Community Paramedic Toolkit REVIEW OF EXISTING COMMUNITY PARAMEDIC TOOLKITS December 2015

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June 2016

Community Paramedic: Existing Toolkits Minnesota Department of Health Office of Rural Health and Primary Care Emerging Professions Program PO Box 64882 St. Paul, MN 55164-0882 Phone: 651-201-3838 http://www.health.state.mn.us/divs/orhpc/workforce/emerging/cp/index2.html

This project is part of a $45 million State Innovation Model (SIM) cooperative agreement, awarded to the Minnesota Departments of Health and Human Services in 2013 by The Center for Medicare and Medicaid Innovation (CMMI) to help implement the Minnesota Accountable Health Model.

Upon request, this material will be made available in an alternative format such as large print, Braille or audio recording. Printed on recycled paper.

Table of Contents I. Introduction ............................................................................................................................. 4

Data Collection Methods ......................................................................................................... 4

II. Existing Toolkits ....................................................................................................................... 5

1. International Roundtable on Community Paramedicine ................................................. 5

Figure 1: IRCP Website Categories .................................................................................. 6

2. Mobile Integrated Healthcare: Approach to Implementation ......................................... 6

Figure 2: Mobile Integrated Healthcare, Table of Contents ............................................ 7

3. National Association of Emergency Medical Technicians: MIH-CP Program Toolkit ....... 7

Figure 3: MIH-CP Categories of Resources ....................................................................... 8

4. Principles for Establishing a Mobile Integrated Healthcare Practice ............................... 8

Figure 4: MIHP Implementation Steps ............................................................................. 9

5. Western Eagle County Health Service District: Community Paramedic Program Handbook ....................................................................................................................... 10

Figure 5: 12-Steps to Developing a CP Program ............................................................. 11

Figure 6: Map of Handbook Distribution Jan. 2014 – Dec. 2015 ................................... 12

III. Conclusion ............................................................................................................................. 12

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I. Introduction In order to make comparisons in Toolkit content and to identify additional resources helpful to employers, The Paramedic Foundation was charged with identifying, obtaining, and reviewing existing toolkits or similar documents related to Community Paramedics (CP) developed at the local, state, national level, or by non-profit, industry, foundation, clinic, health system, or other organizations. This document is a summary of the 5 existing resources identified as of December 2015.

Data Collection Methods Information on existing community paramedicine toolkits was obtained from conducting internet resource searches using the term, “Community Paramedic Toolkit”. The definition of a “toolkit“ used during the search included a “set of tools designed together for a particular purpose or function.” While internationally the kinds of programs operated by ambulance services that are in the realm of Emergency Medical Services (EMS), whether they are provided by Emergency Medical Technicians (EMTs), Advanced Emergency Medical Technicians (AEMTs), Community Paramedics, Registered Nurses, Nurse Practitioners, Physician's Assistants or physicians, are known as community paramedicine. In the United States, confusion has occurred with the introduction of the term "mobile integrated healthcare" (MIH) in 2013. MIH was introduced, by those who invented the term, to describe a system of resources from various sectors of healthcare, including community paramedicine. Unfortunately, the term has been used for purposes other than describing a system and this has resulted in confusion among policy makers, legislators, Congress and EMS agencies. Recognizing this confusion as potentially detrimental to the community paramedicine movement, five national associations met in January 2015for what was described as a "nomenclature incubator" session. Although The Paramedic Foundation is not a national association, they participated in the incubator meeting as the only ad-hoc participant. The group of association representatives came to a consensus on how the two terms should be used. However, as of December 2015, only four of the five association boards had approved the document; therefore, the consensus document has not been released publicly. The final association is expected to endorse the document in January 2016 at which time a joint association statement will be released publicly that includes the use of the terms Community Paramedicine and Mobile Integrated Healthcare as follows:

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Community Paramedicine: Programs operated by EMS agencies using people and systems normally regulated by a state EMS office. Programs focus on reducing hospital and EMS utilizations for patients who have been deemed either high utilizers of the EMS system in the past or have been recognized as a possible vulnerable patient by a healthcare provider including but not limited to medically underserved, low-income, mental health, intellectually disabled and geriatric populations. This is achieved through a combination of advocating for the patient, patient education and assistance navigating through the healthcare and social services industries in an efficient and timely fashion with the goal of financially impacting the healthcare system and medically impacting the patient.

