Rural emergency medical care in the United States has been the backbone of the response paradigm since the National Academy of Sciences’ 1966 EMS white paper. That paper, Accidental Death and Disability: The Neglected Disease of Modern Society, addressed the need for national education on first aid and a coordinated transportation and communications system to increase survival on the nation’s highways, many of which were rural in nature.
We still have lots of rural stretches of highway, but several other things have changed since 1966. We now have fewer physicians practicing in rural areas.1 EMS services that utilize volunteers are decreasing in number,2 and rural patients use EDs more and follow up post-discharge less.3 All of these seem like great reasons to start a rural community paramedic program.
Eagle County, Colo., is an interesting place. We are home to world-class skiing in Vail and Beaver Creek. We are bisected by Interstate 70 and have many small towns that on any other byway would be very rural. The full-time population of Eagle County is nearly 53,000, over 1,684 square miles. That equates to 31 people per square mile. Many of our towns are bedroom communities for the resorts that bring in an estimated 1.1 million skier-days per year.
This hardly seems like a place that’s rural and in healthcare crisis. But we are severely underserved in our community. More than 21% of our people are un- or underinsured (the national average is 13%).4,5 This number is post-Affordable Care Act. We have had an increase in Medicaid patients of 200% since January 2014, and we have few providers in the community who will see our Medicaid or uninsured populations.
In 2009, when we created the first rural community paramedic (CP) program in the United States, we were dubious about the impact it would have on the rest of paramedicine and healthcare. We wanted to create a lasting program built on facts from our local public health agency to serve patients in all areas of need (medical, social service, mental health and prevention). At the same time we wanted to create a program that would further the profession of paramedicine. Finally we knew our program wouldn’t last if we didn’t collaborate and create new pathways for communication and care in the health system. Today this is called integrated healthcare.
Many of the new CP programs that have started around the country are in rural environments. The NAEMT’s recent survey identified 49% of programs as serving rural areas.6 Making CPs the provider of choice in rural environments seems to capture the best of both worlds: They can see patients during downtime and be highly skilled advanced life support providers when emergencies arise. This is the exact vision for what the future of CP can be in rural areas of the U.S.
Here are five key considerations our system faced in launching a program.
One of the questions we are often asked is, “How do I get started?” The idea-to-implementation curve varies. On average you can expect to invest 12–24 months in implementation and education of your paramedics and community. Creating processes and looking at how you will document visits will be high on your list.
Those of us who live and work in rural areas know several things: We know how to innovate, we know how to get things done, and we know people don’t like change. So how do you create a program that essentially changes the healthcare delivery model and innovates at the same time? Patience and persistence. It is important not to take on too much early in your process, but also have a vision of where you want your program and service to be in five years. This will take the stress off the daily grind of setbacks and slow starts.
Step two is to talk with other providers in your community. This includes your public health and social services departments. In most communities this might be 1–5 employees who do it all. Imagine their surprise when you come in and say, “We want to help you serve your clients.” After you pick them up off the floor, you will be surrounded by a team that wants to embrace this concept and your team.
The Right Staff and Vehicle
Finding staffing to support your endeavor will be key. Not all CPs must be paramedics. In North Dakota they’re using EMTs with the same education as community paramedics to operate within their scopes as community EMTs. Think of them as community health workers with some medical background.
Distance to the patient will be another factor in how to staff your program. Vast distances that do not exist in the urban environment may mean a program is only able to treat 2–3 patients per day. This small number is acceptable in a rural setting and will help maintain skills in low-volume systems.
In a rural setting you may not want to use an ambulance for visits. We learned that having an ambulance sit in front of a house for several hours can draw the neighbors out to make sure your patient didn’t die. If you only have an ambulance, community education will be key to letting people know that an ambulance in the driveway may just be a community paramedic visit.
Another hurdle you may have as a rural program is getting education from a college or university to become a CP. There are more than 35 colleges and universities educating CPs today.7 This number is expected to increase in the next five years.
Many colleges and universities offer distance/online options for CP. The online methodology was recently used in the California pilot program to educate over 77 CPs statewide at once. Those community paramedics are now going out to provide care in their communities.8
The education is important, and a new test has been developed that will allow community paramedics to be certified based on a national test and model. The Board for Critical Care Transport Paramedic Certification (BCCTPC) has developed a test that was beta-tested at EMS World Expo in September. This test is based on analysis of the jobs performed in MIH programs as well as from practicing community paramedics. It will lend further credibility to the level of education and skill of the providers giving this care. The certification does not mean you can practice in any given state but will be a basis of competency that could be utilized for a state endorsement or certification.
One other idea often heard is that paramedics don’t want to do this, or they’d be nurses. The fact is, most paramedics and EMTs would like more of a role in disease prevention and health promotion;9 they just don’t know how to accomplish it. Through education and practice paramedics can be taught this role and fulfill it effectively. Community paramedicine expert Dan Swayze, DrPH, of the Center for Emergency Medicine of Western Pennsylvania, often opines that EMTs and paramedics are natural helpers and already accepted in their communities, which makes them a natural fit for this type of work.
The rural CP program must be flexible and open to change. In Eagle County we lost our diabetes educator, sponsored by the hospital, six months after starting our program. Our CPs went and received further education in diabetes education and teach-back. We then took on that role for our community’s physicians. It has been a great benefit for our program and the patients we serve to be flexible and create new programs as needed. It is also important to be willing to drop programs that don’t have much participation or need. This will allow providers to focus their time in more beneficial areas.
With a rural CP program, your providers will know more about the community. They will learn of resources and become more flexible in all areas of medicine. CPs can be the eyes and ears of physicians in patients’ homes while at the same time providing an excellent resource for the 9-1-1 system.
For more resources on starting a community paramedic program, go to www.communityparamedic.org and click on the ProgramHandbook link or look at the various resources provided. The curriculum is freely available to colleges, universities and state regulators under the Colleges link.
1. Rosenblatt RA, Hart LG. Physicians and rural America. West J Med, 2000 Nov; 173(5): 348–51.
9. Lerner EB, Fernandez AR, Shah MN. Do emergency medical services professionals think they should participate in disease prevention? Prehosp Emerg Care, 2009 Jan–Mar; 13(1): 64–70.
Christopher Montera is assistant CEO at Eagle County Paramedic Services in Colorado. He is treasurer of the Central Mountains RETAC, a past president of the Emergency Medical Services Association of Colorado and was the EMS data specialist for the Western Regional Emergency Trauma Advisory Council. Chris has 26 years of experience in EMS and has received numerous awards for service, including being named one of the top 10 EMS Innovators of the Year in 2010. He produces the Internet radio show EMS Garage (http://www.emsgarage.com).