Florida Mobile Integrated Healthcare Community Paramedicine

Florida Mobile

Integrated Healthcare

Community Paramedicine

Program Guidebook

F l o r i d a Mo b i l e i n t e g r a t e d H e a l t H c a r e - c o M M u n i t y Pa r a M e d i c i n e P r o g r a M g u i d e b o o k

CREDITS

Ariella Bak Christine Long

Rich Barner Mac Kemp

Jane Bedford Mark Matthews

Juan Cardona Steve McCoy

Wendy Crews Melissa McNally

James Crutcheld John McNamara

Orlando Dominguez, Jr. Scott Moore

Richard Ellis Jerri Regan

Timothy Ewing Daniel Swayze

Joe Goodwin

Evan Weiner

Mike Hall

Lauren Young

Don Hughes

Matt Zavadsky

Linda Liebert-Hall

Integrated Mobile Healthcare Coordinator,

Gainesville Fire Rescue

Community Health Resource Program Coordinator,

Brevard County Fire Rescue

People and organizations who provided assistance or contributed to the Guidebook

EMS Manager,

Highlands County EMS

Deputy Chief of Clinical Affairs,

Leon County Emergency Medical Services

Director of Education and Clinical Services,

Nature Coast Emergency Medical Services

Chief,

Jefferson County EMS

EMS Division Chief,

Coral Springs Fire Department

State of Florida

EMS Administrator

Area Supervisor,

Excelsior Ambulance

Mobile Integrated Healthcare PA,

AMR

Director of Community Paramedicine,

Manatee County Public Safety

Fire Chief,

Sunrise Rescue

Assistant Chief of EMS Operations,

Brevard County Fire Rescue

EMS Resource

Advisors, LLC

Chief of EMS,

Palm Beach County Fire Rescue

Owner,

Health Services Consulting

Community Paramedic,

Sunrise Rescue

Vice-President and COO, Center for Emergency

Medicine of Western Pennsylvania & Project Manager

of CONNECT Community Paramedicine Program

Ambulance Systems Service Director,

Coastal Health Systems of Brevard

EMS Coordinator,

Seminole Tribe Fire Department

CEO,

Nature Coast Emergency Medical Services

Mobile Integrated Health Medical Social Work

Coordinator, Palm Beach County Fire Rescue

Fire Chief,

Satellite Beach Fire Department

Chief Strategic Integration Ocer,

MedStar Mobile Healthcare

President,

Liebert-Hall & Associates, LLC

Chapter 2

What’s Need Got to

Do with It?

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TABLE OF CONTENTS

Chapter 3

Stakeholders

A. Template Outline for Business Plan

B. Template Budget

C. Template Memorandum of Agreement (MOA)

D. Template Organizational Chart

E. Template Marketing Plan

F. Template Patient/Client Satisfaction Survey

G. Template Performance-Based Job Description

H. Sample Mobile Integrated Healthcare Provider Referral Entry into Care

I. Sample Mobile Integrated Healthcare Provider Initial Contact Form

J. Example Palm Beach County MIH Pilot Program

Introduction

The purpose of this Guidebook is to do

just that – guide you

Chapter 4

Developing Your Program Plan

Chapter 5

Developing Your Program Budget

Chapter 6

What Difference Did You Make?

Chapter 7

Sustaining Your Program

Chapter 8

Tying It All Together

Chapter 1

Mobile Integrated

Healthcare – Community

Paramedicine

(MIH-CP), Models, and

Legal Considerations

Manatee County Florida Community Paramedicine Manatee County Florida Community Paramedicine

Manatee County Florida Community Paramedicine

APPENDIX

INTRODUCTION

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The purpose of this Guidebook is to do just that – guide you through the research, analysis, planning, development, and successful

launch of your own customized Florida Mobile Integrated Healthcare – Community Paramedicine (MIH-CP) Program. This resource

is straight-forward and easy to read. In addition to guidance, it provides recommendations and lessons learned from MIH-CP

programs in Florida, advice from experts across the country, with expanded resources and templates.

This Guidebook is not designed to tell you what you must do,

but to provide suggestions and ideas on what to consider in

developing your own MIH-CP. As you read it, remember that

not all the information in the Guidebook will apply to you or

your organization. Use it to think through the elements of

your program and remember that a successful program must

be anchored in your community.

The Guidebook is organized linearly – take each step by step,

so you end up with an operational program. However, it is

strongly recommended that you use the Budget Template

found in Appendix B as you work through the chapters. You

will be prompted to insert nancial information into the

budget throughout the Guidebook. So, as you develop your

program, enter even the most basic information on your costs

and revenue.

Entering your cost and revenue information will help you when you get to Chapter 5 where you’ll complete your program budget.

(Yes, even if all your revenue is through your organization, you will need to develop a budget to help you get initial support for

your MIH-CP and monitor the sustainability of your program.)

The authors of this Guidebook conducted interviews with

eleven organizations who operate MIH-CP Programs in

Florida. During the interviews we asked questions about why

they started their MIH-CP, how they did it, the funding used,

the challenges they faced, what changes they would make in

their implementation, and what advice they would give to an

organization wanting to begin a MIH-CP. We have integrated

their experiences, thoughts, and advice into this Guidebook to

help you identify what will work in your community.

As the vision of your program becomes clearer, reect on

what you’ve done and evaluate if there are things you need to

do differently. Also, look for the ripple effect. For example,

changing something in the stang may impact the medical

direction, or the expense of a staff member, or how you reach

your target market. A change in almost any piece will make a

difference in your budget.

Chapter 8 is the culmination of the steps presented in the Guidebook. This Chapter presents a case study illustrating the material

we covered and is meant to provide ideas on the content and format of a business plan for the design and implementation of a

MIH-CP program in Florida. We hope this Guidebook proves useful and encourages you to think about how a MIH-CP Program can

transform your community and the people you serve.

Realize you’re not going to change things

overnight. Create a culture. This is a

marathon, not a sprint.

Don Hughes

Overall, this is the future of not only

healthcare, but of EMS. By evolving the

paramedicine profession into more of

a clinician role, EMS will no longer be

merely a transportation benefit.

Melissa McNally

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This Chapter provides denitions and descriptions of different types of Mobile Integrated Healthcare - Community Paramedicine

Programs and reviews Florida statutes that regulate the practice of a community paramedic.

What is Mobile Integrated Healthcare – Community Paramedicine?

This question was answered by the National Association of Emergency Medical Technicians (NAEMTs) in the introduction to their

report on the Mobile Integrated Healthcare and Community Paramedicine 2nd National Survey, a link to which is included in the

references and resources at the end of this Chapter. Their denition is as follows:

CHAPTER 1

Wrap your head completely around the

CP program – have a solid understanding

of the program before starting.

Juan Cardona

Mobile Integrated Healthcare - Community Paramedicine,

Models, and Legal Considerations

Mobile integrated healthcare - community paramedicine (MIH-CP) is the provision of healthcare

using patient-centered, mobile resources in the out-of-hospital environment. MIH-CP is provided by a

wide array of healthcare entities and practitioners that are administratively or clinically integrated

with EMS agencies, while CP is one or more services provided by EMS agencies and practitioners

that are administratively or clinically integrated with other healthcare entities.

The NAEMT report goes on to describe

the range of services provided by MIP-

CP programs as including:

• Sending EMTs, paramedics or

community paramedics into the

homes of patients to help with

chronic disease management and

education, or post-hospital discharge

follow-up to prevent hospital

admissions or readmissions.

• Navigating patients to destinations

such as primary care, urgent care,

mental health or substance abuse

treatment centers instead of

emergency departments to avoid

costly, unnecessary hospital visits.

• Providing telephone triage, advice

or other assistance to non-urgent

911 callers instead of sending an

ambulance crew.

• Using telemedicine technology

to facilitate interactions between

patients in their home and medical

professionals in hospitals or other

locations.

Given the inclusive nature of the

NAEMT’s denition of MIH-CP and the

broad nature of the types of services

they provide, it is safe to say, there is no

one model for MIH-CP Programs. The

best model is the one that works in your

community.

Manatee County Florida Community Paramedicine

Learn about what is

happening nationally and get

out of the area to see what’s

going on.

Juan Cardona

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Across the nation, 78% of respondents to the NAEMT survey

indicated their model was focused on preventing hospital

readmissions for conditions that have hospital penalties such

as chronic lung disease, coronary artery bypass graft surgery,

heart attacks, heart failure, hip and knee replacements, and

pneumonia. Frequent EMS and emergency department users

were targeted by 78% of survey respondents. The respondents

were able to report multiple targets, so the percentage of

respondents is more than 100%.

Chronic disease management for conditions such as congestive

heart failure, hypertension, COPD, asthma, and diabetes was

targeted by 68% of respondents. The fourth area targeted

by MIH-CP Programs was assessment and navigation to

alternative destinations that was reported by 50% of the

respondents. Home health support was cited by 45% of

respondents, and 45% of respondents indicated they were a

primary care/physician extender model.

The remainder reported their target areas as hospice support

(20%), 911 Nurse Triage (7%), and 11% reported other target

areas that included wound care, knee replacement follow-up,

and mental health crisis screening and navigation.

Abbeville County’s Community Paramedic Program

Updated/reviewed May 2018

• Need: To reduce non-emergent visits to the

emergency department as well as inpatient stays in

rural South Carolina.

• Intervention: A community paramedic program

was started in Abbeville County, providing in-home

preventive care to patients.

• Results: Emergency room visits have decreased by

58.7%, and inpatient stays by 60%. Many patients

previously needing consistent services now only

need occasional check-ups.

2. Livingston County Help For Seniors

Updated/reviewed January 2018

• Need: Meeting the health needs of geriatric patients

in rural Livingston County, New York.

• Intervention: The Help for Seniors program was

developed and using its vodcasts, local EMTs were

trained in geriatric screening methods and health

needs treatment.

• Results: In addition to developing a successful model

for educating EMS personnel, the program screened

over 1,200 individuals and identied various risks

among the geriatric population.

The Rural Health Information Hub (RHI Hub) assembled examples of rural MIH-CP Program models. The programs are described

along three parameters, need, intervention, and results. The following information may be found at

https://www.ruralhealthinfo.org/project-examples/topics/community-paramedics

and was taken directly from the RHI Hub website.

Monkey Business Images/Shutterstock.com

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3. Rugby Community Paramedic Program

Added November 2017

• Need: Low patient volumes, a shortage of EMS

volunteers, and an aging population in a 5-county

North Dakota region required a change in the way

the Rugby EMS team delivered care.

• Intervention: Through the Rugby Community

Paramedic Program, EMS staff bring medical care

to patients transitioning back into their homes,

including those with chronic conditions and hospice

patients.

• Results: The program’s early intervention methods

helped reduce the number of emergency room

admissions and the escalation of medical conditions.

Patient satisfaction has improved, and the program

has gained the trust of patients and medical staff in

Rugby and surrounding areas.

4. Eagle County Community Paramedic

Updated/reviewed February 2017

• Need: Rural areas nationwide have shortages of

primary care providers and home health programs.

• Intervention: Eagle County Paramedic Services is

utilizing community paramedics in the provision

of non-acute home care and assistance with

immunizations and screenings in rural areas where it

is dicult for these services to be accessed.

• Results: The pilot program was featured at the

2010 International Roundtable on Community

Paramedicine. After 18 months of implementing the

program, a net total of $288,028 in healthcare costs

was saved

• 9-1-1 Nurse Triage

• “EMS Loyalty” Program

• Readmission Avoidance

• Hospice Revocation Avoidance

• Observation Admission Avoidance

• Home Health Partnership

A helpful MIH-CP summary reference is the National

Rural Health Association Policy Brief titled: Principles for

Community Paramedicine Programs. Other resources include

two texts titled Mobile Integrated Healthcare: Approach to

Implementation (2016) and Community Health Paramedicine

(2018). References for these resources are located at the end

of this Chapter.

An example of an urban MIH-CP program is MedStar Mobile.

They serve the Fort Worth Texas area and 14 surrounding cities

and are considered a municipal governmental agency (public

utility model). The MedStar service area covers 421 square

miles and is home to almost 1 million residents. With a budget

of $40 million, it employs approximately 460 employees and

provides 125,000 responses annually.

Operating a MIH-CP Program since 2009, the initial focus

of MedStar’s program was on high system users for whom

individual care plans were developed. These care plans

included scheduled home visits with follow up with the client’s

primary care provider. Current programs are described as

Patient Navigation Models and Mobile Integrated Healthcare

models.

. As reported by MedStar and available at their website:

http://www.medstar911.org/mobile-healthcare-programs

their models now include:

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Delivery Model

Florida MIH-CP

Survey Respondents

2017

N=11

NAEMT National Survey

Respondents

2018

N=129

Public, Fire-based 55% 33%

Public, Municipal, County, or Regional 9% 21%

Public, Hospital Based 0 8%

Private, Nonprot 9% 11%

Private, For-Prot 9% 11%

Private, Hospital-based 9% 16%

Tribal 9% 0

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For purposes of this document, the terms Community Paramedicine Program and Mobile Integrated Healthcare are used together

and referred to as MIH-CP.

Florida’s MIH-CP

Consistent with the NAEMT’s denition

of MIH-CP, the Access to Care

Committee of the Florida Emergency

Medical Services Advisory Council has

dened Mobile Integrated Healthcare -

Community Paramedicine (MIH-CP) as:

Findings from the recently completed

survey of eleven Florida MIH-CP

programs who self-reported operating a

MIH-CP program, one respondent made

the distinction between a community

paramedic program and a mobile

integrated healthcare program. This

interviewee felt that Mobile Integrated

Healthcare is a more inclusive term

recognizing the contributions of other

professionals working with paramedics

on multidisciplinary teams. When asked

to choose if they were a Community

Paramedicine Program or Mobile

Integrated Health Healthcare Program,

70% of the respondents to the NAEMT

survey categorized their program as

“Community Paramedicine” and 31%

self-described as offering “Mobile

Integrated Healthcare” services.

Using the data from the previously

described survey of Florida’s MIH-

CP programs, Table 1 presents the

distribution of Florida’s programs by

delivery model comparing it to the

NAEMT national survey.

Table 1: Comparison of the Distribution of Florida MIH-CP Programs to MIH-CP Programs by Type of Delivery Model

The provision of healthcare using patient-centered, mobile resources in the out-of-

hospital environment. MIH -CP is provided by a wide array of healthcare entities and

practitioners that are administratively or clinically integrated with EMS agencies and or

other healthcare entities.

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Model 1 – Private for Prot Model 2 – Public Fire Model 3 – Private Non Prot

Focus / Goal

Provide access to concierge

medicine to all in the community.

Primarily the reduction in frequent yers

Reduce COPD / CHF

readmissions to hospital

within 90 day period

Services

24/7 operation

Provide telehealth services,

including medical evaluations and

rapid on-site testing.

Advocacy; resource identication/referral

education; safety/home

assessment; chronic disease

management

Home visits: vital signs,

appearance, medication

reconciliation, and health

safety checks

Stang

1 FTE Paramedic is dedicated to

the

program, ½ FTE using overtime or

part-time Paramedics.

Varies by size of department and services

provided: Some programs have no

Paramedic because the only focus is on

advocacy and resource navigation, not

direct medical care. Others have up to 3

FTE Paramedics with CP coordinators and

administrative support. Some also utilize

volunteers, such as medical and pharmacy

school interns to support program, and

people to provide client transportation to

address any unmet needs.

1 FTE Paramedic

Partners

Hospice;

Fire Department for

part-time stang

Hospice; Senior Centers; Transportation

organizations; Home Health Care; Police;

Social Service; Public Health; Mental

Health; Homeowners Associations; Nursing

Homes; Visiting Nurses; Primary Care

Professionals; Pharmacies; 211 Resources;

TOPS; Veterans Clinic; Hospitals; Insurance

companies; Food pantries; Homeless

shelters; Churches; Civic organizations;

Local government; Education institutions;

Department of Children & Family Services

Hospitals; Police; Fire; Social

Service agencies

Funding

Start-up: All internal funding Start-up: Grants and internal funding Start-up: Internal funding

Ongoing: 100% self-pay. Collect

monies up front, no insurance

billing.