Mobile Integrated Healthcare: The provision of healthcare using patient-centered, mobile resources in the out-of-hospital environment. Agencies that are not EMS agencies and are using a variety of healthcare providers normally regulated elsewhere in a state health department. It may include services such as providing telephone advice to 9-1-1 callers instead of resource dispatch; chronic disease management, preventive care or post-discharge follow-up visits; or transport or referral to a broad spectrum of appropriate care, not limited to hospital emergency departments.

Because of the confusion over terminology of the two programs over the last couple of years, TPFs search for toolkits on community paramedicine has produced results using either; and sometimes, both terms. For the context of Minnesota and this report, the reader should infer "community paramedicine" when reading "mobile integrated healthcare" in the balance of this report. After the associations issue the joint position statement, the confusion between the two terms should slowly dissipate.

II. Existing Toolkits 1. International Roundtable on Community Paramedicine The International Roundtable on Community Paramedicine (IRCP) has been collecting resources and convening an annual meeting since 2005. The IRCP’s mission is to:

“Promote the international exchange of information and experience related to the provision of flexible and reliable health care services to residents of rural and remote areas using novel health care delivery models and to be a resource to public policy makers, systems managers, and others. While its focus is on rural and remote medicine, the lessons learned may prove beneficial to the better provision of urban health care.” (IRCP n.d.)

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The IRCP website provides a collection of information from the following 11 categories listed below in Figure 1, including archives from conference presentations over the past 11 years.

Figure 1: IRCP Website Categories

1 Data Sets

2 Education

3 Expanded Role

4 Funding

5 General Articles

6 Networks

7 Paramedics in Hospitals

8 Performance

9 Policy

10 Research

11 Tools

Source (IRCP n.d.)

2. Mobile Integrated Healthcare: Approach to Implementation In 2016, Jones and Bartlett published a book, Mobile Integrated Healthcare: Approach to Implementation. The book’s list price is $101.95 and can be purchased on the website (Jones and Barlett Learning Webpage (http://www.jblearning.com)). The 148-page book contains 9 chapters and the overview states the following with regard to its purpose:

“Various programs like this have appeared across the United States, but a definitive resource that describes how to successfully implement such a program has not been available. [This book] fills this void by serving as a reference not only to the EMS community, but also to other medical professionals working toward implementation of a successful MIH program. [The book] provides a step-by-step approach for the identification of community needs, forming the appropriate partnerships, selection of staff, acquiring resources, patient identification, and overcoming hurdles to a successful program” (Jones & Bartlett Learning 2014).

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The book’s primary focus is on Mobile Integrated Healthcare, which is outside the scope of this report. However, the table of contents of the book has been outlined below (Figure 2) as a potential resource for future research.

Figure 2: Mobile Integrated Healthcare, Table of Contents

Chapter 1 The Current State of Healthcare and the EMS System

Chapter 2 Healthcare Reform and Mobile Integrated Healthcare Systems

Chapter 3 Organizational Readiness Assessment

Chapter 4 Assessing Community Needs and Promoting Stakeholder Engagement

Chapter 5 Program Development

Chapter 6 Types of Mobile Integrated Healthcare Programs

Chapter 7 Data Tracking and Performance Measures

Chapter 8 Initial and Sustainable Funding Models

Chapter 9 Where Do You Go From Here?

