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MediMike

Paramedic Practitioner

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As a follow up to Hope's post...

https://trackbill.com/bill/missouri-house-bill-907-establishes-a-licensing-procedure-for-paramedic-practitioners/1685013/

Sounds like what the PA profession started off as, much more dependence and oversight than most current clinical environments. But hell, bet they'll be cheaper.

If you notice who testified for and against the bill...I see nurses associations and NP associations...sure don't see any PAs listed. Pretty sure the billed died this session but starting to look like death by a thousand cuts if we're not careful.

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Not sure it actually failed. The bill was introduced along with bills that eliminate  supervision or collaboration requirements for NP. Looks like They , but were sent to committees for further review. I may be wrong, but it appears that keeps them at least somewhat on books for this upcoming legislation. Maybe someone else knows better how it works, but Missouri PA’s may be first to really become extinct. 

 

 

 

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EMS services should be using PAs for follow-ups and frequent-flier diversion; EMT/PAs and Paramedic/PAs know how to function appropriately in a prehospital setting, while your average nurse does not. And yet, LaCOFD just announced using NPs in this role.

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4 hours ago, rev ronin said:

EMS services should be using PAs for follow-ups and frequent-flier diversion; EMT/PAs and Paramedic/PAs know how to function appropriately in a prehospital setting, while your average nurse does not. And yet, LaCOFD just announced using NPs in this role.

LAFD had rolled out their NP staffed ambulances a while ago. The first one hit the streets in January 2017.

https://www.jems.com/2017/01/31/nurse-practitioner-response-unit-launched-in-los-angeles/

It has since evolved to units staffed with a PA or an NP alongside a firefighter/paramedic and the units are no longer designed as “NP” units (NP-1, NP-42, etc). The callsign and designation is now “AP (#)” for Advanced Provider.  These units are a partnership with local hospitals. 
https://www.lafd.org/news/lafd-partners-hospitals-expand-innovative-advanced-provider-response-units

A retrospective study was just published last month (10/17/19) which has supporting data to demonstrate that the program has been a success in its nearly three years of existence.

https://www.tandfonline.com/doi/abs/10.1080/10903127.2019.1666199?journalCode=ipec20

Edited by deltawave
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I’m not sure who here is a paramedic or was a paramedic, so if someone has updated intel feel free add on. 
 

This “paramedic practitioner” push is something  that seems to stem from the recent Community Paramedic programs that some EMS systems have been piloting for about ~5-6 years now. Although, in researching the Missouri bill, I did see that “assists in surgery” was included in there; that is not a function of a Community Paramedic. 
To obtain the certification of Community Paramedic one must take some classes that vary state-to-state and then pass a national exam offered through the International Board of Specialty Certifications (ISBC) (formerly the BCCTPC for the rest of you old timers). It is an advanced paramedic “curriculum” and test on par with the CCP, FPC, and now others such as tactical medic and Community Paramedic. 
 

The goals and function of the role of Community Paramedics can be found here: 

https://www.ibscertifications.org/roles/community-paramedic

(It was too long to transcribe or paste)

I am a paramedic. In the places I have worked (private non-tax subsidized) these Community Paramedic programs have failed due to the cost to implement and operate them in combination with no reimbursement. Sounds nice to get out there and help people, but who foots the bill if this isn’t a traditional EMS transport or other similar scenario covered by Medicare/Medicaid/Insurance. Spoiler alert- the hospitals didn’t help pay for it, even though the goal was to help cut down on re-admits, frequent fliers, and mental health crises to ERs.
 

Suffice it to say, worrying about these paramedic programs suddenly springing up and taking over the PA role is not something you should worry about. These “advanced” paramedic initiatives have been failing for years, which is part of the reason why the LAFD has APPs as noted in my previous post. It’s also one of the reasons why I decided to move up the totem pole to PA.

Edited by deltawave
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If you are Joe or Susan public and have no idea the difference between Nurse Practitioners, Paramedic Practitioners or an "Assistant"....? Who would you choose?

 

Yeah.

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Paramedic practitioners have already been a part of the health system of other countries for several years, including the UK and Australia.  They are to the best of my knowledge prepared at the Masters level, and primarily work in ED's, EMS and some primary care settings.  Here in the US we have no structure set up yet for educational requirements, and importantly billing reimbursement (not really an issue in the NHS). 

