For nearly 70 years, residents of Jackman, Maine, and the
greater Moose River Valley region had found
round-the-clock medical care on Jackman's Main Street.
While the faces and facilities changed over the years
— from a house-turned-hospital opened by nuns,
to a hospital and nursing home run by one of the state's
largest health systems, to the Federally Qualified Health
Center that exists today — one thing remained
consistent: the promise that treatment would be available
24 hours a day, seven days a week.
So when staffing challenges left the Jackman Community
Health Center (JCHC) at risk of being unable to continue
offering urgent care after hours and on weekends
— leaving residents with no other alternatives
than the nearest hospital, an hour away —
healthcare providers in the region knew they would need
to find a solution close to home.
“It very quickly became clear that while
primary care needs were being met, the center did not
have a sustainable model for after-hours care,”
said Dr. Jonnathan Busko, medical director of the
emergency department at St. Joseph Hospital in Bangor.
“And it was something the community really
Enter the Critical Access Integrated Paramedics (CAIP)
program, a new initiative that lets specially trained
paramedics from across Maine take shifts staffing
Jackman's health center after hours and on weekends. The
program, which was designed and developed through a
series of community meetings and discussions, allows the
paramedics to perform basic urgent care procedures and
connect with emergency department physicians at St.
Joseph Hospital for telehealth visits — while
also raising the level of emergency medical services
(EMS) available in the Moose River Valley. As an official
pilot project for the statewide Maine EMS bureau, the
program offers a potential model for rural communities
across the state looking to fill similar gaps in care.
I think of EMS as the spackle of healthcare: If there's a
crack, you can use EMS ability.
“I think of EMS as the spackle of healthcare:
If there's a crack, you can use EMS ability,”
said Busko, one of the lead organizers of the CAIP
initiative. “This is a big crack being filled
by EMS, but now all of these other small cracks are being
identified — we can also do this, and this, and
An idea that 'just clicked'
With roughly 1,500 residents, the sparsely populated
Moose River Valley region is geographically larger than
Rhode Island, as the CAIP organizers point out, with
fewer people than pass through a Rhode Island highway
rest stop on a typical summer day.
For years, the region had struggled to attract and retain
doctors: Jackman had been unable to keep a new physician
for more than a year and a half for nearly two decades.
“Come to lovely Jackman, Maine —
you've got cross-country skiing, you've got hunting,
you've got fishing, but guess what? You're on call all
the time, so you can't do any of those things,”
Busko said. “So that made it very hard to
An arrangement between the hospital system and one of
Jackman's longtime physicians had allowed the community
to maintain its access to 24/7 care, even after the local
hospital itself was acquired by a new owner and
transitioned to a Federally Qualified Health Center
(FQHC). But when the hospital system ceased operations of
Jackman's nursing home in 2018, a new approach was
A plan to allow medical assistants to provide after-hours
care with the guidance of a doctor or physician assistant
lasted three years but ultimately proved unsustainable.
In the meantime, Busko had learned of the situation in
Jackman and wondered if the Moose River Valley might
benefit from the kind of health practitioner model he had
become familiar with while spending time in Alaska.
Together with Rick Petrie, Chief Operations Officer for
the Maine-based EMS service provider North East Mobile
Health Services, Busko attended a community meeting in
Jackman in 2018. The community had received a grant from
the Maine Health Access Foundation the year before to
work out a solution to its staffing challenge —
but had yet to come up with a viable alternative for
providing round-the-clock care.
When first suggested, the idea for a new program in which
independent practice paramedics would staff the center at
night and on weekends was met with skepticism from some
community members worried about potentially losing access
to certain urgent care services. But over the course of
two more community-wide meetings, which included visits
from state legislators and other officials, the concept
“just clicked,” Busko said. He
attributes the now-widespread community support for the
program to the informed community self-determination
process through which it was created — and the
transparency provided to Moose River Valley residents
throughout that process.
“It was a way of framing the vision that let
the community members not just know what their choices
were but be able to predict to the dollar what the tax
impact would be for them,” Busko said.
“The community really appreciates the value of
what's being done, but also that it's been transparent
By the time it came to a vote, motions to implement and
fund the program passed unanimously by each of the
municipal governments involved.
“The people of Jackman and the Moose River
Valley realized that they desperately needed access to
healthcare 24 hours a day, seven days a week,”
Petrie said. “And this program appears to be
the most viable and effective and efficient way to do
Chief Bill Jarvis, head of the largely-volunteer
Jackman-Moose River Fire and Rescue Department, said he
found Busko and Petrie's idea
“necessary” when it was first
proposed at the community meetings.
“Gaining community support was easy as the
community knew that if we did not have this, then there
would be no after-hours care,” Jarvis said.