Source (Jones & Bartlett Learning 2014)

3. National Association of Emergency Medical Technicians: MIH-CP Program Toolkit

In July 2015, The National Association of Emergency Medical Technicians (NAEMT) compiled and published a Mobile Integrated Healthcare-Community Paramedic (MIH-CP) Toolkit on their website National Association of Emergency Medical Technicians (http://www.naemt.org). Five initial EMS agencies contributed forms, documents and questionnaires that they were currently using to run their MIH-CP programs. Since August 6, 2015, 37 documents have been posted to the website, which are sorted by 15 different categories. Figure 3 provides a list of those resource categories.

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Figure 3: MIH-CP Categories of Resources

1 CHF

2 High Utilizer

3 Hospice

4 Job Description

5 Legislation

6 Mental Health

7 Nurse Triage

8 Observation Admission Avoidance

9 Outcome Measures

10 Patient Assessment / Evaluation

11 Patient Handouts

12 Patient Referrals

13 Patient Satisfaction

14 Post-discharge Follow-up

15 Talking to Stakeholders

Source (MIH CP Program Toolkit 2015)

4. Principles for Establishing a Mobile Integrated Healthcare Practice

The Principles for Establishing a Mobile Integrated Healthcare Practice is a toolkit developed by The Mobile Integrated Healthcare Practice Collaborative, supported by Medtronic Philanthropy, and published in 2014 by the RedFlash Group. The publication outlines the 9 different steps to establish a Mobile Integrated Healthcare Practice (MIHP). Community paramedicine is referenced in the second section and the Program Taxonomy, states the following:

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“Despite the diversity of MIHP programs, common themes and defining characteristics are now present with sufficient maturity to warrant a descriptive taxonomy that expands beyond the community paramedicine model”.

The publication separates out MIHP and CP, emphasizing MIHP as the model of the future. Figure 4 includes the 9 different steps outlined in the document.

Figure 4: MIHP Implementation Steps

Step Description

1 Population Health Needs Assessment

Describes need for a population assessment including finding other relevant documents from previous assessments. (Page 8- 11)

2 Program Taxonomy Describes need for EMS to be included in taxonomy in four general types. (Page 12 – 16)

3 Infrastructure and People

Describes the types of personnel to consider helping run a program. (Page 17 – 20)

4 Competency and Education

Describes the need for education on competencies required for a specific program but not necessarily broad education. (Page 21 – 25)

5 Clinical Leadership and Medical Oversight

Describes the roles and responsibilities of the Medical Director (Page 26 – 28)

6 Financial Considerations

Describes how to engage partners and considerations for cost share and reimbursement. (Page 29 – 32)

7 Legal and Political Considerations

Discusses the challenges and opportunities in starting a program regarding local and state regulations. (Page 33 – 34)

8 Health Information Technology

Discusses need to create health information exchange and the viability to create this resource. (Page 35 – 37)

9 Program Evaluation Discusses needs and steps to create an evaluation program. (Page 38 – 40)

Source (Beck, E. & Beeson, J. et.al. 2014)

At the conclusion of the publication, 6 MIHP programs from 4 agencies were showcased from urban settings across the country. Unfortunately, the document can be difficult to obtain because the website for additional resources is no longer working.

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5. Western Eagle County Health Service District: Community Paramedic Program Handbook

The Western Eagle County Health Service District’s (Eagle County Paramedic Services) handbook was published in 2011 to help programs develop and learn from the processes that were developed in Colorado which created the first Rural CP program in the US. The handbook highlights the best practices from planning a CP program to medical direction. The handbook has many appendices that can be used for startup companies including sample Memorandums of Understanding (MOU’s), physician orders, and other helpful information.

