Rural Health Network Development Program: Washington County Ambulance Service
The Georgia Health Policy Center recently spoke to Justin Duncan, CEO of the Washington County Ambulance District; Karen White, CEO, of Missouri Highlands Health Care; and Doris Boeckman, partner at Community Asset Builders, about the partnership between the ambulance district and the Federally Qualified Health Center (FQHC) to provide mobile integrated health care through community paramedics and community health workers in Reynolds County and a part of Dent County.
To date, what has been the biggest accomplishment or win in your program?
Justin: At the state level, we believe that mobile integrated health care is diverse, inclusive, whole-person care, and we helped build 20 of these networks across the state. I think we were able to get these networks up and going because the egos were checked at the door. We drafted memoranda of understanding, and policies and protocols, and nobody considers them proprietary. We are just sharing that information for the good of the universe and then tailoring them for the needs of each of the ambulance districts, which in Missouri are all considered a part of state government. My big win for this grant was we were welcomed with open arms in Reynolds County after having very uncomfortable, honest conversations, but pulling this off has been easy.
Karen: We talk a lot around the scariest day at a clinic is the day after a hospital closes. You do not know what will come through that door. In 2016 when we lost the hospital here in Ellington, we became the only form of any type of care, and it was super scary. The ambulance district had its challenges here in Reynolds County, especially after the hospital pulled out and pulled their ambulance service with them. I know the needs within my county. I know the fabulous work that Justin and his team had done in Washington County with that Federally Qualified Health Center and that community. For me, having them come to the table to sign a 10-year contract with Reynolds County to provide ambulance service was a huge win because I knew I had a trusted partner in health care.
What is a tip or early learning that you would share with an organization launching a similar network?
Justin: Someone asked me recently how are these networks successful? And I said, it is relationships and networking. I did not know what an FQHC was five years ago. I have been in healthcare my entire life and I ignorantly referred to them as the free clinic down the road. We did not know what community health workers were or social determinants of health. Now, when you look at the definitions, we address all of those things. So, while yes, we render health care every single day, politically and regulatory wise, we don’t interact with health care because we are considered a transportation service provider by the Centers for Medicare and Medicaid Services and is housed under the Department of Transportation. So, I believe relationships and networking can break down some of the barriers and silos to providing care that benefits the community.
How do you see participation in the Federal Office of Rural Health Policy’s Network Development Grant Program impacting your broader health improvement efforts?
Karen: We have several patients who struggle to maintain appointments and their medications. We reside in an area with no public transportation and very poor broadband, so, many of the solutions that are available elsewhere are not available in the counties we serve. So, this network fits in with our regional health plan, but we are also facing an ever-decreasing number of folks wanting to go into health care as a career. The reality is that community paramedic sounds a heck of a lot sexier than licensed nurse practitioner at a clinic. So, as we talk about how to sustain and improve our model of care, we definitely see this as an important opportunity for partnership and growth as we move forward. We see this as a way to improve the baseline health and wellness of our communities, and as a way to not further exhaust our workforce and maybe entice them into working alongside us by coming on board through the community paramedic program.
Doris: When you are scaling up an integrated health network, those community paramedics can actually still be regular 911 paramedics on the emergent side. You are improving EMS services by directing the right resources where they need to be at the right time. This aligns not just with the local and regional health improvement plans, but it really ties to the state health improvement plan. It is the premise of whole-person care.
Justin: When people first hear of this they say, ‘You’re using paramedics for primary care.’ Yes. And while that might sound novel to you, it is not a novel concept. I have been doing primary care my entire time as a paramedic. People misunderstand that because we are called emergency medical services that all we do are emergencies when arguably 85% of what we do is primary care, patient navigation, resource navigation, and education. So, yes, it is novel that an FQHC and an EMS agency are married at the hip, but we are doing the same work just in different settings. We are bringing the brick-and-mortar care that Karen and team provides to the living room. Now we have some data to back up our hypothesis that for about half of the people we reach using this high-touch approach, we will improve their outcomes, reduce their utilization of the emergency department.
Do you guys have a specific story or something that illustrates the benefit of working together as a network?
Justin: The goal is to set up the community paramedics to use the clinic as their base for multiple reasons. What we have found in other counties is that the moment the community health worker-emergency medicine technician works with the nurse practitioner, you have collaboration. When somebody comes in with chest pain, the paramedic can grab the critical care equipment, so they are not just providing primary care, it is in their wheelhouse to provide acute care, too. It goes beyond sharing and augmenting staff, but we are now looking at joint maintenance, logistics, purchasing, etc.
Karen: While Justin and I endorse this partnership and we have good working relationships and we know we can trust each other, when it comes down to carrying out that actual patient care I need for my clinic teams to know that they can equally trust Justin’s team to carry out the work just as they would do it. And you only get that from that type of one-on-one exposure on a daily basis. Justin and I can have the most brilliant ideas on the face of the earth, but without buy-in of those who do the real work, we will go nowhere.
What will your organization be doing more of or differently to emerge stronger from the pandemic?
Justin: The pandemic is what gave us the opportunity to have the hard conversations. I call this adventure one of the hidden blessings of the pandemic. We were forced as an industry, to keep people at home. For the first time ever, hospitals said, please don’t bring patients here unless absolutely necessary. We set up hospital-at-home programs. We kept patients that normally would have been admitted at home and we did that well on a national level. We also gave 18,000 vaccines in Washington County, a population of 25,000 in one year.
Karen: For all of the bad that COVID brought on health care, and all of the additional challenges, there were so many good things such as this, partnerships that we would never have thought about before the pandemic. Prior to COVID, we would sit across the table from our ambulance districts and try to figure out how to serve the needs of a community, but we would not make real progress because we viewed each other differently. Post-pandemic, there is a sense we are in this together and we need to figure this out. It really comes down to just Justin’s team and my team in this community. There is no one else here other than the county health department, and they struggle alongside us. We love having partners that are willing to think outside the norm and are willing to try new things. If there can be anything that came out of the pandemic, it was broader partnerships, with everybody working toward a common goal.