Good start (on legislative draft). Loose language as to who can do this which is good. I think language to permit EMT/mid-level blended crews should be added. In some areas having and EMT at any level with someone who can prescribe makes sense.
Training must be able to be provided by a DHS approved training facility. Remove the college or university language.
Rick. Sent from my iPhone
I have to disagree on the college part. Some of us are working really hard to build the paramedic (EMT, AEMT and paramedic) profession using community paramedicine as the launching platform. This is the first time the majority of the country has rallied around putting anything EMS into the college system (everybody fought it, and is still fighting it, when the National Registry tried). All of the states that have so far enacted some sort of legislation have included the college education component, to the best of my knowledge. Those are Minnesota, Missouri, North Dakota, Washington, Maine, Idaho and Arkansas (and California, which used a loophole to start pilots - that included college training).
There will be an internationally standardized Community Paramedic exam this Fall, for those at the paramedic level. The entry requirements for the exam are likely to include college training. Why would we want to lock our paramedics out of being able to demonstrate their competency using a standardized exam and earning a CP-C credential that will cross not only state but international boundaries? Why would we want Wisconsin to be the only state not having this in the higher education system?
Dr. Barney isn't the only physician that has made a comment like this, and frankly, I'm personally a little bit put off by a profession that just went through a multi-year very difficult process of creating a sub-specialty not supporting the education of paramedics (EMTs, AEMTs and paramedics in the US). That the people that did that process now want to hold us back. That's not leadership.
We need physician leaders in the United States more like Dr. Andy Travers in Nova Scotia. He has gone to bat for their paramedics to be a self regulated profession under the Nova Scotia College of Paramedics, following suit of other Canadian Provinces, in lock step with the United Kingdom, and headed down the same pathway as Australia. We need people to go to bat for our profession like in the United Kingdom where there is a current effort to get paramedics with master's and doctoral degrees independent prescribing rights. (If you want to hear more about that, tune in to next month's International Roundtable on Community Paramedicine webinar when Andy Sharman from the UK College of Paramedics will talk about it - www.ircp.infowww.ircp.info - and join us in Melbourne, Victoria, Australia in October when he does it live and presents the political outcome that will occur sometime this summer.) Who needs mid-levels when master's and doctoral prepared paramedics are mid-levels and can prescribe?
I heard Baxter Larmon put this in simple terms at a conference last month. He asked the audience if they wanted their 5th grade sons and daughters to receive school-based training in sex or be educated about sex.
Dr. Barney, stand up for us. We need people like you to push us forward into the future, not hold us back in the past.
The industry put forward a consensus document that includes a more professional workforce by including college education for just this piece. I don't like everything in it. Using the label CMRT is not helping advance paramedicine, but I recognize it as consensus work, and until now was choosing to be silent about that part, mostly because while I had the chance to be part of the consensus building, it didn't fit my schedule. Down the road Wisconsin can put another regulation in that ties the CP-C credential to parts of the CMRT.
If we did this smartly, we'd skip creating a new state license level and instead (for paramedics at least) let the CP-C credential bypass all state process for those that attain it. Like some states have done making the CCP-C an "endorsement" to a paramedic's license instead of creating a new licensing category for critical care paramedics. Why create all that state process and work when there is already an exam through which competence is determined? What was put forward is not ideal probably for any of us, but it is workable. One component that would be helpful is unencumbered reciprocity for those licensed in another state, but you don't need that if you tie CP-C to it in regulation.
Since the bully pulpit has been opened, I'll take the time to use it. If we're going into licensing, this is the time for us to change EMT to primary care paramedic, AEMT (and all other middle levels) to intermediate care paramedic, and paramedic to advanced care paramedic. If we not ready to go all-in by aligning internationally, we can start by leaving those three alone, but giving the label primary care paramedic (PCP) to EMTs that have a degree, intermediate care paramedic (ICP) to AEMTs that have a degree and advanced care paramedic (ACP) to paramedics that have a degree. Now that would be a professional step forward. It would separate the technicians from the clinicians - at all three levels. It's time we stop being the third world country, of all industrialized countries, in EMS.
