Community Paramedics Widen Medical Services in Rural Areas

Pilot Programs in Minnesota and Colorado Are Bringing Emergency Personnel Into Homes and Other Settings to Provide Non-acute Care

by Candi Helseth

Chris Berdouly is excited about the new challenges he will encounter this fall when he begins going into homes in western Colorado as a community paramedic, providing primary care for patients with chronic illnesses and medical needs.

“We’ll still be EMS providers doing what we normally do but adding this service in our counties will be great, saving money and ultimately giving people better care,” said Berdouly, who works for the Western Eagle County Ambulance District (WECAD) in Colorado’s Eagle and Garfield counties. “We’re in this job because we’re all people persons and we think it will be satisfying to help people in a different capacity.”

Community Paramedic Program, Colorado

Paramedics Kevin Creek (l), Kate Hawthorne, and Eric Gundlach are participating in the community paramedic program in Colorado state.

WECAD and a Minnesota EMS program have been selected for a five-year pilot program by the Community Paramedic Program, a program run by the Community Healthcare and Emergency Cooperative that focuses on expanding the EMS role by training emergency personnel to provide primary care and public health in underserved areas.

EMS personnel have a lot of expertise that can be used for more than responding to 9-1-1 calls, said WECAD Chief Chris Montera. Last year WECAD responded to 1,131 calls in a sparsely populated service area of 17,000 residents spread throughout 1,100 square miles. The ambulance service, with four emergency vehicles and 31 paid EMTs and paramedics, provides critical trauma services and transport to hospitals a minimum of 35 miles away. But, like many rural EMS services, WECAD has a lot of downtime between calls.

“So we’ve collaborated with local physicians and Eagle County Public Health Department to be another provider that can be eyes and ears of the physician in patients’ homes,” Montera explained. “In addition to home care, we’ll work with public health assisting with things like immunizations and screenings.”

For the Minnesota pilot, Dr. Mike Wilcox, a family medicine physician and medical director for 85 Minnesota EMS services, selected 10 paramedics from four EMS services. The paramedics will complete a curriculum of coursework and clinical rotations developed by Hennepin Technical College in Minnesota, where Wilcox is the medical director. Rural areas that will be served include an American Indian reservation with a severe shortage of physicians and the 6,000-member community of New Prague where Wilcox has lived for more than 30 years.

Kelly Goodpasture

Minnesota Paramedic Kelly Goodpasture, right, obtains a history from a client prior to doing a physical assessment.

From his experience as a physician for 40 years, Wilcox said patients with chronic diseases fare better when they continue to live independently. They are also likely to be hospitalized less often if they receive home health care. Since rural areas have shortages of primary care providers and home health programs, the paramedics will fill an existing need.

“We’re still in the early phases of working all this out and some of our paramedics are just now completing their final certification,” he said. “We want to tie them into home health care settings working with critical access hospitals.”

Paramedics in the pilot have begun working with Wilcox at a free clinic for low-income residents in Scott County. Wilcox said they hope to have the paramedics providing patient assessment and chronic disease management in homes by November. WECAD’s paramedics completed training and began the first phase of outreach in September.

Colorado’s pilot has attracted international interest because it’s the first model to bring together EMS services with primary care, public health and social services, Montera said. WECAD was featured at the 6th annual International Roundtable on Community Paramedicine (IRCP) held in Vail, CO, in August. EMS providers from five countries and throughout the United States attended.

Challenges Facing Community Paramedicine

Implementing the community paramedic concept is not without its difficulties. It was opposed by the Minnesota Nurses Association, which went on record this summer against a bill introduced in the state that would add community paramedics to the list of community health workers.

“We are opposed to the bill as written because these are duties for a registered nurse,” said Angela Ledger, MNA Political Organizer. “We are going to be sitting down with the stakeholders to work on something that is acceptable for all parties. We completely agree with the need for more services in rural areas.”

Dennis Berens, president of the National Rural Health Association (NRHA) and head of the Nebraska Office of Rural Health, said that community paramedics won’t supplant doctors or nurses.

“We’re not looking to change the scope of practice but to look at existing roles inside the paramedics’ scope and to extend those and then connect these underutilized resources to underserved populations,” Berens said. “This is a team concept. It doesn’t take anything away from the community’s medical providers that are there. Paramedics answer to the local physician. They become the needed extenders in our remote communities.”

Berens, who has been involved in IRCP since its inception six years ago, said NRHA, the National Association of State EMS Officials and the National Organization of State Offices of Rural Health Policy laid the groundwork for change in EMS services in 2003 with development of the Rural and Frontier EMS Agenda for the Future. The Community Paramedic Program grew out of that agenda.

Scott County Free Clinic

Minnesota paramedics providing care at a Scott County free clinic include Kai Hjermstad, left, who is participating in the Community Paramedicine pilot project. Here he checks a patient’s blood oxygen level.

The other challenge community paramedicine faces is funding. For the paramedicine concept to be implemented nationally, reimbursement issues must be resolved, Berens said. State monies currently support both pilot programs. Patients are not charged for the services.

“We’re hoping these pilot projects will result in a new health care model that is beneficial to rural communities and includes a way that we can pay for these services through Medicaid, insurance and reimbursements similar to what other health care professionals receive,” Berens said.

A New Vision of Health Care Delivery

Montera said WECAD staff visited Nova Scotia, Canada, to study a successful paramedicine model implemented on Long and Brier Islands where paramedics provide in-home primary health care services in conjunction with an on-site nurse practitioner and an off-site family physician. Over a five-year period, visits to the local emergency department decreased by 40 percent and clinic visits decreased by 24 to 28 percent on Long and Brier Islands, according to Michael McKeage, operations director at the time.

“I think this work with EMS services can lead us into a new vision of how health care can be delivered, especially for these folks out there that don’t have access anywhere near them,” Berens said. “We have 13 counties in Nebraska with fewer than 1,000 people. In some counties, our only health providers are EMTs. Yet for all practical definitions, EMTs and paramedics are not considered health providers.”

“The timing is right for change,” Berens declared, “and I think this community paramedicine model will provide good answers for rural communities across the nation as well as globally.”

The Rural Monitor (then Rural Health News) described the concept of community paramedics in the article, Solving the Paramedic Paradox. Nearly 10 years later, the idea is slowly coming to fruition.

Back to: Fall 2010 Issue