It is an uphill battle nationally getting  American EMS agencies to pay traditional paramedics a living wage; without a mechanism to improve reimbursement for paramedic practitioners I wouldn't anticipate a huge rush to adopt this level of training if the medic will get a Masters degree and still be lucky to make $20/hour.  I don't know if community paramedicine is driving the Missouri efforts or if there is someone else leading it; just sharing some info about how other countries are structured.  Here's a video highlighting a paramedic practitioner in the UK:

https://www.emsworld.com/video/12106357/u-k-reporter-spends-24-hours-with-nhs-paramedic-practitioner

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Still a paramedic, do very little firefighting any more, do some EMS with my FD.  Agree with everyone who's said that community paramedicine is a great idea but without a funding source.  From what I've seen, the only well paid medics are dual role ff/medics.  Medics who work for 3rd services and ones who work for private ambulance services don't do very well.  For example, in my area, a paramedic classmate of mine makes over $100K/yr as a firefighter/medic but medics works for the privates who do the interfacility transports max out at $20-25/hour like Medic25 said.  There are a few uniformed 3rd service EMS providers, but they still don't make what the dual role ff/medics do.

Unless FD's are able to justify these efforts to reduce the load on their response volumes, or hospitals fund them to reduce frequent flyers, there's no way to pay for community paramedicine.

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4 hours ago, ohiovolffemtp said:

 

Unless FD's are able to justify these efforts to reduce the load on their response volumes, or hospitals fund them to reduce frequent flyers, there's no way to pay for community paramedicine.

Or perhaps, in the proper environment, we could start having the discussion about how silly the idea of fire based EMS actually is.  Yes, I know that separating them, no matter how justifiable it may be, would not solve the funding problem.  At least not immediately.

I agree with the rest of your comments.  I have seen similar compensation discrepancies in my area, too.

As much as I loathe to hold up ALS services in New Jersey as an example, they may be on to something.  ALS is hospital based in NJ.  With a hospital based system ALS services, community paramedicine, even the PA/NP/EMS services cited above could stand a reasonable chance of success once the nitty gritty of funding and economic sustainability are worked out.

 

My NRP is current but on inactive status. 

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I've always wondered why in a scenario where you wished to use someone like a PA, that you couldn't spread the cost between the local municipal service and the hospital network which serves as the medical base station for the service.  Your SP is the EMS medical director.  Their (hospital network) portion of costs could be offset by billing insurance companies for the service provided by the PA in follow up scenarios, or care received during unique transport cases where advanced skills were required on scene.

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The idea of having a PA work in the field has been around for a while. This is from JAAPA in 2005:

 

 

Fast track in the field: Another option to ease ED overcrowding

Emergency department (ED) overcrowding is becoming a serious problem in the nation’s hospitals. Many are forced to go on ambulance diversion status because of a shortage of bed space, clinicians, or resources needed to take care of patients. Patients who seek care in the ED often require ED evaluation and are there appropriately. There is, however, a subset of patients who use the ED for conditions that are neither emergent nor, at times, even urgent. Many of these patients do not have access to a primary care provider, or they live in communities lacking adequate free medical resources for the uninsured or underinsured, so the ED becomes their only choice. One option that meets the needs of patients, hospitals, and emergency medical services (EMS) providers is to create a system by which these patients are seen outside of the ED yet receive the same high-quality care from the same providers that they would in an ED setting.

Fast track in the field

The EMS community is advocating for advanced training for paramedics to perform these functions. But, why not use PAs in emergency medicine to fill this void? They already have the requisite skills and experience, and they could rotate between working in the field and in their home EDs.

Many PAs in emergency medicine started their careers in medicine as paramedics and would welcome the opportunity to use their new skills outside the ED setting. I have spoken about this concept with a number of my PA colleagues who previously worked in EMS. The consensus was that they would enjoy the opportunity to return to the field and be able to concentrate on a single patient at a time instead of the six to eight patients that are followed at one time in the typical ED setting. Some unpleasant aspects of being a paramedic would be absent from this system, such as carrying heavy patients down multiple flights of stairs and being awakened in the middle of the night for low acuity cases. These are among the chief reasons many PAs leave EMS to go to PA school.