And we're getting ever closer to the time when we should start talking about moving into the 1990's and becoming a self-regulated profession under a Wisconsin or North American College of Paramedics. Thanks to parts of Canada and all of the UK (and soon Australia) that process is already built and we can follow their recipe.
(For the record, I don't have a college degree now nor did I have one for any of the 25 years I spent as a licensed EMT and paramedic.)
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Gary Wingrove
Mayo Clinic Medical Transport
1216 Second Street SW
Rochester, MN 55902 USA
Gary!
I get it my man and I am behind making EMS a profession. I appreciate all your leadership and work to date. I generally agree that college education is the way to go. The problem is when local colleges can not provide the training. Then what?
Distance learning is best option with clinicals locally. All I am saying is that a hospital qualified and able to teach should be permitted to do so.
Moving forward with community paramedicine is important. Moving forward with making EMS a profession is important. Let us all work together for the best possible bill in Wisconsin that serves our State and needs. Flexible staffing, ease of education availability are important.
Thanks to everyone on here.
Rick Barney MD
A simple articulation agreement between the hospital and a college will address that issue.
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Gary Wingrove
Mayo Clinic Medical Transport
1216 Second Street SW
Rochester, MN 55905 USA
I sure wish that was true for us. Our local tech college does not have paramedic training, so can not provide credit. I'm hoping another WI Tech College can, but district boundaries become an issue.
I'll look into the matter. I know from being the State Medical Director in the 90's that good ideas, rules, laws etc are always more complicated when dispersed.
We do need accredited colleges and institutions teaching EMS. I agree. But there are many areas where this availability is not close by.
We will get it figured out because this must move ahead.
What is your take on hours requirement to take the international exam?
Thanks for your work and leadership to date. Hope you don't mind the questions.
Rick Barney MD. FAAEM
Associate Medical Director
Mercy Regional EMS training Center
Rock County Wisconsin
We can find you an out of state college to work with if necessary. I hope that's not necessary.
BCCTPC is doing the exam process completely independent of any outside entity in order to maintain integrity in the exam creation process. I will learn a little more about their process and anticipated ready date in a couple weeks when I'll attend a meeting at their place.
Most of the colleges are running between 200 and 300 hours (roughly 12-14 credits).
Hennepin Technical College has a distance learning option, so that is definitely doable. They have students literally all over the world.
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Gary Wingrove
Mayo Clinic Medical Transport
1216 Second Street SW
Rochester, MN 55905 USA
Awesome comments.
The Community Paramedic curriculum works for EMTs and AEMTs. The college has to modify it so they stay in scope of practice. They do more on assessment/advanced assessment, learning take home meds, etc. If we don't change their name to primary care paramedic, then we may have to call them something else, if people won't buy into Community Paramedic EMT.
Airplane door just closed. I'll hit the other topic later.
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Gary Wingrove
Mayo Clinic Medical Transport
1216 Second Street SW
Rochester, MN 55905 USA
Gary
Thanks. This discussion board helpful. Greg West already solved my first issue.
After our assessment, our curriculum needs will be known. I look forward to hearing from you when you know more about the exam.
I have seen the curriculum. Based on our needs, about 120-150 hours seemed about right. This would be at Paramedic level.
A national cert would allow anyone to move and provide the care. I guess we will wait to see what you learn. We would be in a position to train this winter.
Rick
Paul, your second question had to deal with how to compensate for a professional service.
The answer to that question right now is largely local. Minnesota and North Dakota have the ability to pay for the CP services through Medicaid, but Medicaid is generally a small proportion of any agency's payer mix. The big gorilla for payment for CP is Medicare. The Field EMS bill has a provision requiring CMS to pilot such payment. CMS has now funded 6 CP programs for 2 years each to a total of about $42.9 million through their Innovation Center, so they are already learning about it. We are likely a few years away from Medicare paying for the CP services universally, maybe several years. There are several CP programs in the US that have contracts with Accountable Care Organizations or other payers like Blue Cross.
