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.”

  • J. Garcia

    “Paramedics are trained in algorithms,” Mortrud adds.

    As a practicing paramedic, both in a 911 and critical care transport setting, I take great offense to Ms. Mortrud’s characterization of paramedics. Today’s paramedics operate in a primary care/emergent environment at the point of injury/illness. They are trained to conduct a thorough assessment using diagnostic technology that takes a team of people to operate in the hospital/clinic environment. The paramedics take the information from the assessment, form clinical impressions and administer the appropriate treatment, independently, more often than not. In a critical care setting, paramedics care for patients between medical care facilities, continuing care that was initiated in the hospital. Do they use algorithms in some instances? Absolutely. Just as nurses, physician assistants, and medical doctors do.

    Several Minnesota colleges offer two year degree programs in paramedicine, and 4 year degree options exist. This is very similar to nursing where the first level of RN licensure is a two year degree.

    Bottom line, paramedics are healthcare professionals that provide a skilled medical care to the communities they serve. I do not take anything away from the care delivered by the thousands of skilled nurses in Minnesota, but it is time paramedicine is acknowledged as a profession, and regarded as such. It is also time for the powerful MNA lobby to stand aside and allow this program to evolve and benefit our communities, rather than keeping an eye on the all mighty dollar.

  • R. Dougherty

    I completely agree with the above comment. The MNA needs to stop trying to torpedo this and work with the TEAM. Why on earth would a nursing organization not want to endorse anything that can improve health and make a difference for people that may otherwise not get that help. Bravo MNA, bravo.

  • Jodi H.

    We, as paramedics are well trained and think outside of the box on multiple occasions…not just algorhythms.

    We are able to take care and treat many patients on many different levels and for various reasons without asking for an order for something.

    We can hold a paitents hand who in in pain, crisis, or just needs ‘someone.’

    We function without breaks, sleep (many work 12-24 hours shifts too), or a contract.

    We get paid little money to do A LOT and without being in a controlled environment.

    We don’t do it for the glory or the kudos…we do it because we care for people.

    There are many more things that I could write about what WE do and why we do it. We are not out to take jobs from anybody as what one person believes. Ms. Mortrud’s only concern seems to be for the dollar and not for patient care. Did she remember that with the last few strikes that her “caring” people were on?

    I would love to see Ms. Mortrud go and ride with a number of services for the duration that we work and in the conditions we work in. She may have a different opinion of what is really out there.

  • Peter Bonadonna

    I object to the ridiculous comment of being “lesser trained” than a nurse. As a paramedic educator for over thirty years, I have had dozens of Registered Nurses who wanted to challenge our paramedic program. When we administer the final to see if they can pass it, not a single nurse has ever come close to passing it. Those nurses who remain in our program and take the full paramedic program say that this is very different and very intense education and that nothing in nursing would prepare them in this way. It takes longer to become a paramedic than it does to become an RN in our state.