MIH-CP services are revolutionizing how EMS is delivered across the country. The growth of these programs from only a handful in 2009 to more than 130 currently operating is a demonstration of this revolution.1
One of the keys to successfully implementing and sustaining an MIH-CP program (and, arguably any EMS model) is selection of the right people to deliver the service. In this column we explain our experience in selecting and training MIH-CP providers for this enhanced role.
ECA, EMT, EMT-P, CAN, LPN, RN, NP, PA, MD, DO, CHW or BHS? Deciding the basic credential of the folks to provide this service depends in large part on the role your MIH program is going to play in your community.
An EMT or paramedic could be a logical choice if the program is part of the local EMS system. In both the Christian Hospital EMS (Missouri) and MedStar (Texas) programs, EMT-Ps are the primary MIH providers in the field. They are part of our organizations already and have a clinical scope that includes most of the services needed by our high-utilizer and readmission-prevention patients.
That is not to say EMTs are not a good fit as MIH-CP providers. The UPMC Community Connect program in Pittsburgh uses EMTs very effectively to achieve its goals. There are also instances when an emergency care attendant (ECA) might be the perfect fit for certain services, such as doing vital sign checks and home safety evaluations.
In some locations, however, using EMTs or EMT-Ps may not be realistic. The services requested by the partners in your community might require a higher scope of practice for the personnel delivering them. An example of this approach is the Mesa, AZ, MIH-CP program, now funded through a Health Care Innovation Award grant from CMS. The goals of this program are to alternatively manage 9-1-1 callers with low-acuity medical, trauma or behavioral health situations. Nurse practitioners, physician assistants and behavioral health specialists paired with fire department EMT-Ps respond to and alternatively manage low-acuity and behavioral health calls in the city.2 The NP can suture, provide advanced assessment and even prescribe medications to prevent an ambulance transport to the ED. The behavioral health specialist can assess the behavioral needs of patients and determine whether they need an ED or can be safely referred to an inpatient or outpatient behavioral health facility.
Some states limit the role of EMTs and EMT-Ps to only “emergency” responses or activities during the transport of a patient in an ambulance. In these instances it may be necessary to use providers who are not limited by the state’s EMS regulations, such as a licensed practical nurse (LPN), registered nurse (RN), nurse practitioner (NP) or physician assistant (PA). Fierce Healthcare recently profiled a program by Valley Hospital in Ridgewood, NJ, that provides proactive postdischarge home checkups to patients with cardiopulmonary disease who are at high risk for readmission and either declined or didn’t qualify for home care services.3 Due in part to the limitations in state regulations for EMTs and paramedics, the program uses a team of a paramedic, an EMT and a critical care nurse to conduct a physical exam of the patient, offer medication education, reinforce discharge instructions, complete a safety survey of the patient’s home and confirm the patient has made a follow-up appointment with a physician.
The program began with patients hospitalized for heart failure. “This population of chronically ill patients, who are generally elderly, have frequent bounce-backs to the hospital, which we know is not good for them,” Robin Giordano, supervisor of the hospital’s Outpatient Transitional Care Program, said in a statement. But the hospital has since expanded the program to include patients who have undergone transcatheter aortic valve replacement procedures because they often have multiple health problems and their postoperative care can be very complex.
Some MIH-CP programs are considering the community health worker model. CHWs are well recognized as being an effective tool to help manage patients who are at risk for high healthcare utilization. In 2009 the Department of Labor’s Bureau of Labor Statistics created a distinct occupation code for CHWs. By definition they will:4
Assist individuals and communities to adopt healthy behaviors. Conduct outreach for medical personnel or health organizations to implement programs in the community that promote, maintain and improve individual and community health. May provide information on available resources, provide social support and informal counseling, advocate for individuals and community health needs, and provide services such as first aid and blood pressure screening. May collect data to help identify community health needs.
There are two things that are specifically attractive about the CHW model. One is that the national curriculum for CHWs (typically about 160 hours) closely mirrors that of the education necessary for EMTs or paramedics to perform MIH-CP services. The second is that a January 2014 CMS rule allows Medicaid reimbursement for preventive services delivered by nonlicensed providers, such as CHWs, upon recommendation from a licensed Medicaid provider.5
Look for Personality
If you use traditional emergency medical services personnel for MIH-CP services, there are several things to keep in mind. First, look for the clinician and practitioner personality. This should be an individual who is good with nurturing people, communicating, thinking outside the box and performing follow-up. It’s a relational role based on educating the patient to take care of themselves and teaching them, through active listening, patience, words and practical advice, how to manage their disease and reduce their anxiety.
EMTs and paramedics often have the opposite personality. They thrive on adrenaline, excitement and one-time problem-solving. They are, by definition, technicians. They see an event, react to it and treat it following specific protocols. This type of personality likes to solve short-term problems. They have what we refer to as the “Johnny and Roy syndrome.” The firefighter-paramedics of the TV show Emergency!, Johnny Gage and Roy DeSoto, were adept at short-term interaction with patients and delivering them to an emergency department, then moving on to another call. They were all about saving lives, and the show educated Americans about what EMS teams did in an era where there weren’t many.
We need Johnnys and Roys in our EMS systems, but they’re often not the best fit for the MIHP role of building relationships over longer periods of time. In MIH, you’ll need to train people who want to make a difference for the patient over the long term, and who will spend an hour or two at someone’s home each time they see them, helping them learn about their disease processes and understand ways they can take better care of themselves. This type of paramedic or nurse practitioner will see the patient change over time, as opposed to changing over 20 minutes.
As an MIH practitioner, one of the hardest things about doing the job is trying not to fix every patient’s problems. An MIHP understands that the only person who can fix a patient’s problem is the patient, and therefore provides therapeutic intervention strategies that help with those resistant or ambivalent. Personality characteristics that coincide with this type of thinking include practitioners who are compassionate, empathetic and adaptable.
