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Pandemic Exacerbates the ‘Paramedic Paradox’ in Rural America

Even after she’s clocked out, Sarah Lewin keeps a Ford Explorer outfitted with medical gear parked outside her house. As one of just four paramedics covering five counties across vast, sprawling eastern Montana, she knows a call that someone had a heart attack, was in a serious car crash, or needs life support and is 100-plus miles away from the nearest hospital can come at any time.

“I’ve had as much as 100 hours of overtime in a two-week period,” said Lewin, the battalion chief for the Miles City Fire and Rescue department. “Other people have had more.”

Paramedics are often the most highly skilled medical providers on emergency response crews, and their presence can make a lifesaving difference in rural areas where health services are scarce. Paramedics are trained to administer specialized care from the field, such as placing a breathing tube in a blocked airway or decompressing a collapsed lung. Such procedures are beyond the training of emergency medical technicians.

But paramedics are hard to come by, and a long-standing workforce shortage has been exacerbated by turnover and resignations related to pandemic burnout.

Larger departments are trying to attract paramedics by boosting pay and offering hefty signing bonuses. But small teams in underserved counties across the U.S. don’t have the budgets to compete. Instead, some rural crews are trying to train existing emergency responders for the roles, with mixed results.

Miles City is among the few communities in rural eastern Montana to have paramedic-level services, but the department doesn’t have enough paramedics to offer that care 24/7, which is why medics like Lewin take calls on their time off. The team received a federal grant so four staffers could become paramedics, but it could fill only two slots. Some prospects turned down the training because they couldn’t balance the intense program with their day jobs. Others didn’t want the added workload that comes with being a paramedic.

If you’re the only paramedic on, you end up taking more calls,” Lewin said.

What’s happening in Miles City is also happening nationwide. People who work in emergency medical care have long had a name for the problem: the paramedic paradox.

“The patients who need the paramedics the most are in the more rural areas,” said Dia Gainor, executive director of the National Association of State EMS Officials. But paramedics tend to gravitate to dense urban areas where response times are faster, the drives to hospitals are shorter, and the health systems are more advanced.

“Nationally, throw a dart at the map, the odds are that any rural area is struggling with staffing, with revenue, with access to training and education,” Gainor said. “The list goes on.”

The Michigan Association of Ambulance Services has dubbed the paramedic and EMT shortage “a full-blown emergency” and called on the state legislature this year to spend $20 million to cover the costs of recruiting and training 1,000 new paramedics and EMTs.

At the beginning of this year, Colorado reactivated its crisis standard of care for short-staffed emergency medical service crews experiencing mounting demand for ambulances during a surge in COVID cases. The shortage is such a problem that in Denver a medical center and high school teamed up to offer courses through a paramedic school to pique students’ interest.

In Montana, 691 licensed paramedics treat patients in emergency settings, said Jon Ebelt, a spokesperson for the Montana Department of Public Health and Human Services. More than half are in the state’s five most-populous counties — Yellowstone, Gallatin, Missoula, Flathead, and Cascade — covering a combined 11% of the state’s 147,000 square miles. Meanwhile, 21 of Montana’s 56 counties don’t have a single licensed EMS paramedic.

Andy Gienapp, deputy executive director of the National Association of State EMS Officials, said a major problem is funding. The federal Medicaid and Medicare reimbursements for emergency care often fall short of the cost of operating an ambulance service. Most local teams rely on a patchwork of volunteers and staffers, and the most isolated places often survive on volunteers alone, without the funding to hire a highly skilled paramedic.

If those rural groups do find or train paramedics in-house, they’re often poached by larger stations. “Paramedics get siphoned off because as soon as they have those skills, they’re marketable,” Gienapp said.

Gienapp wants to see more states deem emergency care an essential service so its existence is guaranteed and tax dollars chip in. So far, only about a dozen states have done so.

But action at the state level doesn’t always guarantee the budgets EMS workers say they need. Last year, Utah lawmakers passed a law requiring municipalities and counties to ensure at least a “minimum level” of ambulance services. But legislators didn’t appropriate any money to go with the law, leaving the added cost — estimated to be up to $41 per resident each year — for local governments to figure out.

Andy Smith, a paramedic and executive director of the Grand County Emergency Medical Services in Moab, Utah, said at least one town that his crew serves doesn’t contribute to the department’s costs. The team’s territory includes 6,000 miles of roads and trails, and Smith said it’s a constant struggle to find and retain the staffers to cover that ground.

Smith said his team is lucky — it has several paramedics, in part because the nearby national park draws interest and the ambulance service has helped staffers pay for paramedic certification. But even those perks haven’t attracted enough candidates, and he knows some of those who do come will be lured away. He recently saw a paramedic job in nearby Colorado starting at $70,000, a salary he said he can’t match.

