example, blood testing for a large number—but you may not see the same patients frequently. In a rural setting, community paramedics are more likely to be seeing the same patients over and over again, following the same patients’ health conditions.”

McGinnis says Maine leaders also assumed the program would not mesh with fire department-based EMS and volunteer-based EMS.

“Now, on a national level, we have many urban fire department EMS systems delivering very high-quality CP medicine,” McGinnis says. “We have many volunteer programs doing CP as well, including one in Maine. In Maine we currently have about 15 ambulance service areas served by a dozen formal programs. That’s going to increase because the legislature recently took the cap off of how many programs there can be. There are a variety of ways it’s being done. One of the underlying premises of CP is that it should fill gaps in a community’s healthcare, and because different communities have different healthcare needs and gaps, it’s going to look a little bit different in each community.”

The Maine program primarily provides house calls for basic wellness checks, follow-up care, etc.

“The different services are ordered in different ways in various communities,” McGinnis says. “In Maine it has to be a physician-ordered service, with one limited exception: patients who have fallen and call 9-1-1 in one program, those are referrals from an EMS crew if those patients don’t go into the ED. In that one case it need not be a doctor referral. Most of these referrals are follow-ups from ED visits, from primary care physicians, from other hospital health services like anticoagulation clinics. The types of checks we’re talking about here are more like if you have a chronic disease—we want to avoid it becoming so acute it becomes a hospitalizing event.”

McGinnis also says home visits can include checking to make sure diets are being properly followed, monitoring heart and blood pressure, and checking that patients are following new medication orders.

“The patient may come home with new medications, and you have to make sure there are no duplicates or conflicts with something they’ve been taking at home. And patients often don’t listen to discharge instructions while in the hospital,” McGinnis says. “Once they’re home and in a comfortable setting, they’re more open to listening to instructions. That home visit is also an opportunity for a community paramedic to do a home safety check to make sure there are no fall issues. They can also make sure there aren’t other issues hindering the patient: vision, gait, etc.”

There are no federal funding mechanisms for CP programs, so all states must find funding through grants or local investments.

“Everyone who has started a CP program in the last eight years has invested their own funds because they believed it was the right thing to do and there would eventually be money for it, either through government (local or federal) or the Affordable Care Act,” McGinnis says. “There are some ambitious ambulance services that have gotten grant funds, and some in Maine have had success doing that. But grants are short-term, and investing in your own service, you can only lose money for so long. Financing of CP is a real issue. There also has been some successful financing through Medicaid on the state level. Minnesota was the first state to get funding for CP to provide care to Medicaid patients. Nationally it’s up to the state to decide who can be authorized for Medicaid coverage.”

Still, McGinnis says he likes the progress of the CP concept.

“We’ve seen success all over the place, chiefly the fact that the communities themselves accept and value the CP concept,” McGinnis says. “Lack of acceptance was a challenge initially, but that quickly changed to acceptance by many of the stakeholders. One good example of a barrier that has come down is our relationship with home healthcare services. Home healthcare was a big concern for CP services because CP was perceived as impinging on its services. In Maine we experienced that initially, but we are starting to see services that not only work alongside home health agencies, but are actually embedded in home healthcare.”

And there have been tweaks to implementation along the way.

“The early adopters of CP used a shotgun approach: They tried anything to get patients,” McGinnis says. “A lot of those approaches simply didn’t work, so even programs that are successful today saw half of their initial efforts fail. One of the things we’ve learned nationally is that when you start a CP program, start small. If you start by trying to do too much, you’re going to have in your portfolio of services things that are not going to work and ones that work fairly easily but will suffer as a result.”

And be sure to define the need.

“The very first step in a successful CP program is to be sure that you’ve defined a real community health need—a real one, not one you perceive,” McGinnis says. “Collect the data from all your stakeholders and then make sure everyone involved in that community buys in to those numbers, because they will become your referrers, you will become the source for that service, and that will bring success.

“Another lesson is don’t grow your services too rapidly. If you’re suddenly being asked to do things that were not in your original plan, be careful what and how quickly you’re adding to your services, especially if you don’t have a financial mechanism in place.”

McGinnis says the Community Paramedic website has some excellent resources for anyone wishing to implement a CP program.

As for specific results, Jay Bradshaw, now the CP coordinator for Maine EMS, says there is a lack of data. He says the next phase is to develop a mechanism to better collect it.

Inaugural CP Conference Scheduled

Maine EMS and United Ambulance also are presenting the first community paramedic conference. The inaugural CP 360 Maine Community Paramedicine Conference will be held May 18–19 at the DoubleTree in South Portland.

CP 360 is a two-day public conference to deliver a comprehensive view of CP programs for professionals throughout the country. It is designed for professionals in various stages of community paramedicine—from those who are considering participating as a CP pilot site to those who want to grow and enhance current CP programs.

Attendees will learn about the origins of community paramedicine, current trends and topics, how to start and sustain a CP program and more. CE credit will be available.

The conference will host state and national speakers on the forefront of the CP movement, including physicians, medical directors, and education and training experts. Keynote speakers include Dr. Robert Anderson, North East Mobile Health Services CP medical director; Dr. Mike Wilcox, medical director of the CP program at Hennepin Technical College in Minnesota; Gary Wingrove, president of the Paramedic Foundation; and Kevin McGinnis, CP chief for North East Mobile Health Services and CP program manager for the National Association of State EMS Officials.

Session topics include:

• Why Community Paramedicine?
• Current Trends in Community Paramedicine
• Medical Direction of Community Paramedicine
• Community Paramedics Share Their Programs and Insights (case studies) 
• Working Together: Key Relationships for a Successful CP Program (panel discussion) 
• Developing a Community Health Assessment
• How to Develop a Community Paramedicine Pilot Project in Maine
• CP for EMTs and Other Non-Paramedics (panel discussion)
• CP Education

For more information and to register, visit www.unitedambulance.com/EducationDivisionMenu.htm.

Susan E. Sagarra is a writer, editor and book author based in St. Louis, MO.