“And when community members found out that the
paramedics could make house calls, provide needed
training for the EMTs, do community CPR training, and so
on, having the paramedics here was a
New possibilities for paramedics
Skye Carpenter, who joined the CAIP program as a
full-time paramedic after 16 years of working as a
paramedic at a Skowhegan, Maine hospital, recalls
becoming so excited about the CAIP concept when he
learned about the program that he began stuttering
partway through his job interview.
EMS doesn't change very well or very much. This is a
“EMS doesn't change very well or very
much,” Carpenter said. “This is a
major change. And the change is coming at a great time,
because as paramedics, with technology and telemedicine,
we have so much to offer in these small
Like the other paramedics in the program, who come from
across the state, Carpenter spends his 48-hour shifts
living in an apartment inside Jackman's former nursing
home. Each paramedic works one shift a week on an
eight-week rotation; the seventh and eighth weeks are
spent working a 24-hour shift with an additional 12 to 24
hours in clinical rotations at St. Joseph Hospital to
maintain and sharpen their skill set.
Patients can access care outside of the clinic's regular
hours in one of three ways: by calling the clinic's phone
number ahead of time from home, showing up to the clinic
and letting the on-shift paramedic know they're there
using a phone stationed outside the door, or calling 911
with an urgent care need and having a CAIP dispatched.
Patients who call after hours for non-urgent care
services, such as scheduling a primary care appointment
or getting lab results, are referred to a night nurse
The convenience of the program is especially appealing to
elderly members of the community, noted Jackman Town
Manager Cheryl Nadeau.
“We have a lot of older folks here,”
Nadeau said. “Being that they're older, they
don't want to travel out of the community. And for the
folks who did have to leave town for medical care and
come back, the paramedics can check up on them. They know
they have that peace of mind.”
To broaden their skill set, paramedics entering the
program take online courses and participate in laboratory
sessions at Eastern Maine Community College, along with
completing clinical rotations at St. Joseph Hospital's
emergency department. The CAIPs can perform a number of
urgent care procedures, including wound care; local and
regional anesthesia; soft tissue acute foreign body
removal; eye, ear, nose, and throat procedures;
ultrasounds; non-sedated joint dislocation reduction;
fiberglass splinting; and casting. For urgent care cases
that require a physician's oversight, the CAIPs serve as
liaisons for telemedicine visits between patients and
emergency room doctors at St. Joseph.
“As EMS providers, we don't usually fix things
— we manage them until we get the patient to a
doctor and the doctor fixes it,” Carpenter
said. “This opens up new possibilities. We now
have the ability to treat and release, which we didn't
really practice prior to this.”
In the two years since he began working in Jackman,
Carpenter has learned to be prepared for anything: A
shift could include anything from a backcountry
snowmobiling accident to an ear infection to a fishhook
stuck in a finger.
These are things paramedics never did, so you have to
have a different mindset completely.
“Not every paramedic, no matter how good you
are, fits in Jackman and fits this program,”
Petrie said. “You have to be willing to respond
to an accident one minute and several hours later be
sitting in somebody's living room, having a cup of tea,
and assessing an incision from a surgery two days ago.
These are things paramedics never did, so you have to
have a different mindset completely.”
Carpenter agrees that successfully working as a CAIP
requires a certain set of strengths.
“You have to be really good on your feet,
really good with a lack of resources, really good at
giving directions to others, and really good at walking
through a small town and not causing a HIPAA violation
— because everybody knows whose house you went
to yesterday and they probably know more about the call
than you do,” he said. “You've got to
be willing to go to the grocery store and pick up snacks
for somebody just as much as you've got to be prepared to
fix a gunshot wound.”
While the unique job description might be a deterrent for
some paramedics, others might find the CAIP program a
better fit than traditional EMS work, Carpenter added.
“This gives paramedics a different career path
than spending exhausting hours in a truck,”
Carpenter said. “This is hard work too, but
it's a lot different than being out 24/7.”
'Collaboration and coordination'
For nearly two weeks in the spring of 2020 — a
short gap after the JCHC closed its doors after hours and
before the CAIPs had begun their work — Jackman
got a glimpse of what life could have been like without
24/7 care. The health center had planned to continue
offering after hours care up until the paramedics' start
date, leaving no gap between services, but found itself
unexpectedly short-staffed in the final stretch.
For Jarvis and his ambulance crews, a cloud of
uncertainty hung over those weeks. Would patients who
showed up to the health center in the middle of the
night, expecting the same urgent care that had always
been available, call 911 instead? Would the emergency
medical technicians (EMTs) be called to transport any
patients who required advanced care and stabilization
after an accident or other medical emergency —
and have to pass by the closed health center on the
hour-long drive to the hospital?
“One EMT told me that the first time he was
involved with transporting a patient who died because the
urgent care was closed, he would consider
quitting,” Jarvis recalled.
The two-week gap turned out to be relatively uneventful.