“The public has this expectation that if something happens, we always have an ambulance available, we’re there in a couple of minutes, and we have the highest-trained people,” Smith said. “The reality is that’s not always the case when the money is rare and it’s hard to find and retain people.”

Despite the staffing and budget crunches, state leaders often believe emergency crews can fill gaps in basic healthcare in rural areas. Montana is among the states trying to expand EMS work to nonemergency and preventive care, such as having medical technicians meet patients in their homes for wound treatment.

A private ambulance provider in Montana’s Powder River County agreed to provide those community services in 2019. But the owner has since retired, and the company closed. The county picked up emergency services last year, and County Commissioner Lee Randall said that providing basic healthcare is on the back burner. The top priority is hiring a paramedic.

Advancing the care that EMT crews can do without paramedics is possible. Montana’s EMS system manager, Shari Graham, said the state has created certifications for basic EMTs to provide some higher levels of care, such as starting an IV line. The state has also increased training in rural communities so volunteers can avoid traveling for it. But those steps still leave gaps in advanced life support.

“Realistically, you’re just not going to have paramedics in those rural areas where there’s no income available,” Graham said.

Back in Miles City, Lewin said her department may get an extension to train additional paramedics next year. But she’s not sure she’ll be able to fill the spots. She has a few new EMT hires, but they won’t be ready for paramedic certification by then.

“I don’t have any people interested,” Lewin said. For now, she’ll keep that emergency care rig in her driveway, ready to go.

Kaiser Health News is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

HHS Releases Request for Information on Ways to Strengthen and Improve the Organ Procurement and Transplantation Network

The U.S. Department of Health & Human Services (HHS), through the Health Resources and Services Administration (HRSA), released a Request for Information (RFI) seeking input on ways to strengthen and improve the Organ Procurement and Transplantation Network (OPTN) through the upcoming Fiscal Year 2023 Request for Proposal (RFP).

The National Organ Transplant Act of 1984 established the OPTN to coordinate and improve the effectiveness of the nation’s organ procurement, distribution and transplantation systems and to increase the availability of, and access to, donor organs for patients with end-stage organ failure.  The law specifies that the OPTN be operated under federal contract.  In the coming months, HRSA will be issuing a Request for Proposal (RFP) for the next OPTN contract.

The RFI will support HRSA’s efforts to increase accountability in OPTN operations, modernize performance of the OPTN IT system and related tools, and improve engagement with donors and patients.  It specifically focuses on opportunities to strengthen equity, access, and transparency in the organ donation, allocation, procurement, and transplantation process in the contract arrangement that results from the forthcoming RFP.

“HRSA is committed to making organ procurement and transplantation more equitable, accessible, and transparent,” said HRSA Administrator Carole Johnson. “The Request for Information released today is an important step in advancing these goals and we look forward to receiving robust feedback on ways to increase organ donation, improve patient and donor engagement, strengthen accountability throughout the system, and best leverage modern technology to support this life-saving work.”

In addition to seeking feedback on the governance, finance, IT, data collection, policy, and operational components of the OPTN contract more broadly, this RFI specifically solicits feedback on ways to incorporate the findings and recommendations of the February 2022 National Academies of Science, Engineering, and Medicine (NASEM) report titled Realizing the Promise of Equity in the Organ Transplantation System, as well as the lessons learned from HRSA’s 2019 market research, conducted in partnership with the U.S. Digital Service, on ways the OPTN IT system should leverage modern IT architecture.

Interested parties may access information regarding the RFI here: https://sam.gov/opp/df25032b76b1467eabae79a2ba222ead/view.   The RFI is open for a 30-day period beginning April 8, 2022. Responses to the RFI are due to HRSA by May 9, 2022 at 1 p.m. ET.

To learn more about HRSA’s organ transplantation activities, please visit www.organdonor.gov.

New Report: Local Food in Appalachia

The Appalachian Regional Commission’s (ARC) new report, “Agriculture and Local Food Economies in the Appalachian Region,” examines the impact and potential of Appalachia’s food systems.

Based largely on U.S. Department of Agriculture Census of Agriculture data, the report is filled with recommendations and success strategies that can help communities cultivate thriving food economies.  The research also includes overviews and case studies that will prove useful to Appalachian stakeholders interested in developing their own local food systems.

Learn more about opportunities to strengthen Appalachian food economies by clicking here.

Celebrating the Contributions of Pennsylvanians Living with Autism

Commonwealth citizens living with Autism Spectrum Disorder are important to our communities.

