Paramedics take on expanded health-care role in rural Minnesota

In the future, you may not have to call 911 to draw a paramedic to your door. Under legislation signed by Governor Mark Dayton this week, so-called "community paramedics" will be trained and certified to address minor and chronic health problems in your home, rather than automatically driving you to an emergency room.

Community paramedicine is a concept that's been popular for years in other countries, such as Canada and Australia, but has only recently taken hold in the United States. "Minnesota is the first state to recognize this with law," says Dr. Michael Wilcox, Scott County's medical director, who oversaw the state's pilot training program at Hennepin Technical College in 2008/2009.

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The aim of the new law is to help alleviate a shortage of doctors and nurses in outstate Minnesota -- a growing concern in many communities -- and to save precious health-care dollars.

"When you look at the resources in a rural area," says Wilcox, "there are not enough nurses. Expanding the role of the paramedic in a rural setting, where they can do patient care between 911 dispatch calls, makes sense."

A community paramedic might suture a wound, adjust a medication, or address an asthma attack or allergic reaction. They might help a diabetic stay on an even keel or talk through a mental health issue, all on the spot. In fact, in the future, a specially-trained paramedic might make regular, preventative visits to "frequent flyers," those patients who call 911 the most and cost the system dearly.

Advocates of the approach argue it improves patient care while saving money by reducing emergency room visits. They also say it can help preserve ambulance services in remote areas by increasing the fees paramedics are paid. The new law paves the way for community paramedics to be reimbursed under the state's medical assistance program, though only after study by the state human services commissioner, who must submit a fee schedule to the legislature by January.

"I think the community paramedic legislation is a great opportunity, especially in rural Minnesota," says Mark Schoenbaum, director of the Minnesota Department of Health's office of rural health and primary care. "It's an opportunity to use the skills of our rural paramedics who, because they work in isolated and sparsely populated areas, often have time available to go and perform a variety of services they are qualified and supervised to do."

Not everyone is so jubilant. The Minnesota Nurses Association takes a dim view of the new law. While agreeing that health-care services need to be expanded in rural areas, Carrie Mortrud, the MNA's government affairs and public policy specialist, says, "Creating a brand new provider is not the answer."

Mortrud is concerned that community paramedicine merely replaces nurses with cheaper, lesser-trained personnel, at a cost to patient health. "If they would refer and get people into the right system and right care," the MNA would see the benefit, says Mortrud. "If they are going to go in and take over public health nursing, we are not OK with that."

"Paramedics are trained in algorithms," Mortrud adds. "They are trained to respond to what they find on the scene. Nursing is completely different. Nursing is about building a relationship with your patient so you can help them take care of themselves."

Gary Wingrove, governmental relations and strategic affairs specialist at Mayo Clinic Medical Transport, who helped establish the training curriculum, hopes community paramedics will be just one more member of a patient's healthcare team. "If they find something adverse," Wingrove says, "they will do the assessment such that they can call the primary care provider and talk about the care plan." That discussion can lead to a clinic visit, he says, "if they think it's appropriate."

"What's kind of happened over time, as medicine has evolved," says Wingrove, "is we've identified gaps in a community that need to be filled. EMS workers already have a skill set that's common in primary care. When there is a hole in the community and the community searches out a way to fill that gap, the best thing they can do is look to existing providers."

Driving this new approach are changes to federal health-care law. In the future, for example, Medicare will penalize hospitals for some emergency room re-admissions on the theory that they should be coordinating better outpatient care. In other states where paramedicine has been tried, such as New Mexico, it has reduced emergency room visits dramatically.

"Interest in this has exploded very quickly," says Wingrove.

In fact, the program could eventually expand into urban areas, according to Wilcox. "It's geared for rural areas, but down the line, it may give opportunities for patients even in a metro setting who can't access healthcare. There is no reason you couldn't train paramedics in a metro area to handle these patients at home."

Wilcox sees community paramedicine growing in Minnesota, especially now with a certification process in place. "I could easily see 100 (community) paramedics in the state in three to five years," he says. "We start a training program at the end of May. We're going to select 24 candidates this time around."

Young paramedics, Wilcox adds, "go into it because they like the street work and the adrenaline rush. But that gets old after a while. If you talk to them as they move along in their careers, they want to do more for a patient than load them up and move them along. This is a career path they haven't had available before."

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