This system would also benefit EMS because they would no longer have to transport patients with minor complaints to the ED. The large number of nonemergent 911 calls has been a significant cause of burnout and frustration among EMS personnel. The system I am proposing would allow paramedics to focus on what they do best—treating truly emergent patients in the field setting.

How would it work?

The concept would initially utilize a trial ambulance team of one PA and one basic EMT/driver and would be staffed only during the busiest hours of the day. The team would not respond directly to 911 calls but would be summoned after an initial decision by paramedics that the patient was nonemergent and met criteria for field treatment and release. The criteria might involve such complaints as minor lacerations, upper respiratory infections in otherwise healthy persons, prescription refills for noncontrolled medications, ingrown toenails, and so forth. EMS and members of the field group would agree on these criteria in advance. The ambulance company could still bill for a home response and any supplies used, while the hospital ED could bill for the PA’s time and any hospital supplies (such as suture sets) used in treatment.

If a single unit saw a patient every 30 minutes for 8 hours, 16 fewer patients would arrive at the ED and 16 more emergent ambulance calls could be made. Some patients might initially be thought to be appropriate for field treatment and later be found by the PA to need further evaluation. These patients could then be transported nonemergently to the local ED by the PA unit and checked in there in the same fashion as a typical walk-in patient. A busy area could use more than one unit or staff it for more hours daily.

This system would be practical only in a busy metropolitan area where ED overcrowding and a strained 911-response system are daily issues. While using PAs in the field in other settings is an option, there would be no clear benefit to local hospitals or emergency services through such utilization.

Patients would also benefit from such a system. Currently, patients with low-acuity complaints face long waits in EDs, sometimes as long as 4 to 6 hours or more. Field treatment would allow rapid evaluation and treatment of their minor injuries and illnesses, greatly increasing patient satisfaction. Follow-up visits would be done by the same “city call” physicians who see unassigned ED patients after their discharge from the hospital. The patients could also be given a list of local resources, such as primary care providers in the community and social workers who can arrange for federal or state health coverage.

Benefits on many levels

In this system, there would be no decrease in revenue to either the hospital or the EMS company. Members of the team would be paid by their normal employers at their normal rate of pay. No changes would need to be made to the configuration of the ambulances used. The PA could simply carry a tackle box with supplies and a few noncontrolled medications, such as antibiotics. All the pieces are in place for this to work, with very little preparation time involved. The staffing already exists. Oversight would continue per current practices. The supervising physicians of the ED PAs would review the PAs’ field documentation in addition to their regular ED charts. The PAs’ malpractice policy from the hospital would be amended to include work in the field. Hospital EDs would be able to allocate their resources more appropriately to evaluate sicker patients in a shorter amount of time.

This is only the outline of a concept. I hope that this model can be tested in busy urban areas to determine its effectiveness at decreasing ED wait times and improving service to those in need of medical care.

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DMPAC:

Or perhaps, in the proper environment, we could start having the discussion about how silly the idea of fire based EMS actually is.  Yes, I know that separating them, no matter how justifiable it may be, would not solve the funding problem.  At least not immediately.

This is an ongoing debate.  After 35+ years in fire & EMS, I've seen a few departments where it works poorly, a fair number where it works extremely well, and the rest where it works pretty much OK.  I have a very strong preference for fire service based EMS.  Fire departments almost always have better staffing and geographical distribution of stations to provide rapid response and good coverage vs EMS only agencies.  Fire departments are also far better than EMS only agencies at providing plenty of personnel at the initial phases of responses where there are lots of things to get done at once and often many personnel needed to get the patient from where they are to the ambulance.  Hospital based EMS agencies in my experience are far to vulnerable to hospital politics.

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On 11/25/2019 at 8:14 AM, Cideous said:

If you are Joe or Susan public and have no idea the difference between Nurse Practitioners, Paramedic Practitioners or an "Assistant"....? Who would you choose?

 

Yeah.

I have to say Paramedic practitioner because it has the word 'medic' and 'practitioner.' It sounds more legit and someone who can save me in an emergency. 