Ongoing: Internal and some grants

Ongoing: 100% self-pay through the

hospital

Metrics Social Media talk

Reduction in 911 calls; Alignment with

resources and/or primary care physician;

Savings/Cost avoidance; Patient health

improvement; Patient satisfaction survey;

Medication compliance; length of program

stay; ER visits; Average ambulance

transportation cost; Provider satisfaction;

Readmission rates; Ambulance hospital

diversion; Pre and post Quality of Life and

Activities of Daily Living indicators

Hospital tracks COPD / CHF

readmissions

Florida Models

Of the 11 MIH-CP programs interviewed in the state of Florida, there are 11 different models. Each one has a unique format,

focus, operations, and funding. Table 2 displays characteristics of selected Florida models.

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Table 2: Characteristics of Selected Florida Models

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Greatest challenge was…identifying and knowing

where to find resources to help your clients.

Ariella Bak

Medical Direction

NAEMT’s Mobile Integrated

Healthcare and Community

Paramedicine (MIH-CP) 2nd

National Survey asked the 129

MIH-CP programs across the

country about the role the

medical director played in their

program. Protocol development

was the most given response

at 88%, followed by quality

assurance at 78%, immediate

online medical direction 54%,

continuing education 53%,

development and support of care

plans 50%, initial training was

also 50%, and healthcare system

integration was 40%. Looking at

these responsibilities, you can

see why the selection of the right

medical director is so important

to your program.

Under Florida statute 401.265,

EMS services are required to

provide emergency care under

the license and direction of a

physician medical director. The

medical director supervises

and is directly responsible

for the medical performance

of the EMT’s and paramedics

performing the medical

procedures in the eld. They are

required to advise, consult, train,

counsel, and oversee the delivery

of services, including maintaining

quality assurance processes.

As previously mentioned,

paramedics and EMT’s may

perform health promotion and

wellness activities including

blood pressure screenings in

a nonemergency environment

within the scope of their training,

and under the direction of a

medical director. The medical

director may provide this

direction outside of the provision

of emergency care and is liable

for any act or omission of any

EMT or paramedic acting under

his/her supervision and control

when performing these services.

The selection of your medical

director is crucial. Look for your

medical director early in your

MIH-CP development process.

This early engagement will help

you establish strong standard

operating procedures and

protocols with effective quality

These models give you a cross-section of

just how different your program can be

based on the identied need, the focus

of your program, and the community

resources available to support it.

City of Gainesville Florida Community Paramedicine

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be used for both EMS and MIH-CP programs. In the

references and resources section of this Chapter, there

are possible provisions to be included in a medical

director’s contract as well as an interview guide to help

you gauge your medical director’s level of commitment

to and understanding of MIH-CP.

Encourage your medical director to be involved with the

Florida EMS Advisory Council and the Florida Association

of EMS Medical Directors. Additional information about

these groups is found in the references and resources

section at the end of this Chapter.

Finally, in addition to a dedicated medical director, you

may want to use other providers for medical direction,

advice, or consultation based upon the design of

your program. For instance, a person’s primary care

physician or a specialty physician may provide that

direction for a specic client.

Hospital Flexibility (Flex) Program Workplan. A brief

description of selected documents follows providing a

list of potential focus areas for MIH-CP Programs.

Florida’s SHIP identies goals for the state’s public

health system in 8 priority areas that include:

• Health Equity

• Maternal & Child Health

• Immunizations

• Injury, Safety & Violence

• Healthy Weight, Nutrition & Physical Activity

• Behavioral Health both Mental Illness and

Substance Abuse

• Sexually Transmitted Disease (STDs) as well as other

infectious diseases

• Chronic Diseases and Conditions, including

tobacco-related illnesses and cancer

Budget Note: Insert the annual cost of your MIH-CP medical director into the expense line “medical direction

contract fees.” If your MIH-CP medical director is also your medical director for emergency operations, only

include the additional cost for the responsibilities of a MIH-CP program, if any.

control processes, enabling you to identify problem

areas early in the development process.

The medical director should understand the latest

approaches to healthcare being promoted and

evaluate the healthcare trends and service gaps

in your community. You need someone who will

wholeheartedly support the idea of a MIH-CP Program

and be an active participant in the development and

ongoing champion in support of it. One organization

that responded to the interview about their MIH-CP

stressed the importance of medical direction and

of nding a medical director who is open to and

comfortable with paramedics doing things outside of

the traditional “paramedic” duties.

And, if your current EMS medical director does not

meet these criteria, you may select a different medical

director for your MIH-CP program. While it is unusual,

there is no requirement that the same medical director

Alignment

MIH-CP Programs offer cost-effective and ecient

solutions to perennial issues challenging not only

Florida’s healthcare system but our nation’s. MIH-CP

Programs target the medically underserved who suffer

from debilitating conditions that are not only caused by

acute conditions (trauma, infectious diseases) but from

chronic diseases that often require on-going care and

treatment. Successful disease prevention and wellness/

health promotion are grounded in community-wide

interventions. Your local health department is the

organization charged with improving the health of the

county’s population and working with them on common

problems is a cost-effective approach.

MIH-CP Programs have a vital role in achieving the

Florida Department of Health’s (FDOH) Strategic

Plan, the State Health Improvement Plan (SHIP), your

county’s Community Health Improvement Plan (CHIP),

the Florida Department of Health, Emergency Medical

Services State Plan 2016 – 2021, and the Medicare Rural

These goals are further dened by strategies and objectives. A theme throughout the goals, strategies, and

objectives is that goal achievement rests on the collaboration and active engagement of state, local and other multi-

level organizations. The SHIPs goals address persistent issues challenging Florida’s healthcare system that demand

a collaborative response. In this way, resources are leveraged, redundancies eliminated, and problems solved.

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The Florida Department of Health, Bureau of

Emergency Medical Oversight (BEMO), Emergency

Medical Services published the Emergency Medical

Services State Plan (EMSSP), 2016-2021.

The EMSSP identied ve strategic priority areas, each

with an articulated goal/s:

■ Strategic Priority 1: EMS Industry Health and Safety

□ Goal 1.0: Ensure a commitment to the health and

safety of the EMS industry and the citizens and

visitors of Florida

■ Strategic Priority 2: Clinical and Operational

Performance

□ Goal 2.0: Use health information technology to

improve the eciency, effectiveness, and quality

of patient care coordination and health care

outcomes

■ Strategic Priority 3: EMS System Infrastructure and

Finance

□ Goal 3.1: Attract, recruit and retain a prepared,

diverse and sustainable EMS workforce in all

geographic areas of Florida

□ Goal 3.2: Establish a nancially sustainable

infrastructure, which includes processes and

effective use of technology and communication

supporting all EMS systems functions

■ Strategic Priority 4: Readiness for Emerging Health

Threats

□ Goal 4.0: Demonstrate EMS readiness for emerging

health threats and natural or manmade disasters

■ Strategic Priority 5: Community Redevelopment and

Partnerships

□ Goal 5.0: Integrate EMS with health planning and

assessment processes to maximize community

partnerships and expertise in accomplishing its

goals

MIH-CP Programs and the Florida Department of Health Emergency Medical Services

State Plan 2016 - 2021

Photographee.eu/Shutterstock.com

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Each of the strategic priorities has strategies and objectives, and Strategic

Priority 5 explicitly references community paramedic (MIH-CP) programs. The

strategies and objectives for Strategic Priority 5 are as follows:

■ Strategy

□ Provide injury prevention programs to the public

□ Promote the increase of EMS agencies developing community

paramedic programs

□ Improve community health

■ Objectives

□ Increase the percentage of EMS agencies conducting fall prevention

programs from 28.5% to 40% by December 2018

□ Increase the percentage of EMS agencies conducting opioid use and

naloxone awareness programs from 13.5% to 35% by December 2018

□ Increase the percentage of EMS agencies conducting safety

programs sponsored or recommended by the Florida Department of

Transportation (FDOT) from 19.2% to 30% by December 2018

□ Increase the percentage of EMS agencies conducting drowning

prevention programs from 30% to 50% by December 2018

□ Increase the percentage of EMS agencies conducting programs to

reduce infant mortality from 18.5% to 30% by December 2018

□ Increase the percentage of EMS agencies offering cardiovascular health

and wellness programs pursuant to section 401.272, F.S., from 26.4% to

40% by December 2018

□ Increase the percentage of EMS agencies providing HIV health and

wellness programs pursuant to section 401.272, F.S., from 6.4% to 25%

by December 2018

□ Reduce the number of adult low acuity ED visits from 14.15% to 10% by

December 2018

□ Increase the number of EMS agencies with protocols that actively refer

children and adults for early intervention and treatment of mental

health disorders from 0 to 25 by December 2018

□ Increase the percentage of EMS agencies offering immunization

programs pursuant to section 401.272, F.S., from 6.4% to 25% by

December 2018

The following objectives included in the EMSSP are also included in the SHIP;

the information was taken directly from the EMSSP:

□ Increase the percentage of EMS agencies conducting fall prevention

programs from 28.5% to 40% by December 2018

□ Increase the percentage of EMS agencies conducting drowning

prevention programs from 30% to 50% by December 2018

□ Increase the percentage of EMS agencies conducting programs to

reduce infant mortality from 18.5% to 30% by December 2018

□ Increase the percentage of EMS agencies providing HIV health and

wellness programs pursuant to section 401.272, F.S., from 6.4% to 25%

by December 2018

□ Increase the percentage of EMS agencies offering immunization

programs pursuant to section 401.272, F.S., from 6.4% to 25% by

December 2018

Focusing on objectives that are found in both

SHIP and the EMSSP ensures your alignment

with Florida’s state initiatives.

If you are considering aligning your MIH-CP

with the SHIP and the EMSSP, developing

alliances with other community organizations

and groups working in these areas is an

important rst step.

For example, you may enter into a

Memorandum of Agreement with your local

health department to align your MIH-CP

program with the priority areas identied

in your county’s Health Improvement Plan.

If the area identied for improvement is

immunizations, you are in alignment with the

SHIP and the EMSSP.

A template for a Memorandum of Agreement is

included in Appendix C.

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Manatee County Florida Community Paramedicine

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Florida established a Medicare Rural Hospital

Flexibility (Flex) Program that is funded by

the federal Oce of Rural Health Policy,

Department of Health and Human Services.

These federal funds are available to create rural

health networks, promote the regionalization

of rural health services and improve access to

healthcare for rural populations.

Flex Program areas are:

1. Quality improvement

2. Financial and operational improvement

3. Population health management and EMS

integration (optional)

4. Designation of Critical Access Hospitals

(required if requested)

5. Integration of innovative healthcare

models (optional)

The Florida Flex program is overseen by the Florida Department of Health.

In developing rural healthcare systems, the Flex program promotes

collaboration among rural providers, critical access hospitals (CAHs), and

emergency medical service (EMS) providers.

Annual work plans are developed and monitored to track success in the

required and selected optional program areas. Florida’s Flex Work Plan for

2017-18 includes three goals; two required and one optional. Under each

goal, there are activities that may be incorporated into a MIH-CP Program.

Adapted from the Florida Flex Plan and displayed below are the selected

goals, objectives, and activities that lend themselves to a MIH-CP Program:

■ Goal 1: Improve the quality of care provided by critical access

hospitals

□ Objective: Assist CAHs in implementing quality improvement

activities to improve patient outcomes

○ Activities:

» Improve patient safety in CAHs and the community by

ensuring all healthcare providers and eligible patient

populations receive their inuenza vaccinations.

» Improve transitions of care from CAHs to other healthcare

settings to improve patient outcomes

■ Goal 3a. To understand the community health and EMS needs of CAHs

□ Objective: Annually – Determine collective issues and trends in

population health management for CAHs

○ Activities:

» Conduct (participate) in assessments, identify needs,

establish improvement strategies

Another theme running through the documents described above is

that the goals, strategies, and objectives align with the national effort

spearheaded by the Institute of Healthcare Improvement (IHI). The IHI’s

Triple Aim calls for improving population health, improving the client’s care

experiences (including quality and satisfaction), and reducing per capita

healthcare costs.

Florida’s EMS service providers are rallying to meet these

challenges, and MIH-CP programs present a potential

intervention to effect system-wide change.

MIH-CP and the Flex Program

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Chapter 1 References and Resources

1. NAEMT’s Mobile Integrated Healthcare and Community Paramedicine (MIH-CP) 2nd National Survey provides

current data on MIH-CP programs across the U.S. This includes start-up costs, target markets, services provided,

partnerships, stang, and payment. http://www.naemt.org/docs/default-source/2017-publication-docs/mih-cp-

survey-2018-04-12-2018-web-links-1.pdf?Status=Temp&sfvrsn=a741cb92_2

2. The Rural Health Information Hub provides information on rural health issues and MIH-CP programs.

Examples of rural MIH-CP models are found at https://www.ruralhealthinfo.org/project-examples/topics/

community-paramedics

3. National Rural Health Association, Policy Brief titled Principles for Community Paramedicine

Programs. Available at https://www.ruralhealthweb.org/getattachment/Advocate/Policy-Documents/

PrinciplesforCommunityParamedicineSept-2012.pdf.aspx?lang=en-US

4. The federal Oce of Rural Health Policy funded a study to look at the evidence base for community

paramedicine in rural communities. Their ndings evaluated delivery systems, challenges, and the role of state

Flex programs can play in supporting the development of these programs. Karen B. Pearson, MLIS, MA, John A.

Gale, MS, George Shaler, MPH, University of Maine, February 2014. Community Paramedicine in Rural Areas:

State and Local Findings and the Role of the State Flex Program. http://www.exmonitoring.org/wp-content/

uploads/2014/03/pb35.pdf

5. Zavadsky, M. and Hooten, D. 2016. Mobile Integrated Healthcare: Approach to Integration. Burlington, MA:

Jones & Bartlett Learning.

6. Pollack, A.N. (ed.) 2018. Community Health Paramedicine. Burlington, MA: Jones & Bartlett Learning.

7. MedStar Mobile. Information available at http://www.medstar911.org/

8. Florida Statutes and Community Paramedicine

The governing Florida laws for EMT’s and Paramedics are under Title XXIX Public Health, Chapter 401,

specically, Part III on Medical Transportation Services. The law cited for enabling Community Paramedicine is

Florida Statute 401.272(1)-(3), which states:

(1) The purpose of this section is to encourage more effective utilization of the skills of emergency

medical technicians and paramedics by enabling them to perform, in partnership with local county health

departments, specic additional healthcare tasks that are consistent with the public health and welfare.

(2) Notwithstanding any other provision of law to the contrary:

(a) Paramedics or emergency medical technicians may perform health promotion and wellness

activities and blood pressure screenings in a nonemergency environment, within the scope of their

training, and under the direction of a medical director. As used in this paragraph, the term “health

promotion and wellness” means the provision of public health programs pertaining to the prevention of

illness and injury.

(b) Paramedics may administer immunizations in a nonemergency environment, within the scope of

their training, and under the direction of a medical director. There must be a written agreement between

the paramedic’s medical director and the county health department located in each county in which

the paramedic administers immunizations. This agreement must establish the protocols, policies, and

procedures under which the paramedic must operate.

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Chapter 1 References and Resources

(3) Each medical director under whose direction a paramedic administers immunizations must verify and

document that the paramedic has received sucient training and experience to administer immunizations.

The verication must be documented on forms developed by the department, and the completed forms must

be maintained at the service location of the licensee and made available to the department upon request.

Florida Statutes Title XXIX Public Health: 401.272 Emergency medical services community healthcare.

http://www.leg.state..us/statutes/index.cfm?App_mode=Display_Statute&Search_String=medical%20

directors&URL=0400-0499/0401/Sections/0401.272.html

9. The Florida Statutes Title XXIX Public Health: 401.265 a description of medical directors is found at

http://www.leg.state..us/statutes/index.cfm?mode=View%20Statutes&SubMenu=1&App_mode=Display_

Statute&Search_String=medical+directors&URL=0400-0499/0401/Sections/0401.265.html

10. The Florida Administrative Code governing medical direction is 64J-1.004. It provides an outline of

provisions for a medical director’s contract:

• Name and relationship of the contracting parties.

• A list of contracted services inclusive of medical direction, administrative responsibilities, professional

membership, basic and advanced life support review responsibilities, and reporting requirements.

• Monetary consideration inclusive of fees, expenses, reimbursement, fringe benets, clerical assistance

and oce space.

• Termination clause.

• Renewal clause.

• Provision for liability coverage.

