Ever since 2001 when Kevin McGinnis first used the term ‘community paramedic’ (Rowley, 2001, p4) in the United States, the idea of expanding the role of Emergency Medical Services (EMS) providers as an alternative way to provide primary and follow-up care to citizens has moved forward quickly. While originally envisioned to assist rural communities, more and more urban agencies have begun to explore the idea. In response, the National Association of State EMS Officials (NASEMSO) has established a standing Community Paramedicine – Mobile Integrated Health (CP/MIH) Committee in an effort to centralise resources (National Association of State EMS Officials, 2015). Additionally, the North Central EMS Institute in Minnesota has established a trademarked community paramedic logo and collaborated to create a model curriculum for use by collegiate paramedic programmes (Community Paramedic Program, 2014a).
What is it?
What is CP? Put simply, it could be considered an expansion or realignment in the focus of EMS. An effective graphic representation of this change was included in the 2013 CP briefing for the EMS on the Capitol Hill event prepared by the North Central EMS Institute, instead of viewing EMS as EMERGENCY Medical Services, CP's focus is on Emergency MEDICAL Services (Community Paramedic Program, 2014b).
In the ‘Vision statement on MIH and CP’ the major organisations in EMS, including NASEMSO, the National Association of EMT's (NAEMT), the National Association of EMS Physicians, the American College of Emergency Physicians, and eight others define it as the provision of health care using patient-centred, mobile resources in the out-of-hospital environment. It may include, but is not limited to, services such as providing telephone advice to 9-1-1 callers instead of resource dispatch; providing CP care, chronic disease management, preventive care or post-discharge follow-up visits; or transport or referral to a broad spectrum of appropriate care, not limited to hospital emergency departments (National Association of EMT's, 2014).
As it was envisioned by McGinnis in 2001, as an adjunct to their emergent responses, paramedics could be utilised more as an extension of the physician into the community, much like other allied health professionals, promoting and teaching about how to remain healthy and providing a bridge between the hospital and the established home health organisations (Rowley, 2001, p5). This concept was envisioned to benefit rural and frontier communities served by Community Access Hospitals (CAH) and facing unique challenges such as extended response and transport times; significantly reduced call volumes resulting in a higher cost per call and deterioration in skill knowledge; and an inability to attract and keep trained providers and medical directors (pp1–2).
The Joint Committee on Rural Emergency Care, NASEMSO and the National Organisation of State Offices of Rural Health state in their discussion paper, ‘that CP providers provide an expanded role, not an expanded scope. This expanded role is often depicted as the ability for CP providers to perform an expanded assessment and medical history and to develop care plans; use of non-traditional medications” (2010, p6).
Urban systems have begun to take a closer look at CP and have reported success with their implementation, including Seattle/King County, Washington; Winnipeg, Canada; MedStar in Texas; Wake County, North Carolina, and the state of Minnesota (pp3–4).
Regulatory review in Virginia
A review of the Joint National EMS Leaders Forum's survey conducted by the NAEMT in 2013, lists 11 self-identified CP programmes in Virginia; six of them rural, three suburban and two urban (JNEMSLF Survey Map, 2013). However, our focus is on one programme that was not included in the survey in 2013, which has attempted to successfully meet the regulatory requirements to be designated as a CP program in Virginia, Chesterfield Fire and EMS, in Chesterfield County which is located in central Virginia.
Reviewing the previously published minutes of the Virginia EMS Advisory Board Medical Direction Sub-committee finds mention of national CP issues and events as far back as 2012 (Akers, 2012, p3). During this time, discussions were also being held about exploring options to implement CP programmes in various agencies.
As some of the operational medical directors (OMDs) reported plans to start CP responses in their communities, the office of EMS began to receive information regarding some push-back from the home health-care industry. In response, a meeting was held in November of 2013 between concerned OMDs, the assistant attorney general to the Department of Health, the deputy commissioner for public health and the office of EMS to request a review of the current regulations and how they might affect the implementation of CP programmes in Virginia (Akers, 2014, p2).
In late April of 2014, the Office of EMS received information back from the attorney general's office that appeared to throw a roadblock directly in the path of CP programmes in Virginia. This information was presented in a decision memo titled ‘Mobile Integrated Healthcare/Community Paramedicine Licensure Requirements’, which was posted and made available through the office of EMS. Unfortunately, the very definition of EMS in Virginia could block the expansion of the role of paramedics. The ‘Virginia EMS Regulations’ define EMS as the services used in responding to an individual's perceived needs for immediate medical care in order to prevent loss of life or aggravation of physiological or psychological illness or injury, including any or all of the services that could be described as first response, basic life support, advanced life support, neonatal life support, communications, training and medical control (Virginia Office of EMS, 2012, p22).
The Virginia EMS Regulations further define an ‘EMS agency’ as ‘a person licensed by the office of EMS to engage in the business, service, or regular activity, whether or not for profit, of transporting or rendering immediate medical care to persons who are sick, injured, or otherwise incapacitated’ (p22). Additionally, ‘EMS personnel’ is defined in the ‘Code of Virginia’ as, ‘persons responsible for the direct provision of emergency medical services in a given medical emergency, including all persons who could be described as attendants, attendants-in-charge, or operators’ (Commonwealth of Virginia, 2008).
The key point in the analysis hinged on the use of the word ‘immediate’ and ‘medical emergency’. Since the CP programme focuses on ongoing disease monitoring, follow-up, education and, in some areas, non-emergent primary care, it is not defined in the Code or regulations. Also, it was felt that while most of the CP skillset is already contained within the provider's scope of practice in Virginia (http://tinyurl.com/zhghp86) and tinyurl.com/j5yg48m), providing care outside of the ‘immediate medical care’ was not part of an EMS agency's scope under the Code or regulations (Virginia Office of Emergency Medical Services, 2014, p2).