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Paramedic here. (6 years urban 911 in Houston-area)

While I'm applying to PA school to "get out" of EMS, I know I'm going to miss seeing the blue sky all day. I would love to moonlight as a "paramedic practitioner" or as a PA visiting non-emergent cases. I expect that my full-time job will be in a hospital/practice, and I'd like to be able to follow up with my patients more than I can right now (which is almost never).

That being said, I wouldn't mind being called to a gnarly traumas every now and again to insert a chest tube. Just sayin'.

There is a need for a paramedic pathway to...something. So many medics go to nursing, even though it's not really what they want to do. There's not a ton of options for advancement unless you go to supervisor or education/administration.

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On 11/26/2019 at 6:20 PM, ohiovolffemtp said:

This is an ongoing debate.  After 35+ years in fire & EMS, I've seen a few departments where it works poorly, a fair number where it works extremely well, and the rest where it works pretty much OK.  I have a very strong preference for fire service based EMS.  Fire departments almost always have better staffing and geographical distribution of stations to provide rapid response and good coverage vs EMS only agencies.  Fire departments are also far better than EMS only agencies at providing plenty of personnel at the initial phases of responses where there are lots of things to get done at once and often many personnel needed to get the patient from where they are to the ambulance.  Hospital based EMS agencies in my experience are far to vulnerable to hospital politics.

I think this is spot on: for emergency response, fire-based EMS works to get sufficient trained practitioners on-scene soonest.  On the East Coast, with older buildings and inadequate alarms and sprinklers, actually having a fire department do just fires makes a bit of sense.  It doesn't make sense at all on the West Coast, because fires simply aren't often enough or big enough to justify the expense of maintaining a fire department, absent the rescue and EMS components.

When there's nothing going on for a combined West Coast fire/ems agency, what happens?  Disproportionately fire stuff: pre-incident planning, public education (fire-based, of course), code enforcement... Given that the mix between EMS and Fire is about 80/20 on the West Coast, why on earth aren't most career fire/EMS folks doing as much proactive EMS stuff as you would expect based on that 80/20 split?  Tradition, I suspect.

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Why would hospitals want this?

They want as many people in the ER as possible so they can jack up their revenues

You cant charge ER facility fees in an ambulance.

Hospitals are not going to support this. ERs are pure cash cows for them.  It's music to their ears when some idiot goes to the ER for an earache and their ER waiting room is chock full of snotty crying kids.  

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54 minutes ago, TexasPA28 said:

Why would hospitals want this?

They want as many people in the ER as possible so they can jack up their revenues

You cant charge ER facility fees in an ambulance.

Hospitals are not going to support this. ERs are pure cash cows for them.  It's music to their ears when some idiot goes to the ER for an earache and their ER waiting room is chock full of snotty crying kids.  

High utilizers that this might keep away are most often the people who don’t pay at all or at Medicaid rates.

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I was a Community Paramedic for 3 years prior to my life as a PA student.  I took a semester of primary care classes and did 170 hours of clinicals  with the Residents in Internal and Family medicine and in the specialty clinics with the internal medicine program (Cards, Endo, GI, Pulm etc).  With hours with practitioners and nurses in home health, wound care, hospice, palliative and peds.

Our program was a partnership between the hospital system and EMS system.  We were grant funded for 2 years and then the county took over our pay.  The hospital provided offices.  We obtained grants to buy vehicles that are maintain and owned on paper by the county. We worked within the Accountable Communities group at the hospital.

Our target was the uninsured patients which are NOT the cash cows of the ED.  It was highly successful and still continues to be today (I wish I could share data but it's not yet published).  

With the new ET3 that CMS has approved I see (and hope) that there will be more practitioners involved in programs like this. And the hospitals can still make money while patients are getting better treatment.

 https://naemsp.org/home/news/emergency-triage,-treat-and-transport-model-(et3)/

My dream job is to work with a Community Paramedic program as a PA seeing patients in their homes.  I don't see the need to another masters in medicine as PA seems like a natural progression for a lot of paramedics.  If you want to continue patient care there is no upward ladder in EMS.  


 

Edited by thatgirlonabike
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