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Care for underserved communities

Published (4/8/2011)
By Hank Long
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Dr. Michael Wilcox knows the joys and the struggles associated with providing health care to a rural community. After 40 years of practice in southern Minnesota, he believes he’s found an innovative way to utilize often underused resources to care for often underserved populations.

They are called “community paramedics.” Currently, only a handful are working in the state.

Almost two years ago, about a dozen paramedics from the Mayo Clinic, North Memorial Health Care and the Mdewakanton Sioux EMS completed a pilot course that provided 150-200 hours of classroom along with 28 hours of on-the-job training under the supervision of a mentor.

The community paramedics would focus on service for populations with regular health care needs who don’t have regular health care access. Under the guidance of an ambulance medical director, the paramedics would be able to monitor and provide some treatment to patients with chronic disease and perform minor procedures intended to prevent ambulatory or emergency room services.

Wilcox, the medical director for the Scott County-based team that includes community paramedics, a public health nurse and nurse practitioner, hopes the pilot program can serve as a model for expanded use of community paramedics to other rural and underserved populations throughout the state.

“We have a problem in access to health care in our rural communities,” Wilcox told the House Health and Human Services Reform Committee in February. “And this access to health care is becoming especially more problematic as we age and as we have more immigrant folks and culturally diverse folks that tend to gravitate to these rural areas, along with a large number of folks who are uninsured.”

Legislation curbs ‘frequent flyers’

Program advocates say it also helps address the ever present problem of “frequent flyers,” a term coined by those in the emergency medical services industry to describe people who inappropriately use ambulance services and hospital emergency room resources by calling on them often, many times when they may not be needed.

“The community paramedic can come out and sit down with the person, do an interview, find out what’s going on and assess the situation, which sometimes ends up not being a true emergency,” said O.J. Doyle, a lobbyist for the Minnesota Ambulance Association. “What these community paramedics can do is help plug these ‘frequent flyers’ into the local public health setting. They are working to plug their fingers in the holes of the health care delivery system dike.”

Sponsored by Rep. Tara Mack (R-Apple Valley) and Sen. Julie Rosen (R-Fairmont), HF262/ SF119* would create a new statewide “community paramedic” definition that would aim to curb the problem that advocates say is burdening precious ambulatory and hospital emergency room resources across the state, especially in smaller communities.

The bill, awaiting gubernatorial action, would allow experienced paramedics in communities to undergo 120 additional hours of training to become certified by the Emergency Medical Services Regulatory Board as “community paramedics.” The Minnesota State Colleges and Universities system recently approved the accredited training program that would teach and certify paramedics as “community paramedics” at its various schools.

The legislation would require the human services commissioner, in consultation with representatives of emergency medical service providers, physicians and local public health agencies, to determine specified services and payment rates for community paramedics. Services provided by community paramedics would be covered by Medical Assistance.

First of its kind

Program proponents call it an innovative approach in health care reform, saying it represents a first-of-its-kind legislation that actually provides a funding mechanism and incentive for providers to use the model in their health care services.

Various forms of the pilot program used in Scott County are also being used in other states, including Colorado, North Carolina, Wisconsin and Nebraska, but Minnesota would be the first state to have an official “community paramedic” definition and an accredited certification program, said Buck McAlpin, a lobbyist for North Memorial Health Care, who also serves on the Minnesota Ambulance Association.

“The ambulance association supports this program and we decided that we wanted to formalize the community paramedic role,” said McAlpin, a longtime paramedic. “We wanted to be sure our people were certified, that they completed their training so that the EMS board can formally regulate the certification process.”

An obvious benefit of the program is the MA reimbursement for community paramedic services that providers would receive, which in turn would help an EMS industry that struggles to stay financially healthy in rural communities, Doyle said. He estimates that between two and three rural ambulance services close every year around the state because of inefficiency in the health care delivery system.

Concerns over expanded role

The Minnesota Nurses Association has expressed concern about how the integrated role of community paramedics would impact the services that nurses provide to patients in clinics and emergency rooms.

Association President Linda Hamilton said the position is “public health nursing without the nursing license.”

The association is concerned that community paramedics will not have “adequate training and background to do chronic disease monitoring and treatment,” she said, which could pose a threat to the practice of nursing and a risk to patient safety.

“We believe that chronic disease monitoring is outside this role of a community paramedic and it should be further studied,” she said.

Rep. Steve Gottwalt (R-St. Cloud) praised the legislation as an appropriate measure for getting basic care in rural areas where people are “crying for more and better primary care.”

“This is not something meant to be in opposition to nurses or other groups providing care,” he said. “It’s meant to provide a very necessary piece of the puzzle to help people live healthier in rural communities.”

The original language of the bill, which stated that community paramedics must consult with a physician who oversees the program, was amended to include language that states programs may include the consultation of a public health nurse.

“Nurses have expressed concerns, and I share their concerns, about paramedics in this role regarding their educational preparation,” said Rep. Erin Murphy (DFL-St. Paul). “But I also have concerns about the availability of health care providers in rural and underserved Minnesota.”

Murphy, who supports the bill, said she hopes work ahead on the issue includes conversation about increasing resources for public health nurses in rural communities.

Wilcox said the community paramedic program makes logical sense for all players involved in the health care system.

“We talk about utilization of our health care resources within our communities, and there is absolutely no reason at all why these EMS providers, between 911 calls, why they couldn’t actually go out and do health care for folks who are in need.

“This program is looking at a different way we can utilize our resources we have to their fullest extent.”

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