April is Autism Acceptance Month, and the Pennsylvania Department of Human Services (DHS) is recognizing services offered to individuals with intellectual disabilities and their families. However, this is not only important during April. Every day we celebrate individuals who are breaking barriers and contributing to their communities, excelling in employment, and promoting self-advocacy. All individuals living with autism or intellectual disabilities should have autonomy, choice, and opportunities to live everyday lives.

Autism in PA

What is Autism Spectrum Disorder (ASD)?

ASD is a complex, lifelong developmental condition that typically appears during early childhood and can impact a person’s social skills, communication, relationships, and self-regulation. Autism is experienced differently for everyone and to varying degrees. It is defined by a certain set of behaviors and is often referred to as a “spectrum condition.”

In 2021, the CDC reported that approximately 1 in 44 children in the U.S. is diagnosed with ASD. Currently, more than 180,000 Pennsylvanians are living with autism.

What are the characteristics of ASD?

How is ASD diagnosed?

A medical professional who may have experience with Autism — including pediatricians, neurologists, psychiatrists, and psychologists — may be able to make an assessment. The evaluation itself can vary depending on the professional administering it, the age of the person being assessed, the severity of his or her needs, and local available resources. A medical assessment for Autism typically includes:

  • A medical history of the mother’s pregnancy
  • Developmental milestones
  • Sensory challenges
  • Medical illnesses, including ear infections and seizures
  • Any family history of developmental disorders
  • Any family history of genetic and metabolic disorders
  • An assessment of cognitive functioning
  • An assessment of language skills
  • An Autism-specific observational test, interview or rating scale

If you have questions or feel you need additional help, try reaching out to a local Autism Society affiliate, an Autism support group, your primary care provider, or possibly another parent with a child or family member with Autism.

Intervention & Support

Treatment

Every individual with autism has unique strengths and challenges, so there is no definitive approach to autism treatment and intervention. Each autism intervention or treatment plan should be tailored to address the person’s specific needs. A person’s treatment plan can include behavioral interventions, other therapies, and medicines.

Support through ASERT

DHS is responding to the increased prevalence of ASD by expanding access to services, while also working to address the need to build the capacity of professionals trained to assist individuals with autism and their families across their lifespan. The state-funded Autism Services, Education, Resources and Training (ASERT) initiative provides support and information to Pennsylvanians with ASD. ASERT also maintains a collaborative that brings together medical centers, centers for autism research and services, universities, and other providers involved in the treatment and care of individuals of all ages with autism and their families to support service providers, individuals with autism spectrum disorder, and their families.

Additional Autism Resources

Health Policy and Administration Student Receives Jennifer S. Cwynar Community Achievement Award

Maira Nawaz, a student in Integrated B.S. in Health Policy and Administration/Master of Health Administration program within the Penn State Department of Health Policy and Administration (HPA), received the 2022 Jennifer S. Cwynar Community Achievement Award in April 2022. Nawaz, of Mechanicsburg, Pennsylvania, is also pursuing a minor in information sciences and technology.

The award from the Pennsylvania Office of Rural Health (PORH) recognizes community achievement by a Penn State senior majoring in Health Policy and Administration who has demonstrated service and commitment to a community or an underserved population, preferably, but not exclusively, in a rural area of Pennsylvania. The award was established in memory of Jennifer S. Cwynar, a 2008 graduate of HPA and a 2008 undergraduate intern at PORH.

Nawaz was nominated by Diane Spokus, Ph.D., M.Ed., MCHES®, associate director of professional development in HPA. Spokus lauded Nawaz for her dedicated and detail-oriented work ethic, commitment to community service, and her focus on public health. She noted that Nawaz can be depended on to follow through and who continually seeks professional development opportunities and service to others. “Students like Maira, who participate in various internship experiences, and who are involved in clubs and volunteer their time to worthwhile causes, are excellent role models. They will be great future health care leaders.”

During her academic career, Nawaz expanded her knowledge through internships at Mount Nittany Physician Group Primary Care practices in rural central Pennsylvania; Atlantic Health System in New Jersey; the American Lung Association; and WellSpan Health in York, Pennsylvania. Nawaz broadened her operational and administrative skills by standardizing the rooming process for patients, calculated Medicare net revenue, streamlined guidelines, analyzed and evaluated insurance enrollment data, assisted in improving interactive voice response systems and member websites, and created user stories for members to improve customer satisfaction during support calls. She also executed smoking cessation tasks such as Amazon’s Alexa project, a Juul costs project, and smoking prevalence in veterans; organized health promotion community events; wrote articles for local newspapers on moral courage; and worked with the LatinX community to improve health care opportunities and awareness. These experiences gave her a deep appreciation for the social determinants of health and population health.