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Figure 5: 12-Steps to Developing a CP Program

# Step Description

1 History Describes the origins of CP and why it is important to develop programs in the rural areas. (Page 3 – 7)

2 Plan to Plan Describes developing a list of community stakeholders and start with a needs based approach. (Page 8)

3 Assess Program Feasibility

Discusses the feasibility from all perspectives including local and state regulation. Includes a feasibility checklist. (Page 8 – 10)

4 Medical Direction Describes the need for Medical Direction and the type of medical director to involve. (Page 10 – 11)

5 Assess Community Needs

Details how to conduct a community needs assessment with local partners. (Page 11)

6 Program Scope Develops lists for services, needs, and budget (Page 11 – 14)

7 Engage the Community

Describes how to engage stakeholders and keep them engaged over the long term. (Page 15 – 16)

8 Policies and Procedures

Describes ideas and issues with development of policies and procedures including some ideas on what to develop. (Page 16 – 17)

9 Plan and Implement Education

Describes the process for engaging a college or university if needed for the education and training. (Page 17 – 18)

10 Develop an Evaluation Plan

Develops the evaluation tool for the program with data metrics. (Page 18 – 20)

11 Begin Operations Describes how to begin operations and engage the referral sources. (Page 20 – 21)

12 Evaluate the Pilot Phase

Describes how to continually evaluate the program including best practices on CQI. (Page 21)

Source (Western Eagle County Health Services District 2011)

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Since October 2011, the handbook has been requested on average 5 times per day from agencies around the world. Figure 6 below shows the distribution of the handbook from the beginning of 2014 through December 2015.

Figure 6: Map of Handbook Distribution Jan. 2014 – Dec. 2015

Source: (Western Eagle County Health Services District 2011)

III. Conclusion There appears to be at least a few handbooks or “how-to” manuals in existence for employers interested in starting up a CP Program. Each one is very comprehensive when considering program design, implementation, education and evaluation. Although this report described five existing toolkits or resources related to community paramedicine, there are really only three handbooks. The other two are resources mentioned are only sites with program templates. The handbooks described in this report include extensive templates and easy to use guides. The notable differences between the guides appears to be that the MIH handbooks are addressing the broader health care audience and the Community Paramedic manuals are addressing how EMS can integrate at a provider and programmatic level.

One document in this report “Principles for Establishing a Mobile Integrated Healthcare Practice” is no longer offered on the sponsor’s sites, but was searchable on another site. This may be because the principles described or the distribution of that manual was not widely accepted.

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The book titled, “Mobile Integrated Healthcare: Approach to Implementation”, while a convenient resource that includes all the topics in one location which can be shared with other persons in an organization and may be helpful in improving communications between EMS and health care administrators, is also the most expensive option when considering the amount and type of information provided in the book. Most of the topics and guidelines in the handbook can be searched and addressed without having to incur costs.

It is clear that the Western Eagle County Health Service District handbook has been the most widely distributed guide. It is free of charge and there has been an estimated 7,500 downloads on every populated continent globally with the widest distribution in North America. However, it has not been updated with newer practices that might be meaningful in the long term, due to the lack of resources needed to continue its development. Perhaps the Minnesota Department of Health’s Toolkit that The Paramedic Foundation is developing and will be published in 2016 will provide more updated information to help sustain the CP model for the long term.

Overall, there appears to be several resources available to employers interested in starting up a Community Paramedicine Program. Not only are there the resources described in this report on exiting CP toolkits, but also important information that can be gathered from the entities that are currently providing CP services. Those entities can provide a wealth of information on lessons learned, including the successes and challenges of developing, operating, and sustaining their programs as well as other helpful information. Employers are encouraged to consult with existing CP programs when planning their CP Program.

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References Beck, E. & Beeson, J. et.al. 2014. Principles for Establishing a Mobile Integrated Healthcare Practice. Encinitas, CA: RedFlash Group.

IRCP. n.d. IRCP . www.ircp.info.

Jones & Bartlett Learning. 2014. Mobile Integrated Healthcare: An Approach to Implementation. Burlington, MA: Jones and Bartlett.

"MIH CP Program Toolkit." NAEMT. http://www.naemt.org/MIH-CP/mih-cp-toolkit.

"IRCP Downloads Section." IRCP. http://ircp.info/downloads.

Western Eagle County Health Services District. 2011. "Community Paramedic Program Manual Section." Community Paramedic Program. http://www.communityparamedic.org/Program-Handbook.