• Effective dates of the contract.

https://www.rules.org/gateway/ruleNo.asp?id=64J-1.004

11. The Health Insurance Portability and Accountability Act of 1996 (HIPAA) is a law impacting every aspect

of medical condentiality and is important to consider in developing a MIH-CP program. You can access it at

https://aspe.hhs.gov/report/health-insurance-portability-and-accountability-act-1996

12. For a deeper look at the legal issues based on the expanding roles health professionals play in CP programs,

this report by The Association of State and Territorial Health Ocials is a good analysis. James G. Hodge, Jr.,

JD, LLM, Daniel G. Orenstein, JD, Kim Weidenaar, JD, (2014). Expanding Roles of Emergency Medical Services

Providers: A Legal Analysis. http://www.astho.org/Preparedness/ASTHO-EMS-and-Law-Report/

13. Melody Glenn, Olivia Zoph, Kim Weidenaar, Leila Barraza, Warren Greco, Kylie Jenkins, Pooja Paode

& Jonathan Fisher (2017). State Regulation of Community Paramedicine Programs: A National Analysis,

Prehospital Emergency Care, 22:2, 244-251, DOI: 10.1080/10903127.2017.1371260, https://tandfonline.com/

doi/abs/10.1080/10903127.2017.1371260?journalCode=ipec20

14. Community Paramedicine Services by the Minnesota Department of Human Services

available at http://www.dhs.state.mn.us/main/idcplg?IdcService=GET_DYNAMIC_

CONVERSION&RevisionSelectionMethod=LatestReleased&dDocName=dhs16_177475

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Chapter 1 References and Resources

15. While this 2010 article is older, it provides a good overview of different MIH-CP services across the country

and discusses opportunities and challenges in the areas of funding, regulation, roles, education, medical

direction, stakeholders, and evaluations. Joint Committee on Rural Emergency Care, National Association

of State Emergency Medical Services Ocials, National Organization of State Oces of Rural Health. State

Perspectives Discussion Paper on Development of Community Paramedic Programs, December 2010.

http://www.nasemso.org/Projects/RuralEMS/documents/CPDiscussionPaper.pdf

16. Florida Department of Health, State Health Improvement Plan available at

http://www.oridahealth.gov/about-the-department-of-health/about-us/state-and-community-health-

assessment/ship-process/index.html

17. The Florida Department of Health Emergency Medical Services State Plan 2016-2021. http://www.

oridahealth.gov/provider-and-partner-resources/advisory-councils-stakeholder-groups/ems-advisory-council/_

documents/ems-strategic-plan.pdf

18. Florida Medicare Rural Hospital Flexibility (Flex) Program is available at

http://www.oridahealth.gov/programs-and-services/community-health/rural-health/index.html

19. Additional information about the IHI and its Triple Aim may be found on their website: http://www.ihi.org/

engage/initiatives/TripleAim/Pages/default.aspx and http://www.ihi.org/Topics/TripleAim/Pages/default.aspx.

20. The Journal of Emergency Medical Services has a Mobile Integrated Healthcare section. It’s a good way

to stay current on what’s happening in the industry: http://www.jems.com/adminstration-and-leadership/

community-paramedicine-and-mobile-healthcare.html?c=1

21. Sample Medical Director Interview Questions to determine their interest, passion, and involvement:

■ What do you know about the Mobile Integrated Healthcare / Community Paramedicine (MIH-CP) healthcare

models?

■ What do you see as the greatest unmet healthcare need in our community?

■ Under the Florida laws, paramedics work under the direction of a medical director, the MIH-CP model does not

change the paramedic’s scope of practice, but it does change the role of the paramedic. Are you comfortable with

this change in the role of the paramedic working under your license?

■ Are you interested in being the medical director for a MIH-CP program in our community?

■ Are you willing to be involved in the development of our MIH-CP program?

■ Are you willing to be a part of any presentation of our community program to potential stakeholders, clients, and

resource providers?

22. Florida Association of EMS Medical Directors: http://www.emlrc.org/faemsmd/about/

23. Florida EMS Advisory Council: http://www.oridahealth.gov/provider-and-partner-resources/advisory-

councils-stakeholder-groups/ems-advisory-council/

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CHAPTER 2

What’s Need Got to Do With It?

Chapter 2 presents a discussion of need assessment that includes why agencies conduct needs assessment, what goes into a

needs assessment, and where to go to get the data to make a data-driven decision regarding areas for program development.

Do your research about legitimate CP

programs and travel to see how they

operate. Look for volume – is there a real

need to do the program?

Joe Goodwin

Manatee County Florida Community Paramedicine

Characteristics or variables you use to describe your

population are ones that are associated with access to

care and health status. Some of the variables associated

with access to care and health status include (but are not

limited to) emergency department utilization, frequency

of 9-1-1 calls, reasons for 9-1-1 calls, age, income,

educational level, the presence of disease (morbidity),

causes of death (mortality), self-perceived health status,

and the ability to carry out one’s activities of daily living.

If you answered “everything,” you’re on the right track!

The organized and purposeful examination of a group of

people (population) to identify new areas for program

design and implementation is a needs assessment. Using

data, you describe the population. Where the population

is located denes the geographical area that you are

serving or proposing to serve.

If you are a county-funded organization, the population

you serve may be legislatively dened as all residents of

the county. In this case, the county is your geographically

dened service area. Within that geographically dened

area, you may identify a population of interest (target

population) that may benet from a new program

(intervention).

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Data Sources

There are two basic data sources for a needs assessment, and these are data either internal to the organization or external

to the organization. Internal organizational data is your organization’s administrative data that includes client records

and billing data. According to the report summarizing the ndings from the NAEMT 2nd National Survey on Mobile

Integrated Healthcare and Community Paramedicine, the overwhelming majority (82%) of the current MIH-CP programs

across the country used their records to determine community needs. Table 3 was excerpted from the NAEMT report and

demonstrates the reliance on internal administrative data. Your organization’s administrative data is a valuable resource

that should be carefully reviewed and leveraged in your research. Be sure to seek data from potential stakeholders as it

will help them to relate to and ultimately, engage in the project.

In 2004 Florida created the

Emergency Medical Services

Tracking and Reporting System

(EMSTARS) that in turn participates

in the National EMS Information

System (NEMSIS). EMSTARS is a data

collection and analysis system that

captures incident-level data from

participating EMS providers.

The data may be used for

benchmarking to see how your

experience compares to other EMS

providers and for assessing process

and procedures that would benet

from a plan, do, act, check quality

management process. Several

EMSTARS’ data elements are helpful

when assessing the need for a MIH-

CP Program including reasons for

calls and whether a transport took

place.

Included in EMSTARS version 3.4

are questions regarding whether an

organization has MIH-CP protocols,

whether rural counties have MIH-

CP protocols, and the number of

community paramedic events.

Table 3: Data Sources

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82%

EMS data

(such as from

electronic patient

care reports or

dispatch)

69%

Hospital

Admission/

Discharge

Data

63%

Population

Demographics

62%

Emergency

Department

Data

50%

Public Health

Data

22%

Utilization

Data From

One Or More

Ambulatory

Care Practices

10%

Other

09%

Law

Enforcement

Data

08%

Data From

Telephone

System (Acd,

Etc.)

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■ Health Plans: Compare health plans on quality of care, member

satisfaction, coverage areas by county, accreditation status, and

claims payment performance. You can also compare monthly

health plan premium rate options and nd additional resources

on many health insurance topics.

■ Hospitals and Ambulatory Surgery Centers: View performance

and outcome data on selected medical conditions and

procedures in these types of health care facilities.

■ Emergency Room Care: Read educational information about

when and how to use an emergency room, what to do in a

medical crisis, alternatives to emergency room care and other

helpful information.

■ Prescription Drugs: View comparative prices at Florida

pharmacies for the top 100 most prescribed drugs in Florida.

You choose the county where you live and a drug you want

to price. The website displays the current price for most

pharmacies in your county.

Another source of information

and data is the Florida

Department of Health, Agency

for Health Care Administration’s

(AHCA) Florida Health Finder. As

noted on their website, there is

information that compares the

quality and cost performance of

hospitals, ambulatory surgery

centers, health plans, nursing

homes, and prescription drugs:

Of note for MIH-CP programs is the

emergency room data. For more

information about Florida Health Finder,

visit the website at

http://www.oridahealthnder.gov

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Photographee.eu/Shutterstock.com

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Screenshot 1

Focus on the client’s needs and provide

empathetic, patient centered care.

Richard Ellis

When looking for external data,

the Florida Department of Health

Community Health Assessment

Resource Tool Set (CHARTS) is

one of the rst places to nd data

for your needs assessment. The

county is the unit of analysis in

the CHARTS data set. Your county

health department uses CHARTS

data to gauge the health of the

county and prioritize areas for

intervention and improvement.

The CHARTS website is located at

http://www.healthcharts.com/

charts/ChronicDiseases/default.

aspx.

Screenshot 1 is the Chronic

Disease report from the CHARTS

for Alachua County. If you cannot

read it, please go online, nd the

table, and take a minute to look

at it. There are some helpful

things to notice. Variables for

Alachua County are presented

as well as data for the State and,

also the U.S. Healthy People 2020

Goal.

These two columns provide

comparative data for Alachua

County so one may assess if the

indicator is “better” or “worse”

than the rest of the State, and

how well the county is doing in

accomplishing the U.S. Healthy

People 2020 Goal. By way of

review, the U.S. Healthy People

2020 Goal is a federal initiative

that establishes health-related

goals and monitors the health of

the U.S.

State and federal data provide useful benchmarks for comparison. When writing a grant application, funders want to know

what makes the population you propose to serve unique or worthy of funding. Given that poverty is a risk factor for poor

health, Alachua County would highlight the fact that their population has a higher proportion of individuals below the

poverty level. The rate for Florida is 16.1%, and the rate for Alachua County is 24.2%. The difference between your county’s

number, Florida’s number, and the Healthy People Goal is used to highlight inequities or gaps that exist. These inequities

point you to potential areas for intervention around which you may design and implement a MIH-CP.

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Delivery Model Any County Florida U.S. Benchmark

Length of Life Ranked 60th

Premature Death 10,012 6,893 5,200

Poor Physical Health Days 4.4 3.7 2.5

Poor Mental Health Days 4.6 3.8 2.3

Health Behaviors Ranked 35th

Adult Obesity 27% 26% 25%

Adult Smoking 24% 18% 14%

Physical Inactivity 26% 23% 20%

Injury Deaths 109 69 50

Social & Economic Factors Ranked 46th

Children in Poverty 29% 25% 13%

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The greatest challenge was the volume of

need in the community.

Lauren Young

Table 4: Any County Health Rankings Compared to Florida and U.S. Benchmarks

The Robert Wood Johnson Foundation (RWJF) publishes the County Health Rankings. This initiative provides information on

nearly all U.S. counties ranking them on 30 indicators. The indicators are grouped as follows:

Table 4 is an example of the some of the information available at the RWJF site (http://www.countyhealthrankings.org).

The selected indicators included in Table 4 may be particularly helpful if your MIH-CP is focused on healthy-life measures

and chronic diseases. These are two areas that align with the Florida Department of Health’s strategic initiatives.

Of the 11 MIH-CP Programs in Florida who reported operating a MIH-CP program and were respondents to a recent survey,

82% (9) stated they started their programs based on a needs assessment using internal data regarding high volume users.

Of the two remaining respondents, their parent organization selected the focal area in one organization and the other, a

funding source dictated it.

Budget Note: Add the cost of your data collection

and analysis into your budget as a Miscellaneous

expense.

1. Health Outcomes

a. Length of Life

b. Quality of Life

2. Health Factors

a. Health Behaviors

○ Tobacco Use

○ Diet & Exercise

○ Alcohol & Drug Use

○ Sexual Activity

b. Clinical Care

○ Access to Care

○ Quality of Care

c. Social and Economic Factors

○ Education

○ Employment

○ Income

○ Family & Social Support

○ Community Safety

d. Physical Environment

○ Air & Water Quality

○ Housing & Transit

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Let the data drive your discovery of what is needed in your community.

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Chapter 2 References and Resources

1. NAEMT’s Mobile Integrated Healthcare and Community Paramedicine (MIH-CP) 2nd National Survey provides

current data on MIH-CP programs across the U.S. This includes start-up costs, target markets, services provided,

partnerships, stang, and payment. http://www.naemt.org/docs/default-source/2017-publication-docs/mih-cp-

survey-2018-04-12-2018-web-links-1.pdf?Status=Temp&sfvrsn=a741cb92_2

2. Florida Prehospital EMS Tracking and Reporting System (EMSTARS) is available at

http://www.oridaemstars.com/

3. Florida Department of Health, Agency for Health Care Administration provides quality and cost information

on health plans, hospitals and ambulatory surgery centers emergency room care, and prescription drugs. This

resource is available at http://www.oridahealthnder.gov/index.html

4. The Florida Department of Health’s CHARTS website is located at

http://www.healthcharts.com/charts/ChronicDiseases/default.aspx

5. The Florida Agency for Healthcare Administration web site FloridaHealthFinder.gov

This site assembles and displays provider/facility utilization and performance data. Types of data available

include emergency department utilization and cost at http://www.oridahealthnder.gov/index.html

6. The World Bank published a free, online guide for conducting a needs assessment. The reference and site

are as follows: A Guide to Assessing Needs: Essential Tools for Collecting Information, Making Decisions,

and Achieving Development Results. World Bank. © World Bank. https://openknowledge.worldbank.org/

handle/10986/2231 License: CC BY 3.0 IGO.

7. Zavadsky, M, and Hooten, D. 2016. Mobile Integrated Healthcare: Approach to Integration. Burlington, MA:

Jones & Bartlett Learning.

8. Pollack, A.N. (ed.) 2018. Community Health Paramedicine. Burlington, MA: Jones & Bartlett Learning.

9. Robert Wood Johnson Foundation. County Health Rankings. Provides information on how U.S. counties rank

on health measures. http://www.countyhealthrankings.org

10. Another source of health-related information is the Gallup Well-Being initiative. Available at http://news.

gallup.com/topic/COMMUNITY_WELLBEING.aspx

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CHAPTER 3

Identifying Stakeholders

This Chapter introduces stakeholders and the importance of considering both internal and external stakeholders. An important

task of the program leader/administrator is to engage stakeholders early and often.

Several tools can help your thinking, organization, and engagement of stakeholders, and we will look at one of them, the Power

versus Interest Grid.

For purposes of this discussion, power and interest are

operationalized as:

1. If an individual or group has access to the resources

needed to solve a problem or resolve an issue, they have

power. Power bases include wealth, status, knowledge,

and skill.

2. An individual or a group’s interest is a function of

whether they are affected by the issue, change, or

disruption in the status quo. Interest will vary by the

degree to which the issue, change, or disruption of the

status quo affects the individual or group.

Stakeholder identication, as well as their ongoing

engagement, takes time and energy, and organizations

that commit to the engagement of stakeholders are

better able to manage program implementation and

harness the creative knowledge and communication

capacity of stakeholders.

Several scholars who study program implementation

describe stakeholders along two dimensions, both

power and interest. For a more detailed discussion of

power versus interest see the work of Crosby & Bryson

(2005), the reference is at the end of this Chapter.

Finding people that encourage your

innovative thinking and outside the

box approach is the key to program

development and success. Develop

champions to support the program – in

other words, rally the stakeholders.

James Crutchfield

Totsapon Phattaratharnwan/Shutterstock.com

Stakeholder Analysis

High Power/Low Interest High Power/High Interest

Low Power/Low Interest Low Power/High Interest

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Communication with stakeholders

should be continuous and consistent

Richard Ellis

Stakeholders with high

power and high interest

will likely have the most

inuence on a problem or

solution, and a program

leader must manage these

stakeholders closely. This

group may make or break

the stakeholder alliance

if their interests are not

seriously considered.

Note that groups with high

power and low interest also need

attention, and the program leader

should work to sway them into the

high power/high interest quadrant.

The effective leader will attempt

to frame the issue or solution in

such a way as to inspire interest,

harnessing stakeholder energy

to help work on the identied

problem. The program leader

who can frame the issue and

solution, create a powerful and

persuasive message, and fully

engage stakeholders is a visionary

leader. Typically, your target clients

are assigned to the low power/high

interest quadrant. Even if they have

low power, they are important,

and leaders should reach out to

them and seek their input. Clients

may become powerful program

champions if they are treated with

respect and as partners.

