Keeping Emergencies at bay
Community paramedics meet unmet needs.
By Jeanne Mettner
At a recent check-up with his primary care physician, an elderly patient—we’ll call him Jack—presented with weight loss, dizziness and loss of appetite. His medical history revealed a perfect storm for adverse health outcomes: He lives alone, and his only child (now middle aged) is attentive and compassionate but lives out of state. He has no connection to the community, no other family or social support nearby. He has high blood pressure, congestive heart failure and memory issues, and he is taking long-term anticoagulation medications.
Jack is the kind of patient who has fallen through the cracks in the health care system. He doesn’t qualify for home care but is unable to manage his own health well. As a result, he is at high risk for hospitalization or ER visits. He’s also the kind of patient who might be well-served by a community paramedic.
In 2011, Gov. Mark Dayton signed into law the Community Paramedics Bill, creating this new category of health care worker as one way to address health needs, particularly in underserved parts of the state. Minnesota is the only state in the country that has passed a law creating this new classification.
Physicians’ eyes and ears
In this new role as community paramedics, specially trained paramedics may provide health screenings, mental health assistance, wound care, wellness care, immunizations, disease management, and medication compliance and reconciliation. Most will visit patients in their homes, although some will work out of mobile clinics. “I see the community paramedic as a provider who, under a physician’s medical license, can be the eyes, ears and even hands of the physician in the home setting,” says Michael Wilcox, M.D., medical director of the community paramedic program at Hennepin Technical College (HTC) and associate medical director for North Memorial Medical Center’s ambulance service.
Currently, HTC has the only community paramedic certification training program in the United States. To be accepted into the program, candidates must have worked as a paramedic full time for two years or more and have a letter of approval from the medical director of the ambulance service for which they work and under whose license they will likely practice. They must complete 112 hours of didactic and 196 hours of clinical training, which includes community assessment work, coursework in chronic disease management and pharmacology, refreshers in pathophysiology, and clinical rotations in primary care clinics, hospice facilities and at Children’s Hospitals and Clinics of Minnesota. As of January, Minnesota had 24 certified community paramedics; nearly 80 more are likely to receive certification this year.
A different mindset
One of the challenges for community paramedics is changing the mindset of professionals trained to react in emergency situations. When they visit a patient, they are no longer wearing their ambulance services hat, says Kai Hjermstad, a certified community paramedic who serves as HTC’s training director. “EMTs and paramedics are credited for being reactive within an emergency setting, but as community paramedics—even if we are only doing it very part time, as most of us are—you have to slow down, get to know your patient, and make a well-thought out plan for him or her,” he says. “It’s totally different from what we are used to, where a call comes in and we race out to the truck and we go off with our lights and siren.”
Barb Andrews, a veteran paramedic and ER nurse, received her community paramedic certification last August and now coordinates the community paramedic program at North Memorial, the first organization in Minnesota to implement such a program. She and eight other community paramedics each spend about one day a week visiting patients who are referred through North Memorial’s primary care clinics. The majority of patients are those who do not qualify for home care or other services.
One of the first patients Andrews and her team saw was Jack. “We started by going to his home, organizing his medications, figuring out what he was taking and not taking, and how it was affecting his health,” she says. They found Jack’s INR to be abnormal and that he was taking twice the amount of Lasix and blood pressure medication prescribed by his doctor, even though his doctor had temporarily discontinued those drugs because he was dizzy and losing weight (Jack had forgotten his doctor’s instructions).
Andrews and her team came up with ideas for improving the situation. They put Post-it notes on bottles of medication Jack was not supposed to be taking and moved them to the top shelf of his kitchen cabinet, away from his other meds, and they started doing blood draws for his INR checks because he was missing his clinic appointments. With respect to his weight loss, they learned that Jack didn’t like to cook and often didn’t remember to eat. “These were just a few things that helped us come up with a plan,” Andrews says.
An evolving role
Although the concept of the community paramedic is new in this country, it is not elsewhere. In Canada, Australia and New Zealand, for example, emergency services personnel help treat patients with nonemergent conditions in order to prevent them from developing complications. When the idea of the community paramedic began percolating in Minnesota, it was to help keep ambulance services afloat in rural areas, allowing paramedics to stay busy during their downtime between runs. Then proponents started seeing it as a way to alleviate some aspects of the shortage of primary care providers in certain parts of the state.
“We realized we had a large need in the metro area, too,” says Buck McAlpin, director of government affairs for North Memorial. North Memorial got its program up and running in October 2012. It currently serves Minneapolis and western Hennepin County. “We needed to set the program up in a larger care system to understand how to run it with billing, integrate with EPIC (the electronic medical record system at North Memorial and many other area health systems), set up care delivery models and get used to working within a larger medical home framework,” he says, adding that they plan to add services.
Currently, North pays its community paramedics; others are paid through their county health departments or they volunteer their services. A 2012 law established a payment methodology for community paramedicine. McAlpin says once the federal government provides the state with matching dollars for these services, Medical Assistance will start paying for them.
In the meantime, the community paramedic idea continues to gain traction. The Minnesota Department of Employment and Economic Development awarded HTC, North Memorial, Allina and HealthEast a $250,000 Job Skills Partnership grant to train 100 community paramedics over the next three years. The Minnesota Department of Health’s Office of Rural Health and Primary Care has provided funding to train the six paramedics in Park Rapids, where North Memorial has an ambulance service. Other paramedics from Hibbing, Cambridge, and Maplewood, as well as North Dakota, Idaho, Maine, Florida, California, Missouri, and New Jersey are signing on as well (many participate in classes remotely).
From Andrews’ perspective, community paramedicine is poised for success. Jack, the elderly patient receiving care through North Memorial’s program, is now receiving Meals on Wheels and gaining weight, is more compliant with his medication regimen, and is receiving other services from VA. “I have been in emergency care of one variety or another for 20 years, and throughout the past two decades, I’ve always felt like I was putting a Band-Aid on the patient’s issues,” she says. “With this program, I truly feel like we are making a difference.”
Jeanne Mettner is a Minneapolis writer.