The Maine EMS Critical Access Physician Extender Pilot Project Proposed Implementation for April 1, 2021 in Jackman, ME

Submitted by: North East Mobile Health Services

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Table of Contents

Introduction: ......................................................................................................................... 3

Physician extension models: .................................................................................................. 4

Proposal: ............................................................................................................................... 7

Clinical Practice: .................................................................................................................... 8

Clinical Skills of the Critical Access Integrated Paramedic: .................................................... 10

Oversight: ........................................................................................................................... 12

Training, Education, and Supervised Clinical Experience: ...................................................... 13

Credentialing and Recredentialing ....................................................................................... 19

Pending work products ........................................................................................................ 20

Introduction:

The story of American growth is one of population migration from rural to urban life. In 1960, 30% of Americans lived in rural areas; in 2018, less than 18% did. This shift in population has been accompanied by changes in rural healthcare access with initial growth and then ultimately reduction in the number of rural hospitals. Despite programs like Critical Access Hospital designation, the number of rural hospitals continues to decrease. From 2010 to 2019 119 rural hospitals have closed, with a record 18 closing in 2019. Rural American travel almost twice as far to the nearest hospital as their non-rural counterparts, with the top quartile of rural patients having to travel 34 minutes to the nearest hospital versus 21 and 18.7 minutes respectively for their suburban and urban counterparts.

Recruiting and retaining healthcare workforce in rural areas is also a challenge, although

certainly not a new one. Less than 12% of US physicians practice in rural areas. While nurse practitioners and physician assistants can provide clinician workforce, many of the same challenges that impact physician recruitment to rural areas impact PA and NP recruitment as well. In addition, there is a global nursing shortage that is more pronounced in rural areas. Similar shortages have been identified amongst rehabilitation therapists, radiology technologists, and dentists.

The negative health impact of social determinants of health, particularly socioeconomic

status, are also felt more keenly in rural than urban communities. In particular, poverty levels are higher in rural areas, most new job creation in the US is in metropolitan areas, there are more individuals with disabilities in rural areas, and educational attainment is lower in rural areas.

Despite these disadvantages of rural life, Americans report they would prefer to live in rural

areas more than any other locale. Entrepreneurship as measured by self-employed business ownership and is greatest in rural areas, as is 5-year survival of new business. People tend to be happier in rural areas than urban areas citing less crowding, perceptions of better environmental quality, are more likely to own their own homes, and more likely to live in their state of birth. Rural residents are also more likely to know most or all of their neighbors, be willing to give a neighbor a set of keys to their home, are more likely to be rooted in the community (living in same place for more than 10 years), and more likely to have most or all of their families living nearby.

Like many communities in Maine, organized healthcare in Jackman started in the early

1900s as a Mission of Catholic nuns of the French Order of St. Joseph and the first physician, Dr. Henry Smith, opened his practice in 1948. At that time, the closest hospital was 75 miles away in Skowhegan. In 1951, Dr. Smith worked with Rev. Emile Dussault, the Rev Mother Agnes Marie, and local parties to acquire and renovate the Murtha estate and in September 1952, the Murtha Memorial Hospital opened under the management of the Sisters of St. Joseph. The nuns served as nurses and administrators for the hospital, working to assure clinical staffing

and growing the hospital. Over the first decade there were 727 outpatient encounters, 2,285 inpatients, and 409 deliveries in the hospital. By 1964 it had become clear that demand has outstripped the hospital capacity and plans were made to build the new 14 bed Marie-Joseph Hospital. The facility opened its doors on December 7, 1967 in the building that ultimately became the current Jackman Community Health Center.