A power-versus-interest grid typically helps determine which stakeholders’ interests and power bases should

be considered to address the problem or issue at hand. It also helps highlight coalitions to be encouraged

or discouraged, what behavior should be fostered, and whose buy-in should be sought or who should be “co-

opted.”

Table 5 displays the power versus interest grid and is constructed by categorizing stakeholders into one of

four groups:

High Power/Low Interest

High Power/High Interest

Low Power/Low Interest

Low Power/High Interest

Table 5: Power Versus Interest Grid

George Rudy/Shutterstock.com

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It is important to consider both internal and external stakeholders. For example, if you are the MIH-CP champion in your

organization and your boss thinks MIH-CP’s are a waste of time, your efforts may be in vain. In this case, your boss has high

power/low interest and can derail your efforts. Moving your boss to the high power/high interest quadrant may solve this

problem. Recognizing internal weaknesses exist is the rst step in developing strategies to turn the weaknesses into strengths.

Included in Appendix J is a document describing the Palm Beach County Fire Rescue MIH Pilot Program focused on high frequency

callers. It is an example of a concise description of a program that would be helpful to inform stakeholders including your local

radio stations and newspapers. You may even turn them into champions.

Organizing a Local Alliance

Whoever leads the program must be all

in and excited about the program.

Wendy Crews

For purposes of this discussion,

an alliance is the group of

stakeholders and other individuals

or groups that you have organized

to help you. Organizing an alliance

is an important task, and they

are an important variable in all

stages of the program design and

implementation. The relationship

between the program leader

and the stakeholders is key as

stakeholders may be powerful

foes or allies. Since trust is at

the heart of a relationship, all

communication must be open,

honest and frequent. The program

leaders must communicate

effectively, listen, seek to

understand, and put the needs of

the stakeholders above their own.

By carrying out these activities,

leaders will create an environment

of trust.

The program leader works with

stakeholders to identify problems

and solutions, as well as resources

in the community that are already

focused on the need/problem. The

stakeholders provide important

information regarding the political,

social, and cultural waters that the

leader must navigate.

Potential alliance members you

may include:

■ Primary Care Providers

■ Nursing Home Professionals

■ Hospice Professionals

■ Hospital Administrators

■ Senior Center Representatives

■ Visiting Nurses Professionals

■ Third Party Payors

■ Law Enforcement Representative

■ Fire Department Representative

■ Social Service Agency

■ Representative

■ Public Health Representative

■ Pharmacy Professional

■ Mental Health Professional

■ Federally Qualied Health

Centers

■ Local Charities Representative

■ (based on the type of service)

■ Civic / Veterans Organizations

■ Education Institutions

■ Potential vendors (e.g.,

Telemedicine)

■ Church Representative

■ Public Representative

■ Local Government

Representative

■ State Government

Representative

■ Transportation Organizations

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Keep in mind that all parties must see value when participating in the program. NAEMT’s Mobile Integrated

Healthcare and Community Paramedicine (MIH-CP) 2nd National Survey illustrates the quid pro quo of

referrals between stakeholders and your MIH-CP Program and the information in Table 6 came from that

report. It summarizes the quid pro quo modied to show the central position of your MIH-CP Program. Be

sure to think about how you can provide value to the stakeholders, not just what they can do for you.

One tool you can use to help craft your message is a NAEMT resource, EMS 3.0: Explaining the Value to

Payers. It provides talking points and answers to key questions asked by specic types of stakeholders. You

can nd it at http://www.naemt.org/docs/default-source/2017-publication-docs/ems-3-0-talking-points-to-

payers-2018.pdf?sfvrsn=952fcb92_2

Historically, it has been dicult getting third-party payors, such as insurance companies, to partner with

MIH-CP programs. But, that is starting to change. After piloting projects with MIH-CP programs throughout

the nation, they are now more interested in talking about and developing partnerships with MIH-CP’s to

provide services.

Be multifaceted – everyone can be used

to help a patient. Look at community

options because each is unique (Meals

on Wheels, churches, etc.). Be sure

to also consider national partners as

resources.

James Crutchfield

Table 6: MIH-CP Referrals

67% Hospitals

58% Physician groups/clinics

40% Home health

36% Social service agencies

35% Care management organizations

30% Law enforcement

24% Mental healthcare facilities

26% Other EMS agencies

25% Hospice

23% Public health agencies

19% Addiction treatment centers

17% 3rd party payers

(such as insurance companies)

10% Nursing homes

8% Urgent care facilities

51% Social service agencies

50% Home health

48% Mental healthcare facilities

43% Addiction treatment centers

39% Physician groups/clinics

39% Hospice

35% Care management organizations

28% Hospitals

25% Public health agencies

24% Urgent care facilities

10% Nursing homes

10% Law enforcement

9% Other EMS agencies

8% 3rd party payers

(such as insurance companies)

Referrals To MIH-CP Referrals From MIH-CP

MIH-CP

PROGRAM

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Matt Zavadsky, Chief Strategic Integration

Ocer at MedStar Mobil Healthcare,

recommends you be selective. Your focus

should be on the organization’s largest

third-party payor, not the one you bill the

most. For example, if Medicaid is billed

$600K, but only pays $200K, and XYZ

company is billed $300K and pays $250K,

they should be partnering with XYZ, not

Medicaid. Zavadsky goes on to say,

“You

want to bring those organizations to

the table to see if they are interested

in developing a new model where they

pay for all responses irrespective of

transport.”

Leaders need visionary skills to develop a shared

understanding of community problems, build

support for benecial solutions, and develop

a commitment to collective action. They need

political skills to turn a proposed solution into a

specic program. One important consideration:

The relationship between the stakeholders and the

program leader may disintegrate if the program

leader is perceived as biased towards one group

or another. The effective program leader must

nurture the stakeholder alliance by participating in

honest and open dialogue.

Also, the program leader may not be able to

give the stakeholders everything they desire,

but this must be communicated in open and

honest dialogue. Always consider that alliances

will disintegrate if the program leader fails to

communicate, communicates in a biased manner,

lacks objectivity, has preconceived solutions, has a

personal agenda, and does not listen to members.

The payors have finally awaken.

Matt Zavadsky

More communication with stakeholders

that is continuous and consistent.

Richard Ellis

What It Takes to Lead a Local Alliance

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Chapter 3 References and Resources

1. An older text, but a classic that presents a depth discussion of Power Versus Interest Grids and approaches

to solving perennial and thorny public problems. Crosby, B. & Bryson, J. (2005). Leadership for the Common

Good: Tackling Public Problems in a Shared-Power World, 2nd Edition. Jossey-Bass.

2. Potential alliance members may be found through your regional Healthcare Coalition. To learn more and nd

the one in your region: http://www.oridahealth.gov/%5C/programs-and-services/emergency-preparedness-

and-response/community-preparedness/healthcare-coalitions.html

3. The National Association of County & City Health Ocials provides resources for engaging public health

system partners, stakeholders, and community members. It has PowerPoint presentations, a webinar on

facilitating diverse groups, and many tools and forms for engagement. http://archived.naccho.org/topics/

infrastructure/CHAIP/partner-engagement.cfm

4. For more information on Federally Qualied Health Centers go to https://www.cms.gov/Outreach-and-

Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/fqhcfactsheet.pdf

5. Find your county’s Federally Qualied Health Center at https://ndahealthcenter.hrsa.gov/

6. NAEMT’s Mobile Integrated Healthcare and Community Paramedicine (MIH-CP) 2nd National Survey: http://

www.naemt.org/docs/default-source/2017-publication-docs/mih-cp-survey-2018-04-12-2018-web-links-1.

pdf?Status=Temp&sfvrsn=a741cb92_2

7. NAEMT EMS 3.0: Explaining the Value to Payers. http://www.naemt.org/docs/default-source/2017-

publication-docs/ems-3-0-talking-points-to-payers-2018.pdf?sfvrsn=952fcb92_2

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CHAPTER 4

Developing Your Program Plan

marketing. An example might be:

“Our mission is to

improve the health of every person in our county by

bringing healthcare to their door.”

A helpful YouTube video called Ted Talk by Simon

Sinek illustrates the importance of the “why.” A link is

provided in the resources at the end of this Chapter.

Bring together a diverse group of individuals to

watch the video and work on the development of an

inspirational mission statement. Include people with

differing viewpoints and experiences in this activity

to maximize the generation of ideas and, ultimately,

their buy-in to the program. Individuals to consider

are potential stakeholders/alliance members and

customers, internal leaders, and potential employees of

the program.

Any discussion of what you may do in response to

your needs assessment that used internal, external, or

both types of data, must be based on solid and clearly

dened vision, mission, and goals.

A vision statement is the “Where are we going?”

statement. It should be an aspirational description of

what we want to achieve or accomplish. An example

is:

“To have XYX County free of all preventable illness

and injury.”

It’s a high-level picture of where we want

to be in the future.

Your mission statement is the heart of your MIH-CP.

It is the “why” you are doing it. Everything else ows

from that “why.” It guides what you do and how you

do it. It’s the basis of all your communications and

Clarify your mission, vision, and purpose

for the program. Establish what you want

to accomplish.

Orlando Dominguez, Jr.

What will you do: Mission Matters

Manatee County Florida Community Paramedicine

Goals

Establish strategic partners to support the provision of bringing

healthcare to their door.

Improve the health of residents with diabetes.

Strategies

Create a strategic partner development plan with supporting

materials.

Develop an in-home chronic disease management system for

diabetes.

Objectives

Within the rst 6 months, establish agreements with at least 4

strategic partners to either provide the services “to their door”

or funding to support a Community Paramedic to deliver the

services.

Within the rst 6 months, test the in-home chronic disease

management system with 20 diabetic residents and perform a

baseline health analysis.

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If you’re in it just for the dollars, don’t

do it. Do it for the right reasons: your

mission. Mission matters.

Richard Ellis

Once, you have your inspirational program vision and

mission compare it to your organization’s mission

statement, vision, and goals. Are you in alignment with the

organization? If you are, this gives you leverage in seeking

support and funding because you can emphasize that your

program will help the organization achieve its mission,

vision, and goals. However, if it is not in alignment, the

opposite is true. You may have a challenge “selling” it to the

leaders of your organization. If that is the case, see if you

can revise your program mission to be in alignment with

your organization’s mission.

Program Goals

Strategies and Objectives

Your program goals should dene how you want to achieve your mission. After articulating your goals operationalize

them by specifying strategies and objectives. Using the example mission from above, how do you improve the health of

every person in your county by bringing healthcare to their door? There can be multiple goals focused on different ways

of meeting the mission. Possible goals for this mission statement might be:

■ Establish strategic partners to support the provision of bringing healthcare to their door.

■ Improve the health of residents with diabetes.

These are just 2 examples – you need to have that direction of how your program is going to achieve its mission in your

goals.

Your strategies are more dened actions you are going to take to achieve the goal and your objectives are very tactical

and measurable. Table 7 provides an example goals, strategies, and objectives.

Table 7: Goals, Strategies, and Objectives

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Developing Your Implementation Plan

Finally, verify that your program goals, strategies, and objectives are not in conict with others in your community. You want to

build on other’s work in the community or complement the services they are currently providing. A MIH-CP should not duplicate

or compete with the currently available resources. If you have a conict, see if you can work together to accomplish common

goals, strategies, and objectives or consider addressing another gap in healthcare or unaddressed need in your community.

Working together and not in silos creates higher success rates for everyone involved.

You’ve identied the need or problem to work

on, stakeholders to engage in your alliance, and

developed your vision, mission, goals and objectives.

This is where you describe your intervention – the

what. Again, what are we going to do to accomplish

the program goals? Strongly consider, an evidence-

based practice that has been shown to eliminate

the problem you identied, stop it in its tracks, or

minimize its consequences.

Your program implementation plan includes a

description of:

■ How the proposed MIH-CP services are appropriate

to meet the identied needs.

■ Who are the leaders, managers, and other staff

executing the program?

■ What does the organizational chart look like and

who reports to whom?

■ Will there be a single person doing everything or are

other staff required?

■ How the program integrates with other community

services, providers, other levels of care, and

referrals.

■ The evidence-based practice, best practice, or

data-driven innovation that will be part of the

program. For example, if you are conducting a

fall reduction program the U. S. Department of

Health and Human Services, Centers for Disease

Control and Prevention’s Preventing Falls: A Guide

to Implementing Effective Community-Based Fall

Prevention Programs is an example of an evidence-

based practice you could use.

■ A description of the organization’s standard

operating procedures (SOP) that are on-hand or will

be developed.

When you prepare your implementation plan,

include appropriate and reasonable time-framed

tasks (i.e., infrastructure planning, staff recruitment

and retention, facility development/operational

planning, information system acquisition), as well as

individuals charged with their completion.

Consider evidence-based interventions.

If none exist, consider data-driven

innovation.

Lauren Young

City of Gainesville Florida Community Paramedicine

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28%

Single

encounter

only

30 days or less

31 to 90 days

91 to 180

days

More than

180 days

10% 10%

43%

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Define a specific program and build

processes around it, because the

process allows you to expand to

other types of problems once you

have them in place.

Don Hughes

Regarding policies and procedures, every program should

have clear statements of their policies and procedures that

lead to the articulation of standard operating procedures

(SOPs). It is important to actively involve the medical

director in their development since the Community

Paramedic’s scope of work is based on medical direction.

Policies and Procedures

Specic SOPs to include as part of your program are the

following:

■ General Physical Assessments

■ Home Safety Assessments

■ Medication Reviews and Reconciliations

■ Emergency Situations

■ Patient Consents in compliance with the Health Insurance

Portability and Accountability Act (HIPAA)

■ MIH-CP Entry into Care and Discharge

■ Quality Assurance

Other questions to ask and for which you may need SOPs are: How do clients and referring providers or organizations

reach you? Will clients call a dedicated line or the main number? What are the advantages and disadvantages of using

Email? If you need to develop SOPs, the NAEMT MIH-CP Toolkit provides sample SOPs and forms that may be used to

develop your own program’s SOPs. Be sure to customize the SOPs to match the design of your program and the services

you provide.

Table 8 is from the 2nd National Survey on Mobile Integrated Healthcare and Community Paramedicine. It illustrates

the length of time patients are enrolled in the 129 organizations that responded to the NAEMT survey. It is helpful to

get a “ballpark” idea of what you might expect. This information may be useful as you plan your program and develop

a SOP for how clients enter your MIH-CP Program.

Appendix H is a sample MIH Provider Referral Entry into Care Form and Appendix I is a sample MIH Provider Initial

Contact Form. Use the forms to develop your customized enrollment SOP.

Table 8: Length of Enrollment

How long are patients enrolled in the MIH-CP Program?

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Identifying the resources within

the community, and establishing

the reliability, availability, supplies

and qualifications was the greatest

challenge to starting a MIH-CP

program.

Orlando Dominguez, Jr.

Finding an employee who wanted to

do it was the challenge. Getting the

data was easy and talking to people

is easy.

John McNamara

Resource Guide

Selecting a Leader

Brevard County Florida Community Paramedicine

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As you’ve been developing the mission of your MIH-CP,

there must be a person with the vision of what it will

look like, the passion for getting over challenges, and

the desire to make it run well. This is who you want to

lead the program! You need to select someone who

doesn’t have an “I’m doing it because I was told to”

attitude. Find the real champion to lead your program

– and it may not be the one with the most experience or

the most senior person!

Several of the MIH-CPs in Florida interviewed are

operated by re departments, and one of the issues

they have encountered is the department seniority

system. The system may limit the selection of the MIH-

CP leaders, and, at times, prevents them from placing

the real champion in the leadership position. This

may be a challenge you need to address early in your

program development.

As discussed earlier, leadership skills are not the same

as emergent or acute care skills needed to work directly

with a patient. Look for leadership skills and traits,

such as excellent listening/communication, a heart

for service, empowers others, patience, commitment/

dedication, humility, respectfulness, foresight/visioning,

honesty/integrity, innovative, inspirational/passionate,

and transparent/authentic.

Budget Note: Insert the annual cost of your leader’s

salary and benets under payroll expenses – Salaries

of Leader and Staff. Keep in mind that the actual cost

is not just the salary of the person, but the employer

required matching taxes, unemployment insurance,

workers compensation, retirement benets, and insur-

ance.

Developing a compendium of resources is so important.