While at Penn State, Nawaz served as the guest speaker liaison for the Penn State Chapter of the American College of Healthcare Administrators (ACHCA) Club Executive Team. She participated in the UNICEF Club, was a member of the Pakistani Student Association, and volunteered at the Central PA Food Bank, Country Meadows Senior Center, and was a Holy Spirit Hospital Junior Volunteer.

“We are very pleased to present this award to Maira Nawaz and to honor the legacy of Jennifer Cwynar, who was an exceptional student and intern with our office,” said Lisa Davis, director of PORH and outreach associate professor of HPA. “This is one way in which we can encourage excellence in those who will become leaders in advocating for the health of vulnerable populations.”

PORH formed in 1991 as a joint partnership between the federal government, the Commonwealth of Pennsylvania, and Penn State. The office is one of 50 state offices of rural health in the nation and is charged with being a source of coordination, technical assistance, networking, and partnership development.

PORH provides expertise in the areas of rural health, population health, quality improvement, oral health, and agricultural health and safety. PORH is administratively located in the Department of Health Policy and Administration in the College of Health and Human Development at Penn State University Park.

To learn more about the Jennifer S. Cwynar Community Achievement Award or the Pennsylvania Office of Rural Health, visit porh.psu.edu.

Five-Year Trends in U.S. Children’s Health & Well-being Results from 2016-2020 Released

 

Five-Year Trends in U.S. Children’s Health and Well-being, 2016-2020, a Maternal Child Health Bureau study using their National Survey of Children’s Health data was recently published in the JAMA Pediatrics. A 29% increase in anxiety and 27% increase in depression over the five-year period was noted along with during the period of 2019-2020 (the first part of the pandemic) there was a 34% increase in parents who reported they quit, declined, or changed jobs due to child-care problems in the past 12 months, 32% increase in unmet health care needs, a 20% increase in behavioral/conduct problems, and a 9% reduction in preventive medical visits. You can also read an editorial that accompanied the article, Adversity and Opportunity – The Pandemic’s paradoxical Effect on Child Health and Well-being.

The New CDC COVID-19 Quarantine & Isolation Calculator is Available

 

The Center for Disease Control and Prevention’s (CDC) new COVID-19 Quarantine and Isolation (Q&I) Calculator is now available online. It is a mobile-friendly tool to help people follow quarantine and isolation guidance and receive customized information for their unique situations. It covers an easy-to-use way to figure out when and for how long people with COVID-19 and close contacts need to stay home, get tested, and wear a well-fitting mask and provides important information about what precautions people with COVID-19 and their close contacts can take to protect loved ones and slow the spread in their communities. It is not for people with COVID-19 who are moderately or severely ill, have a weakened immune system as they should talk with their healthcare provider for guidance, who can refer to the Ending Isolation and Precautions for People with COVID-19: Interim GuidanceHealth systems can add the Quarantine and Isolation (Q&I) Calculator onto their websites by embedding the syndicated content code.

FCC Requests Comments on Promoting Telehealth in Rural America

 

The Federal Communications Commission (FCC) seeks comment on revisions to its initiatives to fund access to broadband and telecommunication services for rural healthcare providers. FCC proposes to modify the way the internal funding cap applies to upfront costs and multi-year commitments in the Healthcare Connect Fund Program and to streamline the invoice process in the Telecommunications Program. The rule also seeks comments on ways to further increase the speed of funding commitments.

Keystone Health Study Finds Telehealth of Value in OUD Treatment in Pennsylvania

 

The implementation of telehealth due to the COVID-19 pandemic helped an FQHC retain patients in its opioid use disorder (OUD) treatment program, ensuring continued access to care, a new study shows. As health care became increasingly virtual during the pandemic, telehealth helped in providing high levels of care to opioid use disorder (OUD) patients, particularly those involved in buprenorphine treatment programs. The study took place at Chambersburg, PA-based Keystone Health, an FQHC that serves about 56,000 patients, 60% of whom come from rural areas. Researchers collected information, including visit dates, progress notes, urine drug tests, current and prior buprenorphine formulation, and dosage, to conduct a retrospective chart review. Read more.

The Prevalence of Pre-diabetes in Teens Escalates

 

There was a significant jump in the prevalence of prediabetes among teens in the U.S. between 1999 and 2018, according to an analysis published in JAMA Pediatrics. The researchers used data from nearly 7,000 kids ages 12–19 in the CDC’s National Health and Nutrition Examination Survey, which included the collection of blood samples. The number of kids who were prediabetic increased from more than 11% to 28% over that time. The researchers noted that the U.S. Preventive Services Task Force released a recommendation on screening for prediabetes and Type 2 diabetes among adults but hasn’t yet made recommendations for kids.