As it regards our services in general there are rural places with small populations that have full time ambulance services. I spent some time weeding through Wisconsin's statutes because I had heard that counties were responsible to fund EMS in Wisconsin. I can't find a statute that says that, though. Interestingly while counties (WS 59.43), cities (WS 62.133) and villages (WS 61.64) "may" provide and tax for ambulance service, towns (WS 60.565) are obligated to provide or contract for it. Towns are all unincorporated parts of the state, so basically the places with the smallest populations. If there is a statute that requires a county to fund it, maybe someone else on the list knows what it is.
Several states have county organized and funded ambulance services in rural areas. Kansas, Missouri, North Carolina and Colorado are ones that do. Sometimes by a mandate to the county by the legislature, sometimes because the county commissioners decided to fund it from taxes, and sometimes because there is a state law provision for "ambulance taxing districts". At least one ambulance service in Colorado is funded by forming a "health care district". Taxing districts usually require the county to authorize the district and then the voters decide by ballot at election time. The taxing district usually doesn't affect any levy limits a city or county may have, because an ambulance taxing district is added to the end of a property tax bill just like schools are.
I spent most of last week doing some assessment work and strategic planning with a town of 1,700 in a county with 3,000 residents in Nebraska. This town has a Critical Access Hospital. The CAH gets cost based reimbursement from Medicare and Medicaid. The CAH in town can also get cost based reimbursement for an ambulance service it both owns and operates, if there is no other ambulance service within a 35 mile drive on improved roads in any direction. If this town can get two other volunteer ambulance services to join them and all three would fall under the ownership of the CAH, all three ambulance areas can be covered by full time staff (change the existing staff from volunteer to paid) and it will mostly be paid for by Medicare and Medicaid. There are only a handful of CAHs that get cost based ambulance service payment in the US because in most areas of the country ambulance services are spaced less than 35 miles apart. There are lots of CAHs around the country that use their own EMTs and paramedics or have partnerships with ambulance services whereby the local EMTs and paramedics work inside the CAH in between ambulance runs. When that works, the CAH gets payments for the EMT or paramedic when they are on duty inside the hospital (which they can pass on to the ambulance service under contract), and the ambulance service gets payment for them when they are doing ambulance runs. Almost as good as getting the cost based ambulance payments. The EMTs or paramedics work in the hospitals doing one or more of: work in the emergency department; conduct cardiac stress tests; perform endotracheal intubations in the hospital when anesthesia staff are not available; restock supplies and drugs; assist with suturing, casting and back boarding; move patients within the facility; medical education; training and quality; research; marketing; industrial medical services; community paramedicine; nuclear medicine; customer service; surgery and orthopedic surgery clinic staffing; retail occupational health services; wellness services; and, public health services (such as providing flu shots), among others. Nebraska has a significant number of CAHs that use EMTs and paramedics in their hospitals, maybe the most of any state in the country.
There is one county in North Dakota that can't attract any public health nurses for employment. It is their intention to hire two or more Community Paramedic EMTs once some local volunteer EMS staff get trained, to fulfill many of their public health responsibilities. They will be featured on some upcoming edition of the Community Paramedicine Insights Forum (http://cpif.communityparamedic.org).
There are options. Sometimes those are with the taxpayers, sometimes they are with untraditional partnerships.
Perhaps there are other ideas/working models someone else could share.
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Gary Wingrove
Mayo Clinic Medical Transport
1216 Second Street SW
Rochester, MN 55902 USA
Hi all
I applaud the changes proposed and the alignment with international standards. If we were able to do accomplish this alignment and CoAEMSP adopted these as standards, would Wisconsin have an opportunity to also evolve and modify some of the DHS requirements related to sequencing and delivery of curriculum. Could the state of Wisconsin just “bless” accredited EMS programs? Some of the these requirements make it challenging for educational institutions to deliver programs.
MANY changes will need to occur in order for the profession to grow and become a respected partner in healthcare. We need to support all individuals able to be part of our looming healthcare personnel crisis.
Diane Osterhaus Neefe, BSMT, Ed.D.
Dean of Health and Public Safety
Western Technical College