While it is everyone responsibility to identify community

resources, it is strongly recommended that someone

is assigned to update and continuously maintain a

Community Resource Guide for the program. Most

county social service agencies already have and use a

community resource guide. However, you may want to

remove or add resources which are specically focused

on your program services. Resources may include

medical equipment/supplies, prescription assistance,

and the name and location of food pantries. Creating a

guide for your agency’s program is an essential duty to

ensure overall program success.

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Take time to find ‘good’ staff – they

will make or break your program.

Ariella Bak

Stang

Staff Skills

C h a p t e r 0 4

Things you need to consider are:

■ Does the MIH-CP program t into your current organizational chart? To whom does the leader of the MIH-CP program report?

Or, do you need a separate organization chart for your MIH-CP program?

■ Do you need MIH-CP coverage 24/7, part-time or full-time staff?

■ Will you operate every day or only during the week or weekends?

■ With the shortages in the EMS industry, does it have to be a paramedic? Can it be another medical provider or a partner? Can

it be a non-medical person?

■ How many people do you need to operate it, such as eld personnel, partnership/alliance management, billing, reporting, data

analysis, and administration?

Based on your responses to these questions, the next steps are developing your organizational chart, stang plan, and job

descriptions. For your organizational chart, you can either build on and modify your current organizational chart or use

the template in Appendix D to develop a new one.

Your stang plan is a key component of your business plan that describes the number and types of people to involve,

what they will be doing, and when they will be doing it. After your stang plan is complete, develop job descriptions

for each staff person, including the leader. In the job description, dene the education and experience qualications,

responsibilities, and desired skills. Include any additional expectations of the position, such as continuing education

requirements.

Recently, a MIH-CP online student described the work of Community Paramedics as being focused on closing the gap

between emergency room care and care in less costly settings. So, how are the skills of an emergency care Paramedic

different than the skills of a Community Paramedic? This was a question asked in the interviews with the 11 MIH-CP

organizations in Florida. Here are paraphrases of what they said:

Once you have your leader, you will need to develop

an organizational chart, job descriptions, and a stang

plan. Many MIH-CPs begin their program by placing a

light duty paramedic in a community paramedic role.

■ We hire both pre-hospital Paramedics and Community

Paramedics based on the same criteria. All medics require

critical thinking and problem-solving skills, but we also look

for compassionate Community Paramedics.

■ Looking for expanded history taking and physical

examination skills so that the Community Paramedic can

see broader health concerns.

■ A willingness to take on unplanned service calls.

■ A willingness to expand the scope of practice and do things

outside of EMS critical care.

■ Additional pharmacy and lab training is a plus.

■ Soft skills, communication, and all skills considered part of

an individual’s emotional intelligence.

■ An ability to get things done.

■ Experience navigating the healthcare system.

■ Advocacy skills.

Skills you should look for when hiring Community Paramedics for your MIH-CP are good problem solving, strong advocacy,

excellent listening/communication, observant, a heart for service, patience, versatile technical abilities, compassion,

commitment/dedication, respectfulness, honesty/integrity, innovative, passionate, and authentic.

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The skills in the CP program require more

detective work and root cause analysis

capabilities.

John McNamara

Keep in mind that not all the MIH-

CP skills are taught in paramedic

training programs, and employees

in the MIH-CP program may

not know what is required or

understand the MIH-CP paradigm.

The MIH-CP is a paradigm shift

from the traditional pre-hospital

paramedic practice. It is a shift in

practice and the thought process.

The skills previously described

are consistent with the

recommendations of Dan Swayze.

In his 2015 article published

in JEMS, he identies the core

competencies for community

paramedics as the following:

1. Expanded Patient Assessment

2. Therapeutic Communications

3. Understanding Mental Health

4. Patient Navigation & Advocacy

Swayze goes on to highlight the

concept of localization. That is to

say; programs are unique to their

social, cultural, and geographical

context. Consider your

community’s social, cultural, and

geographical context as you design

your program and recruit and train

staff.

NAEMT’s Mobile Integrated

Healthcare and Community

Paramedicine (MIH-CP) 2nd

National Survey asked the 129

MIH-CP programs about personnel

requirements. Field EMS experience

was by far the most common

response at 88%.

College-based community college

paramedic education was 27%.

Some required more specialized

training, 27% required behavioral

health crisis intervention training,

21% required critical care training,

and 7% required community health

work certication.

A template Performance-Based

Community Paramedic Job

Description is included in Appendix G.

Budget Note: Add the salary cost

of your staff and the salary of your

leader under payroll expenses –

Salaries of Leader and Staff. And, be

sure to once again add the addition-

al costs of benets for the staff to the

leader benets.

Budget Note: If you plan to staff us-

ing overtime, include the salary and

benets of the staff under the over-

time row as overtime is at a higher

rate of pay than standard pay.

Manatee County Florida Community Paramedicine

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Training / Skill Development

Levels of Community Paramedic Training

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Often initial and ongoing training expenses are overlooked. In the section above, you’ve identied the job responsibilities

and skill sets necessary for your program. How will you either obtain those skills, enhance them, or maintain them for a

successful program?

What type of initial training is necessary to launch your program? Will you send the person to training outside of your

organization? If so, you need to consider not only the tuition and fees, but the associated travel expenses, such as

transportation, hotel, and meals. If you are conducting in-house training or doing training on-line, be sure to include any

associated expenses as well.

You may also want to plan for enhancing the skills sets of the staff. Evaluate what skills will expand or elevate your

program to greater success. Will a special certicate or degree be of value to the individual and your MIH-CP program?

There are various levels of training for Community

Paramedics. Here are some examples:

Bachelor of Science – Community Paramedicine Specialization

Seminole State College of Florida offers a medical specialty

degree in Community Paramedicine. The candidate must

have an Associate’s degree with a 2.0 GPA or higher,

completed a Florida Department of EMS approved

paramedic program or be eligible for certication as a

Florida paramedic, or be a certied Florida paramedic. The

program covers legal and ethical aspects, communications,

research, economics, systems, management, general

education courses (i.e., math, science, history); and specic

CP programs in delivery and practice of community

paramedicine. Total hours is 120.

Associate in Science Degree Program:

Northern Maine Community College, Presque Isle, ME

offers an Associate degree in Community Paramedicine.

Required courses are Health & Safety Compliance;

Community Paramedicine; English Composition; CP

Skills Lab; CP Clinical; Leadership in EMS; Community

Paramedicine Seminar; College Algebra; Anatomy

& Physiology I & II; Introduction to Nutrition; a

Communications elective; General electives; General

Psychology; Sociology; and Humanities. A total of 60 hours

of education.

Advanced Certicate Program:

Northern Maine also offers an Advanced Certicate

program, for those already possessing an Associate degree

or higher. The courses are the same as those for the

certicate program described below, excluding the English

and Math courses. Total hours is 16.

Certicate Programs:

Hennepin Technical College, Eden Prairie, MN offers an

advanced Technical Certicate as a Community Paramedic.

It requires a current license as an EMT-P and at least two

years of experience as a paramedic. The curriculum is 14

hours, covering the topics of Role Advocacy and Outreach;

Community Assessment; Care and Prevention Development

Strategies; and Community Paramedicine Clinicals.

Northern Maine also offers a certicate requiring 22

hours of education. It covers Health & Safety Compliance;

Community Paramedicine; English Composition; CP

Skills Lab; CP Clinical; Leadership in EMS; Community

Paramedicine Seminar; and College Algebra.

Certicate Programs – Online:

Nature Coast EMS offers an online Community Paramedic

certicate program focused on two things: skill

development and program design and implementation.

Recognizing that technical and soft skill sets are different

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Human Resources Policy and Procedure Manual

C h a p t e r 0 4

One nal consideration involving stang, verify your organizational chart, stang plan, and job descriptions are consistent

with your organization’s current Human Resources Policy and Procedures Manual. You may need to modify the Manual or

your documents to be sure you are in alignment with the organization.

If you need to develop one for your MIH-CP, there are many online resources. One resource is the sample Community

Development Corporation Policies and Procedures Manual developed by Local Initiatives Support Corporation to assist

community development corporations. You can nd the link to it in the references and resources at the end of this

Chapter.

for acute care, emergent care, and leadership, the

program addresses those skills necessary for a community

paramedic. It also guides you through the development of

a customized business plan for a MIH-CP Program.

Northern Maine is currently testing an on-line version of

their Community Paramedicine curriculums with the clinical

portion being completed locally. At this time, it is not

available, but likely will be offered in the near term.

When evaluating a training program, be sure to look for

one specic to the community paramedic role. Many

training programs are using the term “paramedicine” and

“paramedic” interchangeably. For instance, Metropolitan

Community College, Omaha, NE offers a certicate of

achievement in Paramedicine. However, when you read the

curriculum, you see it is preparing students to become a

paramedic and sit for the National Registry exam. It is not

focused on the specic community paramedicine skills.

Certication:

The International Board of Specialty Certication offers

a CP-C certication exam. It is not an educational

program, but a test designed to validate the competency

of paramedics providing services beyond the roles of

traditional emergency care and transportation.

Budget Note: Keep in mind that higher education levels

will usually impact the salary or wages, so consider this

when evaluating the salary in your budget.

NAEMT’s Mobile Integrated Healthcare and Community

Paramedicine (MIH-CP) 2nd National Survey asked the 129

MIH-CP programs about personnel training. And, nearly all

of them stated they required additional specialized training

as follows:

■ 87% Clinical training, such as medication administration

and chronic disease management

■ 73% Accessing community and social services resources

■ 69% Patient navigation

■ 69% Patient relationships/communications (ex:

motivational interviewing)

■ 58% Enhanced patient assessment

If your organization pays for continuing education credits

for your paramedics, be sure to include the expense in your

budget.

Budget Notes: If applicable, under Miscellaneous Expens-

es, include the cost of initial training and continuing edu-

cation training expenses in the budget in their respective

section. Put the meals and travel costs associated with

the training in their respective sections.

Budget Notes: Under Administration, include the cost of

the licensing fees.

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Logistics and Overhead Expenses

Multidisciplinary Advisory Committees

Identifying your stakeholders and partners for

launching a program is important in the early

stages of program design and the rst step in

beginning a relationship. These individuals may

be working in conjunction with you to provide

client services in the community. But that is not

the end. You should also seek to leverage their

talent, experience, and knowledge for continuous

improvement, quality control, growth, and

directional vision as part of a multidisciplinary

advisory committee. They will be your

community champions.

An advisory committee does just that – advises. It is

not a board of directors and should have no operational

authority or authority to mandate program changes.

However, the power the committee does have is the power

of “feet.” That is if they recommend changes, and, if those

changes do not happen, they can walk away as stakeholders

in your program. This can have a signicant impact on

your program – either for the good or the bad. That’s why

it is important to carefully establish the parameters of the

committee. You can call them By-Laws or Guidelines, but

essentially you are dening what you want the committee

to help you with and how to do it.

Have as many hands involved in the

program as possible. It is tough to

do it alone. Continually develop your

knowledge base. Match knowledge

skills with diverse multidisciplinary

skills of others.

John McNamara

Matej Kastelic/Shutterstock.com

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There are many issues you need to think about to make

your program work. Here are some things to think about:

■ How are you getting your personnel to the clients? Or, are

they coming to you through a partnership arrangement of

some kind?

■ Will your staff wear uniforms?

■ What capital equipment and supplies are needed for

the staff person to do their job? Computers? Software?

Medical equipment?

■ What supplies/equipment, if any, are you giving to the

client? Blood pressure machines? Diabetic monitoring

systems?

■ What kind of space do you need? Home-based or oce-

based?

■ What are your space costs?

■ What communication system is needed? How are clients

contacting you? Are you using the non-emergency dispatch

system?

■ Other administrative overhead, such as oce materials,

supplies, internet, phones, utilities.

■ What changes are required in your insurance coverage?

■ Will there be legal fees to get started?

■ Marketing costs. Be sure to include such things as the cost

of materials, publications, copy costs, and logos on your

vehicles.

Budget Note: As you identify the necessary logistics

and overhead expenses enter them into the respective

budget lines.

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Reaching Your Target Market

An important question to consider is: How will you reach

the target market for your program; the populations most

likely to benet from your program? Regardless of the

way you set up your MIH-CP, you need to consider how to

attract clients. What gives your program client value? You

need to develop a Marketing Plan.

Your rst marketing consideration is to dene who you are

serving. Who is the target market for your service and what

are their demographics? You should have already done

this as part of your needs analysis, so transferring it to a

marketing plan should be fairly simple.

The next questions to ask relate to getting your program

message to those clients. How do you reach these clients?

Do you need to solicit the clients directly? Or, do you need

them to be referred to you by others, such as primary care

physicians, hospital discharge nurses, or your

own EMS staff? If you need referrals, then your

marketing efforts will not be directed to the client,

but to the people who do the referrals. This is an

important distinction as the marketing message is

different for each because their concerns, values,

and desired outcomes are different.

Pay to have professional marketing

materials developed. Don’t do it on

your own. It helps to open doors.

Wendy Crews

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The items to consider when designing you Multidisciplinary

Advisory Committee are the following:

■ Mission of the Committee (verify it is consistent with the

program mission)

■ Goals of the Committee (verify they are consistent with the

program goals)

■ Number and selection process of committee advisors

■ Specic disciplines/professions?

■ Required qualications

■ Removal of an advisor

■ Selection of Chair / Co-chairs

■ Meeting frequency (should be on a set schedule)

■ Calling special meetings

■ Meeting notice requirements, if any

■ Quorum requirements, if any

■ What can come before the committee

■ Conict of Interest

■ Condentiality

The mission of the committee should describe the role

they play in your organization. Generally, they are used

to provide guidance on issues of quality, service offerings,

innovation, and growth. Be sure it is consistent with your

program’s mission.

Establish goals for the committee. What do you want them

to achieve – again, be sure they dovetail into your program

goals.

Identify the make-up of the committee. Establish the

number of advisors. It is often helpful to specically

identify “seats” by profession to maintain a specic mix

of advisors. Strive for diversity in medical disciplines

and practices, selections from various community-based

organizations, and if feasible, a public voice of the client.

Describe the qualications, if any. Who will select the

advisors? How do you remove an advisor?

Finally, create a structure for the meetings. Who is the

chair/co-chairs? How often will the committee meet?

If government based, is public notice required of the

meetings, and if so, what are the requirements for calling

and holding a meeting? Can there be special meetings

called? How? What items can come before the committee

meeting? Even though it’s advisory, do you want to require

a quorum? These functional issues need to be addressed so

everyone knows from the start what is expected of them,

how their advice will be used, and how information will be

discussed and shared.

Budget Note: If you anticipate expenses for the committee,

place those under “Other” in the Miscellaneous section.

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Once you’ve identied who you need to target your marketing

efforts to, then consider what the message will be for that

group. If you are marketing directly to the client, you need to

consider why these clients should use your service? What is

it about your service that makes it unique to any other in the

market? What value do you bring to them? Develop a solid

value proposition or reason a client should use your service.

For example, Our MIH-CP program brings healthcare to your

door. It eliminates the concerns of driving or needing to call

an ambulance when you need transportation for medical

care. If driving is a concern for an elderly person then they

see value in your service.

But, if you’ve targeted primary care physicians for the

marketing message to get the clients you want to serve, the

message will be different. You still need to ask: What is it

about your service that makes it unique to any other in the

market? What value do you bring to them? Your message

may be: Our MIH-CP program extends your compassionate,

competent care through our professional healthcare

providers to your special need patients (insert the needs

you’re targeting). This message speaks to a physician about

how to address patients with specic needs in a professional

manner that he or she is otherwise unable to provide. There

is value to them.

Now that you’ve identied the group to target for your

message, the next issue is how you are going to reach them?

What marketing materials do you need? What kind of print or

social media will work, if any? Do you need to do face to face

or oce visits? Do you need yers, brochures, business cards,

etc.? How can your stakeholders help you get the message

to the target group? As you develop this strategy, be sure to

include the cost of the marketing materials in your budget.

In Appendix E there are two simple one-page marketing

plan templates by Ivana Taylor from Small Business Trends.

Using the link in Appendix, you can access the marketing plan

templates and actually write your plan into the template.

She also provides mocked up sample plans you can use as a

guide.

Finally, an important consideration in marketing is how you

want to be branded in the community. In interviews with

the Florida MIH-CP programs brand visibility is sometimes an

issue. Some programs use unmarked vehicles because their

clients don’t want their neighbors to become alarmed if they

see an EMS logo on the vehicle parked outside their house.

