Problem Addressed: Rural Emergency Medical Services

Healthy People 2010 Objective: 1-11

Web Address: None

SNAPSHOT

The Red River Project addresses the rural concern of community access to primary care services and the preservation of quality local emergency medical services (EMS) through an expanded scope paramedic program. The project has reduced out-of-town transports by more than 50 percent, keeping the valued assets of EMS in the local area for life-saving emergency care. Through an expanded scope level of care provided by local volunteer paramedics, the project answers the calls of a community that was unable to support the primary-care services of a full-time physician and clinic. Paramedics underwent specialized training as Community Health Specialists and are allowed to make many of their own decisions, yet the project relies on protocols that lean toward physician involvement, in most instances. Through a collaborative process, the project fostered the critical buy-in of the medical community in this unique venture away from tradition and addresses rural issues of emergency medical and primary care access.

THE MODEL

Blueprint: Red River is located within the popular Enchanted Circle and the Carson National Forest of New Mexico. It is a seasonal community with an approximate 450 summer and 10,000 winter population. To address the issues of paramedic skill maintenance, a lack of community primary care providers, and the lack of EMS coverage imposed when the only ambulance transported patients to the nearest hospital 48 mountainous miles away in Taos, the community initiated an expanded EMS system to deliver primary care (under physician-directed protocols) using the existing paramedic-trained personnel trained as Community Health Specialists. This expanded role allows the trained paramedic to provide non-emergent but complex care with a physician on the phone, routine care with 48 hour physician follow-up, and minor treatment with follow-up by the Community Health Specialist. The Red River Project allows for increased access to primary care for its local citizens, increases the skills and training of the local paramedics, and reduces the lack of ambulance coverage experienced when non-emergency patients are transported to the regional emergency room for minor/routine care.

Making a Difference: Though little outcome measurement was conducted in the project, the information collected shows a valued community benefit. The usual ambulance transports of three to four hours to the nearest accepting hospital in Taos was reduced from 78 percent to only 11 percent of call volume. This reduction in out-of-town transports enables the limited EMS resource to remain in the community for life-saving response. During the first eight months of service, the project recorded two-thirds of all calls for the Community Health Specialist and only one-third of call volume for EMS. This project gave the community what it really needed and more. As suspected in many rural communities, the majority of medical requests are for minor or preventive intervention such as wound care, immunization, and routine follow-up assessments.

Beginnings: Project planning for the expanded scope paramedic program began in 1992, followed by initial implementation in September 1994. The community formed a coalition and applied for a federal Rural Health Outreach grant, which was awarded by the Federal Office of Rural Health in the amount of $464,000. The coalition consisted of regional EMS components, a community hospital, the University of New Mexico’s EMS Academy, and the state’s public health division. The project goal was to show what could be done when paramedics were trained to care for common acute injuries and illness in rural communities.

Credited for the success of the project was its collaborative, not competitive, foundation. Training of paramedics as Community Health Specialists, or expanded scope paramedics, was conducted by the University of New Mexico, the Taos community of physicians, and its regional hospital. This collaboration fostered the critical buy-in of the medical community in this unique venture.

Challenges and Solutions: There was initial concern regarding the expansion of paramedic licensure, though the state’s 1993 EMS Act, which allowed for special skills, provided the needed avenue for expanded scope of the practice. While Community Health Specialist paramedics are allowed to make many of their own decisions, the project relies on protocols that lean toward physician involvement, in most instances. A significant asset of the project was that it built upon the expanded relationship among EMS, primary care, and public health¾a direction envisioned as the possible future of EMS.

Reimbursement during the first year of the program was solely dependent upon the project’s grant funding. However, subsequent years reflected the reimbursement from private insurance companies, with the greatest source of revenue being self-paying patients. A significant number of the Community Health Specialists’ non-emergent calls were responses to Medicare beneficiaries, and the community interventions had not been recognized by Medicare reimbursement.

PROGRAM CONTACT INFORMATION

This model for practice ended but is included here because it met a primary care access need until a traditional provider could be recruited to the area.