In the mid 1970’s the hospital became part of what would ultimately become the

MaineGeneral Health system. By the end of the 1970’s however, the hospital had ceased inpatient operations and was functioning as an outpatient office and a nursing home. Given the nursing staff on duty for the nursing home, 24 hour urgent and emergency care services were maintained in the community. This arrangement continued until 2014 when MaineGeneral Health was no longer able to support the clinic and management of primary care operations and building ownership was taken over by Penobscot Community Health Center (PCHC), a Federally Qualified Health Center. MaineGeneral continued to manage and operate the nursing home and because the nursing staff remained, PCHC clinician staff were able to provide on-going 24 hour a day urgent and emergency care.

In June of 2017, MaineGeneral announced it was closing the nursing home. With the loss of

that nursing staff, the PCHC board voted to focus the clinic to the core FQHC mission of primary care services and end the after-hours care. However, the Moose River Valley Community rejected that option. Dr. Pat Doyle, who had worked at the Jackman Clinic since 1987, created a temporary arrangement (planned for 6 months while a new sustainable model was developed) using on-call medical assistants to assist the clinicians. This temporary arrangement continued through 2019 when it finally became clear that the human tool of the MA call system was non-sustainable and the call burden on clinicians was making recruitment of permanent physician, NP, and PA staff impossible.

From 2018 to the present, First To Last Health Services Solutions Inc was contracted by

PCHC under a Maine Health Access Foundation grant to collaborate with the Moose River Valley community to identify models of care delivery that would be medically and financially acceptable. Ultimately the community selected what was called the Community Care Physician Extender (CCPE) model. Various modes of delivery including physician delegated practice were considered as the basis for this care. Ultimately it was felt that the best home for such a healthcare delivery model was within the state EMS structure and the name was changed to the Critical Access Physician Extender Pilot Project.

Physician extension models: Physicians have long used variously trained and skilled providers to extend their practice.

Although many models existed through the 18th century, it was in the 1930’s that military medical practitioners were introduced into the federal prison system to provide care under the indirect supervision of physicians. This ultimately led to Dr. Amos Johnson, a physician in North Carolina, to identify Buddy Treadwell as his “doctor’s assistant.” This model set the basis for the

development of the Physician’s Assistant and ultimately the Physician Assistant level of care seen today. Almost simultaneously, formal Nurse Practitioner education and credentialing came into existence.

However, there are also several models in which physicians extended their care using

practitioners with substantially less training in the civilian setting. These could all be considered as forms of paramedicine which is defined as a unique practice of medicine in which:

• Care is directed in its entirety by an overseeing physician, either directly through real-time medical direction or asynchronously through proscriptive protocols

• Care is delivered remotely from the location and practice of the physician • Paramedicine practitioners develop clinical impressions or presumptive diagnoses that

then guide them as to which treatment protocol to follow • Paramedical care is 100% reliant on communication between a physician and the

paramedicine practitioner • Paramedicine is delivered as part of an organized system of care • Paramedicine providers engage in life-long learning as medical knowledge, diagnoses,

and treatments evolve

In 1790, the US Federal Government provided medicine chests to American flag vessels of

150 tons or more and manned by 10 or more persons. What was to become the US Public Health service was founded in 1798 to care for sick and disabled merchant seaman and in 1881 the Handbook for the Ship’s Medicine Chest, essentially a set of protocols, was published to support the non-physician medical providers aboard commercial vessels. This practice evolved to the modern day roles on commercial vessels of the Medical Care Provider and Medical Person In Charge (MEDPIC), clinical practitioners in highly isolated locations remotely supported by physicians to provided sophisticated care.

One of the earliest models of physician extension outside of the maritime industry was the

Alaskan Community Health Aide. Starting as a model of lay community health workers in Alaska Native villages in the 1940’s, by the mid-1990s the program had matured to a system in which highly trained Community Health Practitioners using sophisticated protocols and supported by telemedicine were delivering primary care and limited urgent and emergency care in isolated villages. This quasi-independent practice is now provided by over 500 Community health Aides / Practitioners in more than 170 native Alaskan villages.

