Community Paramedic Model Potential Asset to Rural Healthcare Sustainability

Could an innovative model being used in Minnesota, Colorado, Nevada, and elsewhere across the nation be an answer for the more than 60 million rural Americans in addressing barriers to access of healthcare? Could this same model also meet the triple aim of improving the quality and satisfaction experience of care?

The Community Paramedic Program’s (CPP’s) model expands the role of emergency medical service (EMS) personnel. Through a standardized curriculum, accredited colleges and universities train first responders at the appropriate levels to serve rural communities more broadly. 

Such services include primary care, public health, disease management, population health (as defined by health system and community needs), mental health, oral health, homecare, care for skilled nursing, and treatment for congestive heart failure, diabetes, geriatric issues, and chemical dependency. The services also feature resource navigation for food security and shelter. 

Since 2009, the CPP has been adapted to suit the specific needs and resources of each community, and it succeeds through the combined efforts of those that have a stake in maintaining the health and well-being of their fellow neighbors. 

The CPP model is highly beneficial as it pertains to providing the following:

1. More appropriate use of emergency care services;
2. An increase in access to primary care for the medically underserved in a more efficient proactive way; and
3. The reduction of readmissions and ER misuse.

In some cases, EMS workers provide health services where access to physicians, hospitals, and clinics may not exist or be limited. The aforementioned is so crucial, as a growing number of rural patients lack access to primary care and use 911 services for non-urgent healthcare. This is a burden for volunteer EMS personnel in rural areas. Community paramedics who work in a primary-care role can meet the needs of these residents in a more efficient manner. 

The community paramedics function as fully participating members of a patient’s medical home care team.

They are trained to focus primarily on managing a patient’s emergency condition for 60-75 minutes for procedures including wound care, catheter changes, and tracheotomies, for example. They can also handle central venous line placements and intravenous therapy for skilled nursing facilities, or suturing and simple extremity splinting and venous blood drawing for skilled nursing facility (SNF) units. Under the delegation of the medical director, services are contingent upon appropriate levels of clinical education.

In many rural areas where diabetes is a key focus but education is absent, CPP professionals can receive further education in diabetes through a technique called “teach-back.”

There are also opportunities for the community health worker (CHW) to train as a CPP worker. CHW workers operate under an expanded model of care across the nation, as their services are already reimbursable by Medicaid and other payers.

CPP Application for Critical Access Hospitals and Rural Health Clinics

As if rural healthcare wasn’t complicated enough, the application of the CPPs can be confusing, complex, lengthy, and challenging. Before launching a CPP, communities need to pay close attention to how this model impacts a provider’s bottom line. Consideration should be given to the following:

• Where the CPP fits into the services that qualify for cost reimbursement. A CPP can be ideal for Critical Access Hospitals (CAHs) and Rural Health Clinics (RHCs).
• If the CPP scope of services is outside of those services that are cost-reimbursed, the CPP provides little financial opportunity and may weaken the bottom line.

For CAHs, the actual cost of CPPs serving in a role of caring for patients in an inpatient or outpatient hospital setting would generally be allowable. If a CPP practices in both settings, the CPP cost would need to be allocated between the hospital cost center (where services are provided, such as in an ER) and the ambulance service. 

The cost of a CPP (when operating within the model of a RHC), performing allowable services would be added to the funding for the clinical personnel and treated as an allowable cost.

CAHs that already own and operate an ambulance service may have an opportunity to use the downtime of their paramedics to perform CPP services.  Please note that if the RHC or the CAH proportion of Medicaid and Medicare patients for a given provider is low, then the reimbursement received will be small as a portion of the overall revenue.

On a final note, there is a rather complicated option for CAHs that do not own and operate an ambulance service and would be contracting CPP representatives from their own respective community or using a community ambulance nearby. The result is that the EMS provider that does not receive cost reimbursement from Medicare may be able to establish cost-based reimbursement (in some instances, contracted) or revenue for a CPP working in an area of the hospital where the cost is actually allowable.

Barriers and Pitfalls

One potential issue in implementing a CPP could be lack of commitment and time, as it takes 12-24 months to launch. The success of the model is contingent upon the buy-in of clinical champions and the recruiting referral system. It also requires a strong and organized staff and a structured job description (yet one that incorporates flexibility to build out the program based on community and patient needs).  Additionally, marketing and branding plans are important.

Funding, Programs, and Success

Most CPPs are funded by ambulance services via grants, including Centers for Medicare & Medicaid Services (CMS) innovation grants (right now there are three awardees for Medicare fee-for-service community paramedic services). Although the model is spreading, not all CPP services are reimbursed by Medicaid – but according to the National Conference of State Legislatures, some reimbursement for certain services are applicable and allowable. Additionally, licensure and regulations vary by state.

In several states, practicing community paramedicine is considered is an expanded role for paramedics and EMTs versus requiring an expanded scope of practices. The standard curriculum is free of charge to colleges and universities and can be taken via online courses in some cases.

The program includes 114 hours of education and 200 hours of lab and clinical experience. There are also many free online resources (webinars, articles, presentations, state regulations, community paramedic programs, etc.) available for organizations to use within strategic planning and community health assessments, including  The Community Paramedicine Insights Forum, International Roundtable on Community Paramedicine, the Community HealthCare Cooperative (CHEC), and Community Paramedicine Program Handbook.  The Minnesota Department of Health also developed an “employer’s toolkit” via a Center for Medicare and Medicaid Innovation (CMMI)-funded project that can be used and adapted in several states.

Read Between the Lines for Success

Some key steps to take include:

–      Securing key partner commitments

–      Assessing community needs

–      Securing administrator leadership, board support

–      Budgeting

–      Considering state and national regulations

–      Remaining up to speed on healthcare reform/policy changes

–      Focusing on internal community and healthcare systems, CAH, and RHC support

–      Maintaining adequate personnel levels

–      Securing medical support and internal team operations strategy    

Steps for the Medical Director

–      Development of protocol and medical guidelines

–      Development and implementation of evaluation criteria and outcomes tracking

–      Development of continuous quality improvement initiatives

–      Educating personnel

–      Compliance program for CP education programs

–      Coordination of strategic plan

Sustainability and Programs

In a value-based healthcare world, even rural providers need to think about data sustainability of programs and finances. This includes defining value, innovation, and flexibility; establishing funding, contracts, collaborations, and relationships with payer systems; and aligning data collection and agreed-upon measures and inclusion of other services, including home health organizations, social services agencies, and public health agencies. It is even likely that a CPP Accountable Care Organization (ACO) model could be adapted, such as those seen in urban settings.

Rural Success

There are several successful programs implemented across several states, so the aforementioned examples don’t include all of them. Several additional entities include:

–      Humboldt General Hospital EMS Rescue

–      Eagle County Paramedic Services

–      North Memorial Health Care

–      Northfield EMS

–      Meds-One EMS

–      Northfield EMS

–      Tri-County Health Care

The CPPs are highly advantageous in that they are intimately involved within each community. Because they have access to resources in all areas of medicine, they can actually help build provider satisfaction and patient engagement by serving as eyes, ears, and extra hands of providers.

The bottom line is that we now have fewer physicians practicing in rural areas. EMS services that utilize volunteers are decreasing in rapid numbers, and rural patients use EDs more and follow-up post-discharge services less. The CPP is showing growth success, patient focus, and a promising future, and it just might be a lifeline for rural communities.