For the MIH role, a different personality type is needed. Identify your MIH providers not by their current clinical EMS excellence and performance standards, but by the new role they’ll be providing. Pick that paramedic who has a long view of the patient and a bigger-picture ability to connect, communicate and strategize. This individual will be able to fit all the pieces of the puzzle together to provide education and patient navigation to the right place at the right time.
A good analogy would be a salesperson vs. an account manager. One is a hunter who goes after the business, gets the sale, then moves on. The account manager is the nurturer, responsible for making site visits, strengthening relationships and understanding and fulfilling needs.
The paramedics we tease for taking too long on calls are actually the ones best suited for the new role in mobile healthcare! The paramedic who takes 30 or 45 minutes on scene because they are educating the patient and family are the ones who want to have relationships with patients. They desire more than just a brief interaction, so they take that long view.
Another desirable trait for MIH providers is solid critical thinking skills. They need to understand the connection between the steps taken now and what that might mean to the patient tomorrow or the next day. They take critical thinking to the next level. This provider has a good understanding of disease management, the body systems, pharmacologic needs and other interventions that may be needed for the patient. They are also committed to caring for that patient over the long term.
Training and Educating the Provider
To be successful, MIH programs should be locally derived to meet a gap that exists in healthcare or serve as a bridge in the local healthcare system. There are generally two basic models for MIH-CP programs: One is the primary care replacement model, bringing primary care to areas that lack it. The other is the urban model, which navigates patients to the correct healthcare providers. The role your agency will play in the local healthcare system, and the types of services to be provided, will dictate the type of training program necessary for your personnel.
Every training program should consist of core and elective didactic modules. Core modules may include education on concepts such as the evolution of EMS to MIH, the role of an MIH-CP provider, community resource assessment, motivational interviewing, communication and care coordination. The training should be scenario-based, focusing on the patient approach, assessment and interventions. Other modules that may be included might be high-utilizer management, congestive heart failure readmission prevention, diabetes and asthma management, hospice programs and related interventions.
In addition to the classroom training, specific clinical orientations must be included, again based on programmatic goals. Clinical rotations in our programs included:
ED social worker shadowing;
Behavioral health/mobile crisis team ride-outs;
Behavioral health clinic rotations;
Hospice agency ride-alongs;
Home health agency ride-alongs;
Ride-alongs with current mobile health practitioners.
The community needs assessment you do will determine the role you need to fill, which will drive the type of training you plan and execute. Regardless of what kind of training you do, it is important to include the people who will be interfacing with those providers. So, if you’re going to do an EMS loyalty (high-utilizer) program, the education involves the local case managers and local ED physicians. You’ll also involve the people in your community who deal with those patients every day, such as public health authorities, homeless shelter staff and others.
Minnesota’s Hennepin Technical College, in cooperation with numerous partners, developed the first comprehensive community paramedic training curriculum; it’s now possibly the most widely used CP training program. One option being considered at MedStar is sending MIH-CP providers to the local CHW training program. This not only will give personnel formal certification as CHWs, but also allow the services provided by these newly certified providers to be eligible for Medicaid reimbursement in a growing number of states.
Sample Community Health Worker Training Curriculum
The Rural Assistance Center lists the following potential curriculum areas for community health workers in rural systems:6
Accessing healthcare and social services systems;
The pathophysiology of different diseases;
Translating, interpreting and facilitating client-provider communications;
Gathering information for medical providers;
Delivering services as part of a medical home team;
Educating social services providers on community/population needs;
Teaching concepts of disease prevention and health promotion to lay populations;
Managing chronic conditions, including training on lifestyle strategies, risk factors, self-monitoring and medications;
Understanding community prejudices;
Motivational interviewing and communication;
Utilizing technology, including mobile applications.
CE and Standardized Certification Exams
With some MIH-CP programs now approaching three years in operation, the topic of continuing education and recredentialing is percolating. Core competencies and new skills need to be formally addressed. The evolution of some programs, such as the Christian Hospital EMS and MedStar programs, has led to a need to enhance the basic skills initially contemplated. What started as high-utilizer and CHF-readmission programs has given rise to requests for program expansions to include things like Foley catheter management, wound VAC maintenance and readmission prevention programs for COPD, diabetes and other disease processes.
Further, the long-put-off discussion about a standardized certification can no longer be debated. With more than 130 operating programs across the country (a number that grows weekly) and efforts at uniform outcome and process measures, it’s time to consider standardized testing. The Board for Critical Care Transport Paramedic Certification (BCCTPC) has reached out to several MIH-CP program coordinators to begin a process for it. This group met for the first time in June 2015 and is working through the core competency assessments that will help build the content for a standardized exam.
A beta test of the Certified Community Paramedic (CP-C) examination, from the Board for Critical Care Transport Paramedic Certification, will be held at EMS World Expo, September 15–19 in Las Vegas. See bcctpc.org and EMSWorldExpo.com.
Desiree Partain is the clinical program manager at MedStar Mobile Healthcare in Fort Worth, TX. She is a critical care paramedic with 13 years’ experience in EMS and five years as a mobile healthcare practitioner at MedStar. MedStar was named the 2013 Paid EMS System of the Year by NAEMT and EMS World. Its MIH-CP program is profiled in the AHRQ’s Healthcare Innovation Exchange.
Shannon Watson is the community health supervisor at Christian Hospital EMS in St. Louis, MO. She assisted with the development and implementation of the service’s Community Health Access Program and currently manages its mobile integrated healthcare program. Christian Hospital EMS was named the 2014 Paid EMS System of the Year by NAEMT and EMS World. Its MIH-CP program is profiled in the AHRQ’s Healthcare Innovation Exchange.