In 1995, New Mexico Senate Joint Memorial 44 directed the NM Department of Health to

explore ways in which EMS could be leveraged to enhance community health. This directive led to one of the earliest expanded scope of service and practice EMS projects in the town of Red River. The Red River Fire Department trained 5 paramedics to provide a number of urgent and primary care services (Ludwig, 2014). Although initially heralded as success, ultimately the program was plagued by bad outcomes and practice outside of the program scope. This was attributed to failure of the medical oversight and loss of control of the practice.

Other models such as the Navy’s Independent Duty Medic (IDM) program and various

industrial resource extraction medic programs also serve as models of physician extension to a greater or lesser degree. None of these models directly translate into the type of urgent and emergency care that is needed in Jackman but all of them offer elements that would be important to the execution of such a program. The CCPE is an expanded scope of service and practice EMS practice based on the extended training and telemedicine support of the Alaska CHA/P program with an emphasis on the urgent and emergency care which are the core of the IDM and the MEDPIC practice.

Proposal: North East Mobile Health Services proposes to operationalize the Critical Access Physician Extender in Jackman as an Expanded Scope EMS Pilot Project. Using a model of response to emergency calls, the Critical Access Integrated Paramedics (CAIPs) will facilitate physician delivered urgent and emergency care either under the direct supervision of Jackman Community Health Center practitioner staff or by emergency physicians via telemedicine to the patients in the Moose River Valley. North East Mobile Health Services will staff a specially trained paramedic, the Critical Access Integrated Paramedic (CAIP), in Jackman. These CAIPs will provide response to emergency calls in all locations in the Moose River Valley in accordance with arrangements with the primary responding agency, Jackman Moose River Fire Rescue. When treatment without transport to a hospital emergency department is appropriate, these CAIPs will provide definitive care using their expanded scope of practice under the direct supervision of either a qualified in-person practitioner or an emergency physician via telemedicine. Upon approval by the Maine EMS Board, the intended go-live date is April 1, 2021 with training and education to be initiated in September 2020. Parallel work over the summer of 2020 will include the development of all educational materials, institution of the final QAPI program, and finalizing the credentialing process. It is important to note that this pilot project is for the provision of emergency medical services managed with an expanded set of protocols and skills and integrated with Qualified Healthcare Practitioner care and management. Therefore, EMS Board approval is necessary to move forward with demonstrating the critical role that EMS can play in providing at-risk populations with appropriate, high quality, and system integrated urgent and emergency care access.

Clinical Practice: First and foremost, it is critical to understand that the Critical Access Integrated Paramedic can NEVER perform any skill or procedure outside of the scope of practice of a Maine EMS Licensed Paramedic without a DIRECT and REAL-TIME order by a physician or, in the setting responding to an emergency call at the Jackman Community Health Center (JCHC) during regular business hours, an approved qualified healthcare practitioner. This is not a pilot project to create “super-medics” who are practicing independently. This is a proposal to marry telemedicine with the expanded skill set of a paramedic to improve acute and emergency healthcare access. This pilot project will be executed in the Moose River Valley. Responses will occur to any non-hospital location in the Moose River Valley (there are currently no hospitals in this region) including the Jackman Community Health Center. The JCHC is currently operated by Penobscot Community Health Care (PCHC). Direct care will be provided by paramedics employed by North East Mobile Health Services serving as Critical Access Integrated Paramedics (CAIP). Telemedicine will provide by the St. Joseph Hospital Emergency Department. The workflow for patient encounters will be as follows:

1. The CAIP is dispatched to an emergency call a. The patient will receive triage screening by the CAIP and a history and physical

i. Patients will be triaged to one of the following categories 1. The patient is generally stable but requires services beyond the

capacity of CAIP a. The patient will be transferred to an emergency

department by ambulance unless the patient refuses 2. The patient is unstable and requires services beyond the capacity

of CAIP a. The patient will undergo a telemedicine visit with an

emergency physician who will direct care b. The CAIP will execute the physician orders within the

scope of practice of the CAIP c. Arrangements will be made for the transport of the

patient to an emergency department by the most appropriate modality

3. The patient is stable and may be appropriately treated by the CAIP

a. The patient will undergo a telemedicine visit with an emergency physician who will direct care

b. The CAIP will execute the physician orders within the scope of practice of the CAIP

c. The patient will be discharged with an appropriate disposition

2. A patient presents to the JCHC during regular business hours with an urgent or emergency complaint

a. The CAIP will respond to the patient as requested. b. The CAIP will assist the on-site provider as directed within the CAIP scope of

practice. c. The CAIP may initiate a telemedicine consult with an emergency physician as

directed by the on-site provider.

Clinical Skills of the Critical Access Integrated Paramedic: The CAIPs will be trained using standard medical pedagogy including didactic education, laboratory training, and supervised clinical experience (please see the section on “Training, Education, and Supervised Clinical Experience” for full details). Additionally, CAIPs will go through initial and on-going credentialing including mandatory minimum performance of skills and ongoing review and updates. Upon the completion of initial training, the CAIP will be credentialed to perform the following skills and procedures by the order and under the direct live or tele-supervision of qualified healthcare practitioners who have also been credentialed to perform these skills and procedures by their respective organizations (Penobscot Community Health Care or St. Joseph Healthcare). The standard for the performance of any procedure without a specific protocol is the guidance of the supervising qualified healthcare practitioner. The Standard of Reference will be either the current edition of Roberts and Hedges: Clinical Procedures in Emergency Medicine or its derivative texts, Roberts and Hedges: Clinical Procedures in Emergency Medicine and Acute Care and of Roberts and Hedges: Clinical Procedures in Emergency Medicine for Physician Assistants/Nurse Practitioners. Skills and procedures:

1. Fiberglass splinting 2. Non-sedated joint dislocation reduction

a. Finger b. Shoulder c. Patella d. Fracture-dislocations

3. Urinary catheter placement 4. Wound management

a. Cleaning b. Limited debridement c. Closure

i. Topical skin adhesive ii. Wound tape

iii. Single layer closure (suture/staple) iv. Two layer closure (suture/staple)

5. Local and regional anesthesia a. Local anesthesia b. Field blocks c. Digital block d. Hematoma block

6. Soft tissue acute foreign body removal (e.g. fish hooks)

7. Rapid sequence intubation 8. Ventilator management 9. EENT procedures

a. Ear exam b. Ear irrigation c. Ear foreign body removal d. Epistaxis management e. Ocular fluorescein application f. Eyelid inversion g. Topical anesthesia h. Ocular irrigation i. Superficial foreign body removal

10. Ultrasound a. eFast b. Aorta c. Soft tissue d. Peripheral vascular access

11. Nail trephination 12. Skills of the medical assistant

a. These skills will have been taught by PCHC during orientation and training 13. Telemedicine facilitation 14. All skills/procedures within the current scope of practice of a Maine EMS Licensed

Paramedic 15. Other procedures as identified by the Medical Oversight Committee and/or the

Community Oversight Committee

Oversight: In a phrase, Red River got the concept right and the execution wrong. Simply put, close, consistent, and continuous oversight is critical for sustained success of any expanded scope EMS program. Even though this program includes qualified healthcare practitioners in every encounter and a physician in every telemedicine encounter, none the less it is critical that the outcome of every intervention be evaluated to assure that patients are getting the best care possible. The Community Access Physician Extender program will be overseen by a Medical Oversight Committee. Every patient encounter will be audited by the Medical Director or QAPI Coordinator and encounters of concern or excellence will be brought to the Clinical Practice Committee. In addition, during the pilot project phase every encounter in which a procedure is performed will be reviewed by the Clinical Practice Committee. LifeFlight of Maine has agreed to serve as a technical advisors in the implementation and execution of the QAPI plan. Composition of the Medical Oversight Committee:

• North East Mobile Health Services QAPI Coordinator

• Critical Access Integrated Paramedic

• North East Mobile Health Services CAPE Program Medical Director

• Jackman Community Health Center Qualified Healthcare Practitioner

• Jackman Community Health Center Clinical Staff Member

• PCHC CMO or clinical designee

• Maine EMS Regional Medical Director

• St. Joseph Healthcare Telemedicine Emergency Physician In addition, there will be an Operational Oversight Board to which the program answers. Composition of the Operational Oversight Board will include:

• Representative from North East Mobile Health Services

• Representative from Jackman Community Health Center

• Jackman Town Manager

• Community representative from the Moose River Valley

• Representative from St. Joseph Healthcare These process and supporting documents will be developed with input from LifeFlight of Maine between now and the start date for the pilot.

Training, Education, and Supervised Clinical Experience:

1. Initial Education a. Didactic (50 hours)

i. ESI Triage ii. Principles of musculoskeletal injury assessment and management

1. Fractures 2. Dislocations 3. Sprains 4. Strains 5. Management

a. Splinting i. Commercial

ii. Fiberglass b. Crutch use c. Reduction

i. Dislocations 1. Finger 2. Patella 3. Shoulder

ii. Fracture-dislocation 1. Ankle

iii. Local and regional anesthesia 1. Local anesthetics 2. Procedures

a. Local anesthesia b. Digital blocks c. Field blacks d. Hematoma blocks

iv. Wound management 1. Pathophysiology 2. Natural course 3. Evaluation of wounds 4. Techniques of wound management

a. Cleaning b. Limited debridement c. Closure

i. Skin adhesive ii. Skin tape

iii. Single layer and two layer wound closures 1. Suturing 2. Stapling

5. Soft tissue injuries including penetrating injuries

a. Pathophysiology b. Assessment c. Management

i. FB removal d. Subungual hematoma

i. Nail trephination v. Soft tissue infections

1. Pathophysiology 2. Assessment 3. Management

a. Superficial abscess drainage vi. Ophthalmologic disease

1. Pathophysiology 2. Assessment 3. Preparing a patient for a telemedicine evaluation 4. Techniques

a. Topical anesthesia b. Lid eversion c. Irrigation d. Fluorescein application e. Superficial foreign body removal

vii. ENT Disease 1. Ear complaints

a. Pathophysiology b. Assessment c. Procedures

i. Ear exam ii. Telemedicine ear exam

iii. Irrigation iv. Superficial foreign body removal

2. Sore throat a. Pathophysiology b. Assessment c. Medical management

3. Epistaxis a. Pathophysiology b. Assessment c. Management

i. External pressure ii. Placement of internal balloon packing (e.g. Rhino

Rocket®) viii. Urinary retention

1. Pathophysiology 2. Management

a. Urinary catheter placement ix. Respiratory and airway management

1. Rapid sequence intubation 2. Initial ventilator management

x. Ultrasound 1. Theory 2. Practical uses for the CAIP 3. Studies

a. eFAST b. Aorta scan c. Soft tissue evaluation d. Peripheral vascular access

4. Telemedicine image transmission xi. Introduction to Community Health Education xii. Skills of the medical assistant

1. Review: taught as part of the PCHC orientation xiii. Telemedicine

1. Theory 2. Practice 3. Facilitation 4. Use of accessories

a. Otoscope b. Ophthalmoscope c. Stethoscope

b. Laboratory sessions (50 hours) i. Completion of CCTI programs

1. Difficult Airway Lab 2. RSI 3. Trauma Skills Lab

ii. Musculoskeletal 1. Splinting

a. Commercial b. Fiberglass

2. Crutch use 3. Reduction

a. Dislocations i. Finger

ii. Patella iii. Shoulder

b. Fracture-dislocation i. Ankle

iii. Local and regional anesthesia 1. Local anesthesia 2. Digital blocks

3. Field blacks 4. Hematoma blocks

iv. Wound management 1. Cleaning 2. Limited debridement 3. Closure

a. Skin adhesive b. Skin tape c. Single layer and two layer wound closures

i. Suturing ii. Stapling

4. Foreign body removal 5. Nail trephination

v. Superficial abscess assessment and drainage vi. Ophthalmology

1. Topical anesthesia 2. Lid eversion 3. Irrigation 4. Fluorescein application 5. Superficial foreign body removal

vii. Ear disease 1. Ear exam 2. Telemedicine ear exam 3. Irrigation 4. Superficial foreign body removal