Alternatively, other programs use their EMS logo vehicles. In

those communities seeing an EMS vehicle is not alarming, and

people are reassured that a trusted and respected provider

is caring for their neighbor. It is something you need to be

sensitive to as you develop your program to meet the needs

of the community you serve and the preferences of the client.

Budget Note: Once you have developed your marketing plan,

assign costs associated with the implementation of the plan,

such as printing, vehicle logos, marketing development and

maintenance contracts, and social media development. En-

ter the cost into the line for marketing/public relations.

Get out there – make contacts, shake

hands, tell your story, and provide

information.

Christine Long

City of Gainesville Florida Community Paramedicine

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Chapter 4 References and Resources

1. Ted Talk by Simon Sinek on developing your mission – your “Why” to inspire action: https://www.ted.com/

talks/simon_sinek_how_great_leaders_inspire_action

2. The NAEMT MIH-CP Toolkit provides sample SOPs and forms that are available at http://www.naemt.org/

initiatives/mih-cp/mih-cp-program-toolkit

3. Centers for Disease Prevention and Control’s fall prevention resource Preventing Falls: A Guide to

Implementing Effective Community-Based Fall Prevention Programs is available at

https://www.cdc.gov/homeandrecreationalsafety/falls/community_preventfalls.html

4. Sample Community Development Corporations Policies and Procedures Manual: https://community-wealth.

org/sites/clone.community-wealth.org/les/downloads/tool-lisc-procedure-manual.pdf

5. Another guide on writing a Policies and Procedure Manual is from Professor Michael Grin, How to Write a

Policy Manual. It is not a sample, but instead provides guidance and tips on the development of the manual.

http://templatezone.com/download-free-ebook/oce-policy-manual-reference-guide.pdf

6. NAEMT’s Mobile Integrated Healthcare and Community Paramedicine (MIH-CP) 2nd National Survey: http://

www.naemt.org/docs/default-source/2017-publication-docs/mih-cp-survey-2018-04-12-2018-web-links-1.

pdf?Status=Temp&sfvrsn=a741cb92_2

7. Another example job description is found in the NAEMT MIH-CP Program Toolkit at http://www.naemt.org/

initiatives/mih-cp/mih-cp-program-toolkit

8. MIH-CP Knowledge Center has many resources you can utilize in the development of your plan. There are

articles, research, case studies, legislation information, tools, policies, and survey information. http://www.

naemt.org/initiatives/mih-cp/mih-cp-knowledge-center

9. The National Highway Trac Safety Administration, Oce of EMS has resources on education, workforce,

research, data, preparedness, and advancing EMS systems.

https://www.ems.gov/index.html

10. South Carolina Oce of Rural Health, Blueprint for Community Paramedicine Programs, Especially for EMS

Agencies, Version 1: The Abbeville Experience is an overview and resource to see how others have developed

CP programs. https://nosorh.org/wp-content/uploads/2014/08/SC-Community-Paramedicine-Blueprint_V1-

Melinda-Merrill-and-Michele-Staneck.pdf

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Chapter 4 References and Resources

11. Community Paramedicine specic programs:

■ Hennepin Technical College Community Paramedic Certication program: https://www.hennepintech.edu/

program/awards/394

■ Northern Main Community College Community Paramedicine programs: http://www.nmcc.edu/wp-content/

uploads/CP-1718.pdf

■ St. Cloud Technical & Community College: https://sctcc.edu/degrees-programs/community-paramedic/community-

paramedic-certicate-13-credits T

■ Seminole State College of Florida: https://www.seminolestate.edu/catalog/program/HS-BS/paramedic2

■ Nature Coast EMS: https://www.naturecoastems.org/education.php

12. Metropolitan Community College Paramedicine programs – which are actually Paramedic training programs:

http://mccneb.smartcatalogiq.com/en/2016-2017/Course-Catalog/Programs-of-Study/Health-and-Public-

Services/Health/Paramedicine-PMPMC

13. Florida Administrative Code 64J-1.009 governing certication of Paramedics: https://www.rules.org/

gateway/RuleNo.asp?title=Emergency%20Medical%20Services&ID=64J-1.009

14. A couple of templates for a one-page marketing plan by Ivana Taylor from Small Business Trends can be

found in the Appendix You can nd links to others on the website: https://smallbiztrends.com/2008/06/one-

page-marketing-plan.html

15. Chronic Disease Management for the Community Paramedic at

https://www.emsworld.com/article/12240314/chronic-disease-management-for-the-community-paramedic

16. The Minnesota Department of Health offers an EMS toolkit with resources that help to address common

issues faced by rural EMS organizations:

■ The Recruitment and Retention section covers writing volunteer position descriptions, nding daytime volunteers,

and retaining members: http://www.health.state.mn.us/divs/orhpc/resources/ems/recruit.html

■ The Leadership and Management section provides links to podcasts and other resources: http://www.health.state.

mn.us/divs/orhpc/resources/ems/leader.html

17. International Board of Specialty Certication for Community Paramedics: https://www.ibscertications.org/

roles/community-paramedic

18. You may nd this link to the State Board of Education for Oregon’s resource called Developing a Local

Advisory Committee Resource Handbook helpful: http://www.oregon.gov/ode/learning-options/CTE/resources/

Documents/Developing%20a%20Local%20Advisory%20Committee%20Resource%20Handbook.pdf

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CHAPTER 5

Developing Your Program Budget

Payroll, Operations, and Capital Expenses. There are

many subcategories under each section. You may not

have ALL of these expenses. They are there to simply

help you think through what is needed in your program.

You may have others to add as well.

Work through each expense category of the budget.

Initially, the numbers will be a “guess” – yes, a guess.

The gures you use are estimates based on the most

current knowledge you have at the time. The numbers

WILL change as you learn more and rene your

program. It is important to always re-evaluate your

budget gures when you make a change in any other

part of your plan.

First, the easier element, the expenses. Here are

some basic, brief denitions by Investopedia to help

you understand the budget. Expenses can be broken

down into recurring and nonrecurring. Recurring are

those expenses that are ones a company expects to

have on an ongoing basis as an ordinary cost of doing

business. Examples are fuel, equipment maintenance,

salaries, leases, utilities, and supplies. Nonrecurring

(or Capital expenses) are one-time or extraordinary

expenses. Examples are vehicles, non-disposable

equipment, buildings, and renovations to facilities.

In the Budget Template (Appendix B) you’ll nd

Expenses in yellow. The template is divided into

Expenses

Brevard County Florida Community Paramedicine

Putting numbers to a new MIH-CP is a challenge for most people. So, as you’ve been working through the development of

your MIH-CP plan you’ve also been building a foundation for your rst-year budget. Now, let’s concentrate on how to fully

develop your MIH-CP budget. We have provided a Budget Template in Appendix B to assist you.

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Revenue

Jirapong Manustrong/Shutterstock.com

For the Payroll section, as mentioned earlier, the actual expense is not just the salary or wage, but the matching taxes,

unemployment insurance, workers compensation, retirement and health benets paid by the organization. Talk to your

human resources person to determine a percentage of salary to use for these “extras” instead of breaking them down into

individual categories on the budget. For instance, if a person’s salary is $50,000, and the percentage for the “extras” is 30%,

then you would enter $50,000 on the salaries line and $15,000 on the Benets line.

If you anticipate overtime expenses, you’ll need to do the same – overtime wages + 30% for benets.

According to the Mobile Integrated Healthcare and Community Paramedicine 2nd National Survey, only 44% of the

national MIH-CP programs are reporting revenue generated by their programs. And, this is up from only 36% in 2014.

Also, 36% continue to receive grants, and 30% say they receive no payments. Of the 49 programs generating program

revenue, almost half of them made less than $50,000, only 24% made over $100,000. Revenue generation continues to be

a real issue for most MIH-CP programs.

This revenue issue poses the greatest challenge in developing the budget for most start-up programs. If you are fortunate

enough to be able to internally fund your program, then simply enter the amount of your total expenses into the “internal

sourced funds” budget line, and you have a balanced budget. Easy. For most, you’ll need to determine where your

revenue is coming from, and how much it will be.

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Grants

■ Identify exactly what you need the funding for - Equipment,

Training, Personnel, Operations, etc.

□ Your plan and budget will help you to identify what you

need to fund and how much you need.

□ Make sure your boss approves the plan and budget

for your grant proposal and that any partners already

involved in the project are on board with it. It is a waste

of your time to write a proposal if your boss or partners

are not on board with your plan.

■ Research grant opportunities which closely match your needs

□ It is a waste of your time to write a grant that is not in

alignment with your needs.

□ See the references and resource section at the end of

this Chapter for possible research sites.

■ Once a grant opportunity is identied, research as much

information as possible about it

□ What is the funding cycle?

○ Does it meet your project timeframe?

○ Do you have time to complete a strong proposal?

□ What are the eligibility requirements?

○ Is it only government/non-prots/for-prots?

○ Is only for rural or urban communities?

○ Is it only for serving specic demographics?

○ Can you partner with an eligible applicant to meet

the requirements?

□ What are the geographic limitations?

○ Is it limited to a certain state, county, town?

□ Are specic partnerships required?

○ Is it feasible to develop the necessary partnerships

in the required time frame?

□ Is the funding level appropriate?

○ It is a waste of your time to seek a very small grant

if it does not get you to the amount you need to

have a successful program. This is not to say that

you can’t use several smaller grants to fund a larger

ticket item or the overall project but be sure in the

end that you will have enough funding to complete

the project if you are awarded the grant.

○ Are matching funds required? Do we have, or can

get, those funds?

□ Who has received funding in the past?

○ Most funders will provide a list of past recipients.

This will give you a good indication of whether your

organization ts their funding prole.

□ What has been funded in the past?

○ Reviewing what has been funded will tell you a

couple of things – either they focus exclusively on

certain things – and you must be focused on the

same thing. OR because they have been funding

certain things for a long period, they are actually

looking for something that goes beyond their focus.

Be sure to ask yourself whether the current grant

details support their continued focus or whether

they are expanding beyond what they have funded

in the past.

□ Who will be reviewing the grant proposals?

○ Some grants will provide you information on who

will be handling the proposal review. If that is the

case, it is very helpful to understand their style

and focus: academic, data geeks, statistics, stories,

impact, etc.

■ Start getting the required support from any inuential partners,

government, or others which can help your grant application.

■ Read EVERYTHING several times – the details on the grant are

VERY important

□ Many, many grant proposals never make it to the

reviewer because of late submission, errors in required

formatting, failure to provide all information requested,

etc. Understanding and meeting every detailed

requirement in the grant is the only way to make it to the

reviewers.

■ Based on your research, revisit your plan to see where

adjustments can be made to more closely t the grant

requirements.

○ Don’t compromise the integrity of your program just

to get funding. Stay true to your mission.

○ If you do want to make changes to your plan, be

sure to engage your boss and your partners in the

conversation.

■ Call any contacts listed in the grant to help you clarify their

requirements.

■ Attend any conference calls or webinars hosted by the granting

organization.

□ This is where they will clarify what they are looking for in

projects and will usually respond to questions from the

audience.

■ Develop strong data to support your grant proposal.

□ Use data which supports THEIR priorities, not just yours.

□ Find comparison data to put your data into perspective.

To say the percentage of calls for falls in your community

is 30% doesn’t provide a context for the number. If you

use comparative data, such as the percentage of calls for

falls in the state is 20%, then the reader understands the

context and relevancy of the number.

■ Prepare a le to maintain your application documentation.

So, the big question on everyone’s mind: Where is the

money?

Before you seek any type of outside funding, especially grants, you must be prepared. Here is a list of specic questions

and things you need to do BEFORE you begin writing a grant for your program:

Here are some ideas for funding your program:

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Using grants are like the chickens in a breakfast –

they contributed (eggs), where funding the program

internally is a commitment, like the pig in a breakfast

(bacon). Commitment is a long-term focus.

Don Hughes

FUNDING SOURCES

Screenshot 2

Government Grants

When MIH-CP was a new concept in the industry, the

opportunities for grant funding was more abundant.

Monies were invested in pilot programs at the federal, state,

and local levels to learn more about the optimal design of

a program, the possible impacts a community paramedic

could have to improve the health of a community, and

alternative methods on how healthcare could be delivered.

As those years of research have now shown that MIH-CP

can have positive impacts on health and the delivery of

healthcare, fewer grants are available for pilot or new

programs, especially at the federal and state levels.

However, that does not mean federal grants don’t come

up on occasion. Most will be focused on testing a specic

concept within a community paramedicine program or a

health issue that a community paramedic could potentially

address. It’s less likely you’ll nd federal funding for a

start-up program unless your program has unique features

which address a specialized federal initiative.

You can go directly to a federal agency to search for

funding, such as FEMA’s Assistance to Fireghters Grant

Program at https://www.fema.gov/welcome-assistance-

reghters-grant-program, or the US. Department of

Homeland Security for active shooter and provider

protection equipment at https://search.dhs.gov/

search?query=grants+&op=Search&aliate=dhs.

You can also check for federal grants at the website, www.

Grants.gov. The opportunities listed change daily, regularly

checking it may help you stay on top of any quick due dates.

By putting in key search words, like “Paramedics” shown

in Screenshot 2, the current grant opportunities with that

word in them will appear. You can click on the Opportunity

number for greater details.

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Don’t rely on one funding source. Develop a diversified

funding model so that you can expand your programs

to meet the needs of your patient population.

Melissa McNally

Foundations

Foundations, endowments, and organizations with a philanthropic branch are another source of grant funding, or in some

cases in-kind donations. However, each will be focused on very specic areas of interest to them. To help you nd these

opportunities, The Grantsmanship Center is one online site which may be benecial. While not all their information can be

accessed without a paid subscription, there is some free information. For example, this link will take you to the Top Giving

Foundations in Florida: https://www.tgci.com/funding-sources/FL/top. By clicking on the name of a foundation in the list,

you will nd contact information and geographic focus. It will also provide a link to the foundation’s website, where you

can do additional research to determine whether their giving focus is in alignment with the focus of your MIH-CP.

Associations

Various re and EMS associations will occasionally offer grant funding to support new initiatives, training, or capital

purchases which could support the start-up of an MIH-CP program. But in reality, they are usually more focused on being

a resource for locating new grant opportunities. For instance, and as displayed in Screenshot 3, FireRescue1 sponsors a

page on their website called FireGrantsHelp. This resource may assist in locating grants for re departments, volunteer,

and reghter grant assistance: www.regrantshelp.com.

State grants for start-up programs are not as abundant as

they used to be. State matching grants are offered through

the Emergency Medical Services Trust Fund at a 75/25

match or 90/10 match for rural service providers. Under FS

401.113 the grant funds are to be used to conduct research,

increasing existing levels of emergency medical services,

evaluation, community education, injury-prevention

programs, and training in CPR and other lifesaving rst aid

techniques. Rural providers may also use the monies for

improvement, expansion, or continuation of services.

However, this grant has experienced a steady decline in the

availability of funding through the Trust Fund.

Check with the Florida Department of Health, Emergency

Medical Service Section at 850-245-4440 and the Oce

of Rural Health at 850-245-4009 for current opportunities

or look at: http://www.oridahealth.gov/%5C/provider-

and-partner-resources/ems-grants/index.html. Again, like

federal grants, they may be focused on testing a specic

concept within a community paramedicine program or a

health issue that a community paramedic could potentially

address.

Many MIH-CP have been started with grant funding from

a local source. The Emergency Medical Services Trust

Fund also provides monies to the counties for emergency

services. When starting your program, work with your

community and local government to see what may be

available to help address a community health need.

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Screenshot 3

Screenshot 4

If you click on the Lowe’s link in Screenshot 3, you’ll nd additional information. Screenshot 4 shows you what you’ll nd:

As you can see, it gives you enough baseline information to see if you may be eligible for the grant. However, if you

want more information or assistance with the grant, it is only available to members subscribing to FireRescue 1 services.

Alternatively, you could go directly to the Lowe’s page and do a detailed analysis of the opportunity.

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Insurance Partners Florida Model National Model

Set up

Organization started and designed based on

the partnership

Collaboration between the City of Pittsburgh

and its bordering 36 municipalities. Started to

address the nancial burdens certain patients

were having on EMS agencies. Established a

countywide resource team – no single EMS

agency runs the program.