But if after-hours care had been discontinued in Jackman
indefinitely, “we would have certainly had more
ambulance runs,” Jarvis said. “And if
patients had been needlessly lost, we might have had EMTs
quit, putting our already short-staffed service in worse
Until 2017, the local ambulance service had been operated
by the hospital system — but when Jackman's
nursing home shut down, so did the ambulance service. It
was then that the Jackman-Moose River Fire and Rescue
Department created its own ambulance division, which
covers more than 700 square miles with a staff of eight
EMTs — all licensed to administer Basic Life
Support — and three ambulance drivers.
Having paramedics on call at the JCHC has allowed the
Jackman-Moose River ambulance service to offer a more
advanced level of care than it would otherwise be able
to: When a 911 call comes in for a medical emergency,
county dispatchers can now dispatch both a Jackman-Moose
River crew and the CAIP on duty, with the paramedic
driving separately to the scene. If Advanced Life Support
is needed, the paramedic comes on board the ambulance; if
not, he or she returns to the health center.
Before the CAIP program, without the ability to
administer pain-reducing medications, “all our
crews could do for these patients was to be as gentle as
possible,” Jarvis said. “We've had
numerous patients over the years who were transported in
excruciating pain because there was nothing that we could
do for them to ease their pain.”
Now, Jarvis continued, “the paramedics can
administer medications to greatly reduce the patient's
pain level, making the trip in the ambulance
significantly more comfortable for the
Meanwhile, the Jackman-Moose River EMTs are available to
help out with after-hours urgent care visits when needed:
The CAIPs can call on ambulance service volunteers for
assistance if they need an extra set of hands for a
procedure at the center.
“The success of this really is the
collaboration and coordination between a bunch of
different agencies,” Petrie said.
Creating a sustainable model
As a Maine EMS Pilot Project, the CAIP initiative has
four years to prove its value to the state's EMS board;
if the program is deemed a success, any EMS agency in the
state will be able to apply to participate.
Certain aspects of the Jackman pilot project, such as the
fact that housing was readily available in the town's
former nursing home, might be more difficult to replicate
elsewhere. But the organizers believe the program could
be adapted to fit other rural communities' unique needs
— taking the form of an urgent care house call
service, for instance, if a town doesn't have the same
physical infrastructure available.
“We have the benefit of basically having an
apartment complex and a clinic just sitting there waiting
for us to work out of,” Busko said.
“A lot of rural areas don't have that, but this
program can be run without that.”
To make the program more easily replicable,
“one of our early objectives was to find the
least expensive way of doing everything we're
doing,” Busko said — for instance,
using smart phones, tablets, and laptops for virtual
visits rather than significantly more expensive
telehealth equipment. Still, any community that adopts
the CAIP model in the future should be aware of the costs
going into it, Nadeau said.
It is a huge undertaking…
“It is a huge undertaking, and it takes a lot
of planning and ongoing effort to keep the funds coming
in,” Nadeau said. “Other communities
need to be aware of that when they get started
— that it's going to be a continuous
A Health Resources and Services Administration grant for
$1.2 million has “helped to get the program off
the ground” by covering the costs of training,
education, and other start-up expenses, said Ellen
Thurlow, a project manager with Penobscot Community
Health Care, which operates the Jackman Community Health
Center. The grant, which spans four years, was awarded in
“We're halfway through the grant period, so
we've got two years to make this program
sustainable,” said Thurlow, who oversees grant
activity for the CAIP initiative. “The
challenge is that most grants are to fund the creation of
these programs, rather than continue to operate
With little grant money available for the ongoing
expenses of running the program, all operational costs
are covered by taxpayers in the town of Jackman and the
greater Moose River Valley region. To help offset the
yearly $500,000 operational price tag — and
make the program financially sustainable for the
long-term — local officials are working with
federal and state lawmakers to seek new grant
opportunities, while the program's organizers look into
other potential funding mechanisms.
In the meantime, a committee made up of Jackman residents
— known as the Community Health Advisory Team,
or CHAT — has worked to bring down taxpayer
costs through raffles and other fundraisers. One raffle
raised nearly $20,000 for the CAIP program, Nadeau
recalls; another raffle for a donated antique canoe
brought in more than $7,000.
On one Sunday morning, Carpenter remembers, a community
member had planned to sell raffle tickets at a local
grocery store from 9 a.m. until 1 p.m. By 4:30 in the
afternoon, the demand for tickets was so high that she
was still there — and she decided to come back
to sell more tickets the next day.
There's just unbelievable support throughout the
community. It's absolutely amazing.
“There's just unbelievable support throughout
the community,” Carpenter said. “It's
Gretel Kauffman has been a web writer for the Rural Health Information Hub since 2022. She writes on a variety of rural-specific issues in the Rural Monitor and Models and Innovations. Gretel has a bachelor of arts degree in American Studies from the University of Notre Dame. Full Biography