viii. Epistaxis 1. External compression 2. Balloon placement

ix. Urinary catheter placement x. Initial ventilator management

xi. Ultrasound 1. eFAST 2. Aorta scan 3. Soft tissue evaluation 4. Peripheral vascular access

xii. Telemedicine 1. Initiation of a visit 2. Facilitation of camera views 3. Use of accessories

c. Clinical rotations (competency based, 50-150 hours, numbers in “()” indicate required minimums)

i. Endotracheal intubations (20) ii. Fiberglass splinting (15)

iii. Crutch teaching (3)

iv. Joint reduction 1. Shoulder: (1 Live or 5 simulated) 2. Digit: (1 live or 5 simulated) 3. Patella: (1 live or 5 simulated) 4. Ankle fracture/dislocation: (1 live or 5 simulated)

v. Hematoma block (1 live or 5 simulated) vi. Wound management

1. Wound injection of LA (15) 2. Field block (5) 3. Wound irrigation (30) 4. Wound closure

a. Single layer (25) i. Minimum of 15 with sutures

b. Two layer (10) c. Staples (5)

vii. Nail trephination (1 or 5 simulated) viii. Abscess I&D (5)

ix. Ophthalmology 1. Topical anesthesia (5) 2. Lid eversion (5) 3. Fluorescein application (5)

x. Epistaxis 1. Balloon packing placement (1 live or 5 simulated)

xi. Urinary catheter placement (5) xii. Ultrasound

1. eFAST (25) 2. Aorta (25) 3. Soft tissue (10) 4. Peripheral vascular access (10)

2. Ongoing education / skills validation a. Annual

i. CCTI 1. DAL 2. RSI 3. TSL

ii. Medical director skills evaluation iii. 50 hours of clinical rotations at St. Joseph Hospital iv. Proof of (can be completed during clinical duties or during clinical

rotations) 1. Wound management (10) 2. Epistaxis management (1) 3. Ultrasound (5 of each study type) 4. Splinting (10)

b. Semi-annual

i. 8 intubations c. Additional didactic and skills laboratories as assigned

i. CAIP scope of practice as originally trained ii. Additional skills and procedures as approved by the MDPB

Credentialing and Recredentialing Upon completion of all didactic, laboratory, and clinical training, CAIPs will be required to submit an application for credentialing. This will be comprised of all evaluation forms from instructors and preceptors as well as procedure logs. This packet will be reviewed by the Medical Oversight Committee and, upon approval, the CAIP will go through oral boards with the Medical Director and a physician representative consisting of a simulated telemedicine encounter. Successful completion of this oral board will lead to a vote by the Medical Oversight Committee to approve or deny the credentialing application. A unanimous vote by the Medical Oversight Committee is required for credentialing. Recredentialing will occur on an annual basis. Application for recredentialing will include proof of successful completion of all required continuing education activities, completion of a skills test with the medical director or physician designee, and endorsement by the Community Oversight Board. A unanimous vote by the Medical Oversight Committee is required for unrestricted credentialing; otherwise, the CAIP may by recredentialed with a limited remediation plan or not recredentialed.

Pending work products Although this application provides considerable detail, we expect that the following work products will need to be submitted to Maine EMS prior to final approval: Complete QAPI plan Syllabus for Initial training Skills evaluation / verifications forms Procedure log forms Credentialing forms RSI protocol Other documents and processes as requested by Maine EMS