Community Paramedicine in a Rural Setting

In the future, access to healthcare in the rural setting will become increasingly problematic. Fewer and fewer primary care providers will be choosing to practice in rural areas.

From 2010–2050, the U.S. population is expected to increase by 40% (from 310 to 439 million). One quarter of Americans will live in rural/remote areas, but only 10% of physicians will practice there. Also, there will be an increasing number of immigrant patients who live in rural settings. By 2042 diverse, racially aggregate minority populations will become the American majority.

In addition, there will be a growing number of elderly living in rural areas. By 2030 more than 20% of the U.S. population will be over 65 years of age. Many of these people will have chronic diseases with limited financial resources.

To partially address this lack of healthcare access, the community paramedic can be used to provide some benefit for these groups. As a pioneer in the area of community paramedicine, Minnesota has substantial experience with rural CP programs and needs.

The Rural Community Paramedic

To prepare for their roles, the state’s CPs undergo standardized training developed by experts at Hennepin Technical College in partnership with the Minnesota Ambulance Association. The program includes 144 hours of classroom instruction (half live or via interactive TV; half online/distributed learning) followed by 196 hours of clinical training in their area. Rural CPs gain additional skills by expanding their clinical hours while working with their rural mentors.

Areas of clinical focus include primary care, community health/hospice, wound care, behavioral health, cardiology and respiratory issues, pediatrics and geriatrics, and networking.

As a part of their training, the CP develops a gap analysis of healthcare needs within their community. They then bring to the healthcare team options to assist in filling these gaps. They expand their role in providing healthcare, but they do not change their scope of practice.

The state has operated rural programs in three counties.

Rice County—Rice County is located in southeastern Minnesota. It has a population of 65,000, of whom 14% are over age 65, 4% are African-American and 8% are Hispanic.

The CPs in this county work within a free clinic (the HealthFinders Collaborative) with the guidance of a case manager under the licensure of a medical director and in partnership with a community health worker to make home visits. They focus on shut-ins, the disabled, the mentally challenged and the underinsured. Their tasks include home safety checks, nutritional counseling, medication review, patient assessment, interaction with support personnel, and mental health monitoring. Collaboration with other healthcare providers has been a key to the program’s success.

Wadena County—Wadena County is located in northwestern Minnesota. It has a population of 13,757, of whom 22% are over age 65 and 4% are Native American.

The CPs within this county are a part of the local hospital system and partner with the Wadena County public health program. They provide several procedural services, including lab draws for long-term, chemical dependency and homebound patients; tracheal tube stoma care; ostomy care; bladder scans; medication administration to the mentally ill; medication education and review; EKG procurement, IV starts, laceration repair and simple extremity splinting for long-term care patients; wound care; home visits to patients pre-orthopedic surgery to assess for fall hazards; and postsurgical visits to ensure proper wound healing and prevent unnecessary ER visits.

Over a two-year period, this program has averaged 100 hours of service per month and 5-10 patient encounters per week. Their work heavily involves collaboration with other healthcare workers.

Scott County—Scott County is located in south-central Minnesota. It has a population of 140,000, of whom 9% are over age 65, 4% are African-American, 5% are Hispanic and 6% are Asian. Its program was the first in the state to use community paramedics, which began in 2009.

The CPs within this county work with the public health system in collaboration with the Mdewakanton Sioux community and local faith communities to provide a free clinic for the un- and underinsured. This clinic is mobile and travels within the county in a medical van provided by the Sioux community, seeing 14–20 patients per session.

There is an additional clinic that provides similar services and is stationary. It is housed within the Community Action Partnership Agency (CAP). This is a resource center for food access, job placement and public assistance resources. Through the clinic’s efforts, a “medical home” is established for the patient that includes provider services and reasonably priced prescriptions.

Over a five-year interval, 600 patients have been cared for through this venue. Collaboration is a key factor in the success of this program as well.

Problems Encountered

There have been four major problems encountered in developing CP programs in Minnesota’s rural settings. Solutions to these problems remain an ongoing challenge. These are:

1. The lack of an electronic medical record that is inexpensive, user-friendly and interactive with other systems in sharing data.

2. Funding sources to sustain the programs: Third-party payers are just now realizing the cost savings their plans may realize with CP-type programs using front-line healthcare workers (CPs, CHWs).

3. The lack of common data elements that support the quality of care provided by community paramedics. This is being worked upon by national EMS experts.

4. Potential liability concerns on the part of the CP medical director, especially in areas of increased procedural request and usage. 

Conclusion

Access to healthcare in rural areas will be an increasing issue in the future. Especially problematic will be the management of chronic disease in the elderly, the management of immigrant health and the promotion of public health mandates (immunization updates, follow-up of sexually transmitted diseases, mass-casualty event preparation, mental health care and treatment).

The community paramedic, through his or her program’s gap analysis of healthcare needs and attention to complex, underserved and vulnerable populations, will become a valuable resource to assist in addressing these gaps.

[Editor's note: For more on rural healthcare challenges, see the linked white paper from U.S. Sen. Al Franken of Minnesota.]

Commentary: Universal Challenges, Local Solutions

With fewer people spread out over greater distances, rural EMS agencies face a complex set of calculations in launching community paramedic programs. This month community paramedicine pioneer Dr. Mike Wilcox highlights three CP programs in Minnesota that may serve as models for other rural communities. While urban and suburban agencies may want to focus on programs to help hospitals and health plans reduce readmission rates, these three rural agencies have played a vital role in supplementing their communities’ primary care, public health and hospice services. 

The challenges summarized by Dr. Wilcox are universal to community paramedic programs regardless of their geography. Integrating our medical record systems with other healthcare providers has been a challenge even for hospital-based EMS agencies (and, for that matter, the rest of the healthcare system). Finding appropriate measures to evaluate the quality of CP services and finding sustainable funding are still barriers for many agencies, but great progress on both fronts has been made in the past two years. Of the challenges Wilcox cites, obtaining liability coverage for physicians willing to push at the borders of our traditional scopes of practice is likely to be more daunting a challenge than that faced by programs that primarily focus on patient navigation and advocacy services. However, when the only other option for rural EMS agencies is to let their communities languish without adequate primary care or public health coverage, it seems the type of battle worth fighting. —Dan Swayze

Michael R. Wilcox, MD, FACEP, FAAFP, is a clinical associate professor in the Department of Family Health and Emergency Medicine at the University of Minnesota Medical School in Minneapolis; a medical consultant for EMS educational programs with the Minnesota state college and university system; and medical director for community paramedic and EMS educational programs with Hennepin Technical College and South Central Technical College, Eden Prairie, Minn. Contact him at mwilcox3090@yahoo.com.