Finally, it was determined that much of the proposed care being attributed to CP programmes nationally, falls squarely in the realm of home health care as listed in the ‘Code of Virginia’ § 32.1-162.1 through § 32.1-162.15 and in the Virginia Administrative Code 5-381. With this, any OMD or EMS agency interested in providing CP services would be required to comply with the addition sections of the Code and regulations, which requires them to obtain a licence from the Office of Licensure and Certification (OLC) in addition to the EMS agency licence issued by the office of EMS (p2). With these findings and the publishing of the guidance document, it seemed that CP delivery in Virginia had been stalled before it even began.
‘Since the beginning of the CP programme, Chesterfield has seen a total of 320 patients. It has made a huge difference, with a reduction in its more high-risk citizens’
Successful implementation
Or had it? Dr Allen Yee, OMD for Chesterfield Fire and EMS was undaunted. He had been an outspoken proponent for the implementation of CP in Virginia, even lamenting that the rest of the country was moving forward and Virginia was stagnant (Akers, 2014, p2).
According to Dr Yee, Chesterfield Fire and EMS obtained the required application and set about meeting the requirements. When asked why implementing a CP programme in Chesterfield was so important, Dr Yee replied, ‘I had three main reasons for moving forward, 1. Reduce unit utilisation; 2. Increase the health and welfare of the community; 3. Reduce preventable death’ (Personal Communication, June 7, 2015).
Additionally, Dr Yee needed to move forward quickly to comply with the new interpretation handed down in April of 2014, as they had already recruited and completed training for three paramedics from the EMS Division in November of 2013. After conducting a needs assessment within their community, Dr Yee and the training staff designed in-house training for the expanded role of their CPs.
The programme is self-funded by the county and currently there are no plans to seek reimbursement. The programme is designed exclusively around reducing ‘recidivism of our “loyal customer” base,’ continued Dr Yee, as well as ‘resource referrals.’
To begin the process of CP, the EMS Division conducted data-mining of both their electronic Patient Care Report (ePCR) files and dispatch records. Once they had a good handle on their ‘loyal customers’ and their medical profile, Dr Yee and the EMS Division designed the necessary training to prepare their CP cadre to work with the identified patient population. The training was primarily didactic and included information on available resources within the county.
Changes necessary to the system were identified and included information and training for all EMS crews and an update to the ePCR software. ‘In addition to our existing customers, new patients are referred to the CPs by the providers on the county ambulances. If the attendant-in-charge identifies a patient who could benefit from a follow-up visit, all they have to do is click a box on the ePCR. At 8 am the next morning, a compiled report is sent to the dayshift CP with all new referrals and they reach out and start the process,’ Dr Yee explained.
What services Chesterfield provides through their CP varies for each patient. For those patients who are identified as having a high number of transports through 911, the focus is on reducing the causes. Identifying and putting the patient in touch with needed resources is key, including ensuring prescribed medications are refilled prior to running out and putting patients in touch with local, state or federal payors which could include helping to identify affordable insurance options, thus reducing the looming financial burden of continued care. It may also include assisting chronic diabetic patients with placement under the care of endocrinologists and nutritionists, focusing on actively working to normalise blood sugar. However, as Dr Yee points out, the CP's are involved in other community-centred care as well. They provide follow-up to help mitigate fall risks by conducting home surveys focusing on fall and injury prevention. They have also partnered with the local Social Services to help combat elder abuse. ‘It's a two-way street,’ said Dr Yee. ‘If we suspect something unusual, we contact them directly and provide follow-up, or if they have a concern, they contact us to address any medical issues.’
To comply with the document posted by the office of EMS, Chesterfield completed the application, paid the $500 application fee and scheduled the licensure visit with OLC. Surprisingly, when the representative reviewed their programme, he determined that none of the services the Chesterfield CP programme provided fell under the Home Health regulations and declared they did not need to obtain a licence at this time.
Dr Yee continued: ‘We are considering adding some additional services in the future, but first we will need to work with the Virginia Department of Health and go through the regulatory process to change both the EMS and Home Health Code and regulations or we would need to go back and pursue the licence.’ Since the beginning of the programme, Chesterfield has seen a total of 320 patients. When asked if he felt the Chesterfield CP programme has made a difference, Dr Yee concluded: ‘We have clearly seen a reduction in our high risk citizens.’
Dr Yee confirmed that the OMDs, through the Medical Direction Committee, are continuing to discuss options for Virginia and some others have begun programmes in their localities. ‘Portsmouth is doing a “loyal customer” study, but Arlington has hired a physician assistant (PA) and is conducting a 90-day pilot study on low acuity calls,’ Dr Yee advised.
Conclusion
Ultimately, for Virginia to mirror the successes of other CP programmes on the national level, changes to the ‘Code of Virginia’ and the regulations of the Health Department will need to be made. The Code changes could be made as early as 2016 if a strong patron for the bill could be found, but without an emergency regulatory change, regulatory changes could languish for some time as the last EMS regulation changes took almost nine years to complete the approval process. In the end, evidence seems to indicate that changing the regulatory environment to update the paradigm that has been EMS for the last 40 years, may lead to improved patient care.
Despite perceived regulatory obstacles, EMS agencies and medical directors should consider further innovative CP programmes designs to provide new non-traditional services to their patients and community. By thinking outside the CP box, a programme that meets the goals of the OMD and improves patient care and outcomes can exist despite restrictions.