Services

Chronic care; transitional care; advanced

illness management, health risk assessments;

and unplanned urgent/emergent care

Chronic disease management for diabetes,

asthma, and chronic heart disease

Target Market

Insured patients with Medicare Advantage or

Affordable Marketplace Healthcare

Referrals from EMS agencies, hospitals,

University of Pittsburgh Medical Center, and

Highmark Blue Cross Blue Shield

Insurance Partners Florida Blue and Aetna

Blue Cross Blue Shield and one other leading

health insurance provider

Funding

Capital funding upfront monies from insurance

provider in the Medicare Advantage population.

Marketplace Healthcare was primarily a fee

for service billing. Additional fee for service

models were added to Medicare population as

the program grew.

Funding from health insurance providers

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Some partners are willing to invest in a MIH-CP program

because of a strategic advantage it will create, or nancial

savings it can generate for them. We’ve all heard about

hospitals being charged signicant nes for hospital

readmissions. And a few Florida MIH-CP have partnered

successfully with hospitals to reduce readmission rates.

Most of the Florida MIH-CP we interviewed have had little

luck getting hospitals to invest signicantly in an MIH-CP

despite the programs ability to help reduce readmission

rates and subsequent hospital penalties.

However, insurance companies have been investing in

and testing the MIH-CP model to determine if the model

improves their members’ health and reduces the overall

cost of providing care. Table 9 presents a brief summary

of some of the characteristics of a Florida MIH-CP

program, Evolution Health, and the CONNECT Community

Paramedic program, a national model, who created funding

partnerships with insurance companies.

According to Dan Swayze, Vice President and COO of the

Center for Western Medicine of Western Pennsylvania,

Inc. and project manager for the CONNECT Community

Paramedic program, rural EMS agencies are often too

small to work individually with insurance companies. They

are usually looking for geographic markets with a higher

concentration of their members.

Discussions have been ongoing with the Florida Association

of Health Plans to engage and partner with the association

and their members on MIH-CP programs across the state.

Finally, keep in mind that some partner funding can be in-

kind donations. Even if your partners cannot provide cash

funding, they may be able to provide equipment, supplies,

and other items helping to offset your cash outlays.

Partner Funding

Table 9: Characteristics of MIH-CP and Insurer Partnerships

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SeventyFour/Shutterstock.com

Client Funding

Another source of funding is revenue from the patients or

clients receiving the care. There is a new MIH-CP in Florida

who recently launched their program using only patient pay

as their ongoing revenue source. They have designed a model

with enough client value that patients are willing to pay for

the service without using third-party payers. Unfortunately,

generating sucient revenue to support your program is

unique, but something you should also consider when you

develop your program.

Medicare/Medicaid Reimbursement

Unfortunately, Medicare and Medicaid programs do not

reimburse for community paramedics in the State of Florida

at this time. They will reimburse for services which include

treatment if the patient is transported to a medical receiving

facility. The patient must be transported. The reason for

this is Medicare and Medicaid only reimburse for the actual

transportation of a client by EMS/Paramedics/EMT’s.

Some MIH-CP Programs will try to get around this

reimbursement issue by using other types of medical providers.

If this is something you want to consider, we strongly suggest

you work with an attorney with expertise in this area to

make sure you are in compliance. The penalties for violating

Medicare/Medicaid laws are signicant and not to be taken

lightly.

Budget Narrative

Depending on the complexity of your budget, you may want to

include a budget narrative in your plan. The narrative simply

explains to the reader anything you want them to know about

the budget. For example, you may want to explain how you

calculated a gure (i.e., employee benets), or variances from

previous year gures, or if it is a 3-year budget, the differences

in gures between each year. The narrative can also be helpful

for you in the event you want to make changes or to analyze

year-end performance.

Appendix A is an outline for a complete business plan.

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Chapter 5 References and Resources

1. Investopedia, https://www.investopedia.com/ask/answers/072815/what-difference-between-recurring-and-

nonrecurring-general-and-administrative-expenses.asp

2. Community Tool Box: Writing a Grant Application for Funding: https://ctb.ku.edu/en/writing-grant-application

3. Another grant resource is Grant Station. It is a member-based program: https://grantstation.com

4. NEMSIS and EMSTAR are good resources for comparison data to support grant proposals: https://nemsis.org/

and http://www.emstar.org/

5. Medicare Benet Policy Manual, Chapter 10 - Ambulance: https://www.cms.gov/Regulations-and-Guidance/

Guidance/Manuals/downloads/bp102c10.pdf

6. Medicare Claims Processing Manual, Chapter 15 - Ambulance: https://www.cms.gov/Regulations-and-

Guidance/Guidance/Manuals/Downloads/clm104c15.pdf

7. The American Ambulance Association has a strong advocacy program for championing changes to the

Medicare and Medicaid laws. You can follow their efforts and changes in the laws at this site: https://

ambulance.org/advocacy/.

8. Even though you may not be able to get Medicare/Medicaid reimbursement for MIH-CP programs, there is a

current program through the Agency for Health Care Administration (AHCA) to seek additional reimbursement

for Medicaid transports: Public Emergency Medical Transportation (PEMT) Supplemental Reimbursement

Program. There are very specic qualication requirements, such as you must be an emergency medical

transport provider, enrolled as a Medicaid provider, and owned or operated by an eligible governmental entity.

The reimbursement does not cover recipients enrolled in a Florida Medicaid Managed Care Plan, non-fee

service transports, and non-transports. Utilizing this program might be a way to infuse new money into your

EMS organization to internally support a MIH-CP program. The 2 links below provide additional information and

access to Excel spreadsheets for the PEMT:

■ Agency for Health Care Administration: http://ahca.myorida.com/medicaid/Finance/nance/LIP-DSH/PEMT/index.

shtml

■ Florida Fire Chiefs Association: https://www.ffca.org/pemt-public-emergency-medical-transportation-supplemental-

reimbursement-program

9. The Minnesota Department of Health offers an EMS toolkit with resources that help to address common

issues faced by rural EMS organizations:

■ The Funding and Finances tools include nding grants, writing grant proposals, fundraising ideas, and a very

detailed budget spreadsheet: http://www.health.state.mn.us/divs/orhpc/resources/ems/funding.html

10. Florida Association of Health Plans, Inc. http://www.fahp.net/

11. NAEMT’s Mobile Integrated Healthcare and Community Paramedicine (MIH-CP) 2nd National Survey: http://

www.naemt.org/docs/default-source/2017-publication-docs/mih-cp-survey-2018-04-12-2018-web-links-1.

pdf?Status=Temp&sfvrsn=a741cb92_2

12. Article in JEMS magazine, January 17, 2015 on the CONNECT Community Paramedicine program: How

Pittsburgh’s Community Paramedic Program Links Patients to the Correct Care by Dan Swayze, Dr.PH, MBA,

MEMS. http://www.jems.com/articles/print/volume-40/issue-1/features/how-pittsburgh-s-community-

paramedic-pro.html

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CHAPTER 6

What Difference Did You Make?

This Chapter discusses techniques for assessing whether your program is making a difference in the lives of your patients, in the

population you serve and in your community.

It’s important to know if your program is making a

difference. It’s important to you – you want to know

if you’re successful or not! It’s also important to your

clients, stakeholders, and funders. Whether or not you

are making a difference is where the rubber hits the

road.

After you have identied needs, engaged stakeholders,

decided on an intervention, the next step is to decide

how you will measure the success of your program.

How did it make a difference to the people you

served? Whether or not your program was a success

depends on how well you met your goals. Performance

measures operationalize your goals allowing you to

assess your performance. Sharing the results of your

assessments is one way to share your success story with

internal and external stakeholders and to satisfy the

requirements of grants and contracts for service.

What difference did you make?

Look at realistic metrics based your

population and make sure it serves the

mission of your program. Utilize data

to bridge information gaps, evolve the

practice of patient care, and improve

patient outcomes.

Melissa McCarthy

City of Gainesville Florida Community Paramedicine

Patient experience

74%

Patient healthcare

service utilization post

MIH-CP enrollment

67%

Patient healthcare service

utilization during MIH-CP

enrollment

83%

Patient health status

72%

Income Data

Expenditure data

Other

20%

30%

Patient pre-MIH-CP

enrollment healthcare

service utilization

(911, ED, hospital

admissions/readmissions)

76%

Patient demographics

92%

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Four things to remember: It is much easier to dene

your measures up-front, so you can capture the

information required as you operate your program. It

is much harder, if not impossible, to retrot or force

your data into a performance measure later. Second,

if you are funded by a contract or grant, your funding

agency will likely require performance measures. Third,

you should measure what’s important. Performance

measures must be relevant and responsive to the

health needs you are meeting and the evidence-based

intervention you are providing. Finally, use your

performance measure data as grist for your quality

management program. Engage staff and stakeholders

in a plan, do, check, and act improvement cycle if you

nd areas for improvement.

Performance measures ow from your mission,

strategies, and objectives and are important to

determine the difference you make to the people you

serve. Developing the mission, strategies, objectives,

and performance measures sequentially allows you

to see how they t together. Taken collectively your

mission, strategies, objectives, and performance

measures are SMART:

■ S for Specic

■ M for Measurable

■ A for Achievable

■ R for Relevant

■ T for Time-bound

Performance Measures

Data Collection

Data collection and analysis is the lifeblood of performance measures. Without establishing a strong data collection and

analysis process the accuracy and reliability of your outcomes and the overall value of your program can be questionable.

Table 10 describes the types of data collected by the 129 MIH-CP programs surveyed as part of the NAEMT’s Mobile

Integrated Healthcare and Community Paramedicine (MIH-CP) 2nd National Survey. Keep in mind these collection

points are based on what their goals and what they have determined is important to measure. What you need to

collect will depend on how your program design.

Table 10: Data Collected BY MIH-CP Programs

What Data is

Collected?

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The survey also asked respondents what methods they

used to document client interactions. About half (47%)

used EMS electronic patient care reports (ePCR) systems,

39% used shared electronic patient records systems

(like with a hospital or primary care provider), 25% use

commercially available MIH-CP specic systems, 21%

use locally developed electronic record systems (word

processing, spreadsheets), and 13% use pen/paper

method. You will need to evaluate your resources, access

to systems, what data you want to capture, and staff

capabilities to determine the methods most effective for

your program.

Another question is with whom should the data be shared?

First, your staff and then your stakeholders. A best

practice identied among respondents to NAEMT’s survey

is the bi-directional sharing of data between the MIH-CP

Program and its stakeholders. Two-thirds of the MIH-CP’s

surveyed reported bi-directional sharing of patient health

information. This bi-directional data sharing is an integral

part of a successful program.

Several tools and examples of performance measures

are available. They run the gamut from simple and

easy to use to complex and resource intensive. A

brief description of a few is provided, and you can nd

additional information on them in the resources section

at the end of this Chapter. An important consideration is

that all performance measures must be relevant to your

organization and your community, and logically ow from

the intervention your program is implementing.

The Community Paramedicine Evaluation Tool (CPET),

published in 2012 by the federal Department of Health

and Human Services, Health Resources and Services

Administration, Oce of Rural Health Policy, provides a

comprehensive program evaluation tool. It is designed

for programs to use to evaluate an existing program or for

programs who are considering starting a MIH-CP program.

The CPET is organized around three core functions of

assessment, policy development, and assurance under

which benchmarks and indicators are described. Each

benchmark (performance measure) is scored on a scale

from 1 to 5, with 5 representing a “perfect score.” Scoring

a ve is ideal and found in best practices. A link to the

CPET is found at the end of this Chapter in references and

resources.

As previously noted, the development and operation of

a MIH-CP program is a process, a marathon not a sprint,

and not all programs will reach a score of 5 for each

benchmark. Using the tool in your program’s continuous

quality improvement is a good start. If you notice a less

than adequate response to a benchmark, start a plan,

do, check, and act quality improvement cycle. Engage

your stakeholders and advisory group to decide which

benchmarks are appropriate to your program, measure

them, and then strive to reach a score of 5.

Finally, take the time to create and document your database and data collection variables and processes. Set standards,

monitor trends, and make program changes if appropriate. Become a data-driven organization.

Measuring Performance

Community Paramedicine Evaluation Tool

You don’t need to go for the 100%

solution, even a 5 – 10% improvement

means the client is better than they were

before.

Lauren Young

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NAEMT MIH-CP Program Toolkit

The NAEMT MIH-CP Program Toolkit contains sample

performance measures that represent the consensus

of a 2015 expert group that had input from over

75 EMS and healthcare associations. The intent of

the performance measures is to assist programs in

documenting their value to their clients, community,

insurance companies, public payors, foundations, and

other payors like federal, state, and local grantors.

The development of the performance measures was

guided by a Steering Committee that included Matt

Zavadsky of MedStar Mobile HealthCare, Brenda

Staffan of REMSA, Dan Swayze of the Center for

Emergency Medicine of Western Pennsylvania, Brian

LaCroix of Allina Health EMS, Gary Wingrove of Mayo

Clinical Medical Transport and Dr. Brent Myers,

former medical director of Wake County EMS.

As presented in the NAEMT MIH-CP Program Toolkit’s

outcome measures, the measures are organized into

two domains each with multiple subdomains. The

two domains and selected subdomains include the

following:

1. Structure/Program Design Measures

a. Executive Level Commitment

b. Needs Assessment/Gap Analysis

c. Resource Identication

d. Stakeholder Engagement

2. MIH-CP Program Measures

a. Quality of Care & Patient Safety Metrics

b. Experience of Care Metrics

c. Utilization Metrics

d. Cost of Care Metrics – Expenditure Savings

e. Balancing Metrics

More information, as well as a description of how

the MIH-CP Program Toolkit outcome measures

were developed, may be found at http://www.naemt.

org/initiatives/mih-cp/mih-cp-program-toolkit.

When you reach the site, look for the following

headings: Assessing the Value and Outcomes of

EMS-Based Mobile Integrated Healthcare Programs,

Measurement Strategy Overview, MIH Measures

Workbook and MIH Measures Workbook Example.

Revisiting the NAEMT’s MIH-CP Program Toolkit’s outcome

measures, Matt Zavadsky categorized these measures as

falling into three basic groups. These are the program

structure, process, and outcomes. These three categories

align with the classical work of Donabedian who theorized

that quality of care might be assessed by examining the

structure, process, and outcomes of care. Some things to

consider in assessing quality in each of these categories, but

by no means exhaustive, are the following:

1. Program Structure – How is the program organized?

Are sucient resources allocated to meet the program’s

goals? Are staff in place to carry out the program? Is the

necessary equipment available and in working condition?

2. Program Processes – These are related to how the

program works and how you carry out your best practice

or evidence-based intervention. Standard operating

procedures are key.

3. Outcomes – These are described in terms of the

difference you made in the lives of the people in your

program. Did the client get their blood pressure under

control? Did they report an improvement in their quality

of life or self-perceived health status? Was there an

improvement in the client’s instrumental activities of

daily life? Sometimes called an intermediate outcome,

did the client’s risk for a condition decrease, for example,

did they quit smoking?

City of Gainesville Florida Community Paramedicine

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INSTITUTE FOR HEALTHCARE IMPROVEMENT, TRIPLE AIM INITIATIVE

Another taxonomy for categorizing quality domains is dened by the Institute for Healthcare Improvement (IHI) in their

Triple Aim Initiative. The IHI denes three domains of quality that collectively are referred to as the Triple Aim; these are

the following:

1. Population Health

2. Patient Experience

3. Per Capita Cost

1. Population Health

There are several options for assessing your program’s impact on the health of the population you serve. The interviews

conducted with 11 Florida MIHP Programs revealed that most programs who assessed the impact of their programs on the

health of a population used self- assessed health status, health-related quality of life metrics, and limitations of activity.

Other Population health measures may be focused on your target population’s general health and wellbeing. Equally

as important, these measures may be specic to your target population’s evidence-based intervention. The following

narrative presents a description of the different tools to assess population health.

A. Self-Assessed Health Status

According to the federal Centers for Disease Control and Prevention (CDC), self-assessed health status is a validated

and useful measure of how a person perceives their health. Respondents are asked to rate their health as excellent,

very good, good, fair, or poor. It is assessed with a single question - Would you say your general is excellent, very

good, good, fair, or poor?” Self-Assessed Health Status is assessed upon entry into and discharge from your MIH-CP

program.

This measure is part of the National Health Interview (NHI), a large sample survey of the U.S. population. It is useful if

you’d like to compare your program’s clients to the general U.S. population. In the resources section at the end of this

Chapter, there is a CDC link for additional information.

B. Health-Related Quality of Life

CDC describes Health-Related Quality of Life as a function of three modules of questions as follows:

1. Healthy Days Core Module (4 questions)

a. Would you say that in general, your health is excellent, very good, good, fair, or poor?

b. Now thinking about your physical health, which includes physical illness and injury, for how many days

during the past 30 days was your physical health, not good?

c. Now thinking about your mental health, which includes stress, depression, and problems with emotions,

for how many days during the past 30 days was your mental health not good?

d. During the past 30 days, for about how many days did poor physical or mental health keep you from

doing your usual activities, such as self-care, work, or recreation?

2. Activity Limitations Module (5 questions)

a. Are you limited in any way in any activities because of any impairment or health problem?

b. What is the major impairment or health problem that limits your activities?

c. For how long have your activities been limited because of your major impairment or health problem?

d. Because of any impairment or health problem, do you need the help of other persons with your

personal care needs, such as eating, bathing, dressing, or getting around the house?

e. Because of any impairment or health problem, do you need the help of other persons in handling your

routine needs, such as everyday household chores, doing necessary business, shopping, or getting around

for other purposes?

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3. Healthy Days Symptoms Module (5 questions)

a. During the past 30 days, for about how many days did pain make it hard for you to do your usual

activities, such as self-care, work, or recreation?

b. During the past 30 days, for about how many days have you felt sad, blue, or depressed?

c. During the past 30 days, for how many days have you felt worried, tense, or anxious?

d. During the past 30 days, for how many days have you felt you did not get enough rest or sleep?

e. During the past 30 days, for about how many days have you felt very healthy and full of energy?

Health-related quality of life is assessed upon entry into and discharge from your MIH-CP program. The CDC provides a

wealth of information about Health-Related Quality of Life measures at https://www.cdc.gov/hrqol/hrqol14_measure.htm

C. Limitation of Activity

Whether a person can carry out usual day-to-day activities is the focus of limitation of activity measures. Part of

CDC’s NHI, these measures ask respondents about their limitations and, as seen above, is considered a quality of life

measure. These surveys drill down into the type and degree of limitations an individual is experiencing. Limitations

of activity would be assessed upon entry into and discharge from your MIH-CP program.

Limitation of activity is assessed by asking people about their limitations in:

• Activities of daily living (such as bathing/showering, dressing, eating, getting in and out of bed, walking, using the

toilet)

• Instrumental activities of daily living (such as using the telephone, doing light housework, doing heavy

housework, preparing meals, shopping for personal items, managing money)

• Play, school, or work

• Remembering

• Any other activity that they cannot do because of limitations caused by physical, mental, or emotional problems

Additional information is available by clicking on the CDC link in the references resources listed at the end of this Chapter.

2. Patient/Client Experience

Assessing your client’s experience is commonly accomplished by administering a client satisfaction survey. There are

standard questions from various sources that you might use to construct a patient satisfaction survey. Typically, these

surveys include the following types of questions that are ranked on a Likert-like scale from 1 – 5 with more points

awarded for a positive patient experience. Client satisfaction would be assessed upon entry into and discharge from your

MIH-CP program.

Potential categories of questions relate to access to care, provider interaction and rapport, ability to make an

appointment or been seen, if you get a prompt return of phone calls, whether the provider listens and takes the time

to understand you, whether the provider explains your care and answers your questions, and if the client thinks the

provider gives advice and treatment. A sample client satisfaction survey is included in Appendix F.

Other areas that impact the client’s experience are related to the organization’s provision of safe, effective, timely,

ecient, equitable, and patient-centered care. For more information about these six dimensions of healthcare, see the

Institute Medicine’s report titled Crossing the Quality Chasm: A New Health System for the 21st Century. This report was

published in 2011 by the Institute of Medicine, National Academies Press; despite its age, its contents are enduring.

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Number

Number of ambulance transports by enrolled patients 12 months post-graduation 1, 750

Number of ambulance transports by enrolled patients 12 months pre-enrollment 3,700

Average payment per transport $421

Expenditure per CP patient contact $ 75

Number of CP patient contacts for enrolled patients 4,750

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3. Per Capita Cost – Demonstrate Cost Saving/Cost Avoidance

The need to demonstrate the value of an MIH-CP is becoming increasingly more important. Funders, insurers,

stakeholders, and other partners want to know the cost saving associated with your program. The NAEMTs MIH-CP

Program Toolkit included outcome measures that might be used to demonstrate the cost savings associated with your

MIH-CP program. These are the following:

1. Ambulance Transport Saving

2. Hospital Emergency Department Visits

3. All-cause Hospital Admissions

4. Hospitalization Average Length of Stay

The following example on Ambulance Transport Savings displayed in Table 11 was taken from the NAEMTs MIH-CP

Program Toolkit. The variables of interest are the number of ambulance transports by enrolled patients 12 months

pre-graduation and the number of ambulance transports by enrolled patients 12 months post-graduation. Two

measurements are used, one pre-intervention and the other post-intervention. The pre-intervention group is dened

as enrolled patients 12 months pre-enrollment, and the post-intervention group is the number of enrolled patients 12

months post-graduation.

Using the data in Table 11, the following calculations are completed:

1. the cost associated with the number of ambulance transports by enrolled patients 12 months post-

graduation is $736,750 (1,750 X $421)

2. the cost associated with the number of ambulance transports by enrolled patients 12 months pre-

graduation is $1,557,700 (3,700 X $421)

3. the cost of CP patient contacts for enrolled patients is $356,250 (4,750 X$75)

Making a case for the MIH-CP Program, one would say that based on a pre and post-enrollment assessment of the

frequency and cost of ambulance transport among enrolled patients, there was a cost savings of $1,557,700. If one

considers the cost of CP patient contacts, the savings is $1,201,450.

Table 11: Ambulance Transport Savings

The goal is to reduce expenditures for unplanned ambulance transports to an ED pre and post-enrollment or per event.

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Intervention-specic performance measures are used

to assess the impact your program (intervention) has

on the clients you serve. If you are implementing

an evidence-based practice, other programs have

demonstrated the ability of the intervention to have

the desired effect. If an evidence-based practice is not

available or is unacceptable to your clients, consider a

best-practice.

If your community is experiencing the effects of

tobacco use that include high morbidity and mortality

due to tobacco-related cancers and chronic lung

disease and your planned program/intervention is a

tobacco cessation program, you could structure your

performance measure as follows:

Goal: Reduce illness, disability, and death related to

tobacco use and secondhand smoke exposure.

Objective: By the end of the rst year of operation,

50% of clients who were screened positive for tobacco

use received tobacco cessation counseling.

Performance Measure: Percentage of clients who

are screened positive for tobacco use and who receive

tobacco cessation counseling.

Numerator: The numerator would be the number of

clients who were both screened for tobacco use and

found to use tobacco who were offered a cessation

intervention.

Denominator: The denominator is all clients who were

screened and are positive for tobacco use.

Note: The tobacco related goal is consistent with the

CDC’s Healthy People 2020 goal. Smoking rates are a

statistic the State Health Department tracks and the

focus of county health departments’ efforts making

this a good area for collaboration. Using the format

presented above will help you hone in on and opera-

tionalize your goal.

So far, we’ve talked about measuring performance

using a quantitative or numbers approach. However, if

you restrict your approach to just numbers, you’ll miss

some valuable information and insights.

Numbers alone cannot capture the impact that you

have on the clients you serve. If you want to know

the difference you make in the lives of the people

you care for, ask them. Clients and their caregivers

are treasure troves of information. Focus groups or

personal interviews, known as qualitative techniques,

are useful to gain an in-depth look at the impact of your

program. You may know that 60% of your clients with

diabetes have elevated hemoglobin A1Cs. But, do you

know why? That information is only available from your

clients.

Qualitative techniques may involve collecting data from

stakeholders (local providers, county commissioners,

insurers, etc.). This data can give you insights into what

these groups value. If your stakeholders gain a better

understanding of the value of your program, it may lead

to new sources of funding.

Don’t overlook the power of anecdotal information.

When you hear a personal story about the impact

and success of your program, capture and share it.

Share it with staff, your clients, and your stakeholders.

Qualitative approaches are essential to understanding

the need for and the impact of your program especially

your client’s feelings and the value they place on your

services. Stories are powerful; they put faces on the

numbers providing context and meaning. Use them to

breathe life into the numbers.

Intervention-Specic Performance Measures

It’s Not All Numbers

GaudiLab/Shutterstock.com

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Chapter 6 References and Resources

1. Oce of Financial Management, State of Washington. Performance Measure Guide found at https://ofm.

wa.gov/sites/default/les/public/legacy/budget/instructions/other/2009performancemeasureguide.pdf

2. Steve Jacob, “EMS Loyalty Program” Slashes Emergency Room Trips, Saves Millions, D Health Daily, 2/12/2014.

This article provides insight into the savings MedStar has seen with their CP program. http://healthcare.

dmagazine.com/2014/02/12/ems-loyalty-program-slashes-emergency-room-trips-saves-millions/

3. NAEMT’s Mobile Integrated Healthcare and Community Paramedicine (MIH-CP) 2nd National Survey:

http://www.naemt.org/docs/default-source/2017-publication-docs/mih-cp-survey-2018-04-12-2018-web-links-1.

pdf?Status=Temp&sfvrsn=a741cb92_2

4. NAEMT MIH-CP Program Toolkit. Available at

http://naemt.org/initiatives/mih-cp/mih-cp-program-toolkit

5. CDC, Self-assessed Health Status

https://www.healthypeople.gov/2020/about/foundation-health-measures/General-Health-Status#selfAssessed

6. Crossing the Quality Chasm: A New Health System for the 21st Century. Committee on Quality of Health

Care in America, Institute of Medicine. Washington, DC, USA: National Academies Press; 2001. Available at

http://www.ihi.org/resources/Pages/Publications/

CrossingtheQualityChasmANewHealthSystemforthe21stCentury.aspx

7. The CDC provides a wealth of information about Health-Related Quality of Life measures at

https://www.cdc.gov/hrqol/hrqol14_measure.htm

8. To learn more about Donabedian see the article titled Donabedian’s Lasting Framework for Health Care

Quality available at

https://sph.umich.edu/glc/news/pdf/Donabedian NEJM 2016.pdf

9. A Guide to Measuring the Triple Aim: Population Health, Experience of Care, and Per Capita Cost. Available at

http://www.ihi.org/resources/Pages/IHIWhitePapers/AGuidetoMeasuringTripleAim.aspx

10. A discussion of evidence-based practices and how they differ from best practices may be found at

http://www.communitygrantsnow.com/2011/08/30/evidence-based-practices-vs-best-practices/

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CHAPTER 7

Sustaining Your Program

grant funds to operate your program beyond one

or two years is unlikely. In Chapter 5 we discussed

different funding sources. You should be continually

evaluating alternative funding sources, models and

partners to stabilize and diversify your ongoing revenue

stream.

You’ll notice the Budget template has two years. For

sustainability, it’s helpful to think about your revenue

and expenses beyond the rst year. Please keep in

mind, while grants can be very helpful to get started,

you should not rely solely on funding your program

with grants. The likelihood of continuing to receive

Funding

Make sure you have financial

sustainability because that’s the main

reason programs go away.

Matt Zavadsky

Sustaining a community paramedicine program is the most dicult part. Many organizations have shown great results

from their MIH-CP but have been unable to sustain the program over time for various reasons.

Of the 129 programs responding to the NAEMT’s survey, the majority (40%) reported they had been in operation for

three or more years. Of the remaining respondents, their time of operation, 22% reported 2-3 years, 23% reported 1-2

years, and 15% reported being in operation for 1 year or less.

Here are some of the sustainability issues you should consider as you develop and operate your MIH-CP program.

Manatee County Florida Community Paramedicine

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Changes in Medicare/Medicaid Regulations

At some point, changes in the Medicare and Medicaid regulations will enable MIH-CP Programs to bill for

and be reimbursed for services other than emergency transport. When it does happen, this will signicantly

impact the ability of MIH-CP programs to be nancially sustainable. You can stay informed on this topic

through the Florida Ambulance Association or American Ambulance Association.

Another sustainable issue is stang. As

previously mentioned, the emergency

medical services industry across the country

is struggling with a paramedic shortage, and

this shortage affects an agency’s ability to

recruit staff for their MIH-CP. Staff turnover

in an emerging MIH-CP program can be very

detrimental to the consistent and effective

operation of the program. Something to

consider is whether you will staff your program

with full-time or part-time staff. Depending

on the need in your community a part-time

position may be more appropriate. Finally,

selecting the right candidates and continually

supporting their professional growth in

conjunction with program growth is crucial.

As your program matures, consider developing

a succession plan for sustainability at all levels

of the program.

Some MIH-CP programs will not be free-

standing organizations but will be a component

or division of a larger entity or service. This

usually means others may have some level of

control over the program. If this is the case,

you must be completely transparent, provide

timely and accurate data, and become the best

storyteller. With good information and stories,

they can make well informed and educated

decisions, and maybe even become a strong

advocate for your program.

Stang

Internal Support

Manatee County Florida Community Paramedicine

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Make sure the individuals who make

decisions about the program know and

understand the benefits of the program.

You must continually be selling it.

Christine Long

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provide a balanced voice and diversity of thought on

continuous program improvement and growth. It

enables ongoing input into the design, processes, and

results of the program.

get testimonials, have them speak at hearings about

your program, or develop marketing materials using

personal stories. Be creative in how you can engage

them in your program.

in your community. Let them know what great things

you are doing. Share client success stories, impressive

data, personal examples of your program’s work, and

educational and volunteer opportunities. This is also

an ideal way to leverage the client support mentioned

above.

If you did not use a local alliance in the development

of your program, one of the best ways to sustain your

partners and supporters is to establish one. A list

of suggested members is on page 30. Stakeholders

Clients can be your strongest voice of sustainable

support for your program. Make sure you measure

patient satisfaction and, if very positive, leverage

it within your organization, your partners, and the

community. Consider using them as volunteers,

One of the most important aspects of program

sustainability is community support. Your reputation

in the community will have either a negative or

positive impact on all aspects of your program.

Therefore, manage communications within your

community. Establish a media plan and campaign to

let the public know how you’re are making an impact

Partnership Support

Client Support

Community Support

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Rural providers who wish to work with insurance

companies need to work collaboratively, even on a

regional basis, rather than try to work to carve out their

program for just the communities they traditionally

serve. If they can’t build a regional program or want to

maintain their independence, community paramedic

programs starting within rural EMS providers are

more likely to be sustainable by partnering with local

providers like nursing homes, medical practices or

health departments to target a market opportunity that

better matches their size.

Daniel Swayze

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Chapter 7 References and Resources

1. Florida Ambulance Association: http://www.the-faa.org/

2. American Ambulance Association: https://ambulance.org/

3. NAEMT publication: Top 10 MIH or community paramedicine

program funding sources. Available at http://www.naemt.org/initiatives/mih-cp/mih-cp-program-toolkit

4. To address the sustainable staff issue, one of the challenges is fatigue. Here is a recent article from the

National Association of State EMS Ocers on the topic: https://www.nasemso.org/Projects/Fatigue-in-EMS/

index.asp

5. The Minnesota Department of Health offers an EMS toolkit with resources that help to address common

issues faced by rural EMS organizations:

• Recruitment and Retention: http://www.health.state.mn.us/divs/orhpc/resources/ems/recruit.html

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CHAPTER 8

Tying It All Together

When you write yours, you may not want to include

detail about the steps you took unless it helps the

reader understand the analysis you used to come to a

conclusion.

This case study provides an example of how to put

together your MIH-CP Program Business Plan. The

entity and community statistics/data are ctitious.

For learning purposes, this plan explains the steps

they took to come to some of the conclusions.

Case Study - Sunshine County Emergency Medical Services

Expect to spend signicant time developing your MIH-CP program. To give you a realistic idea of development and

launch time frames, according to the NAEMT’s Mobile Integrated Healthcare and Community Paramedicine (MIH-

CP) 2nd National Survey, MIH-CP programs across the country spent six months to 2 years from planning to actual

implementation. Be patient and set it up right. You’ll denitely benet in the long run.

Use the format as a guide in the development of your Plan. A template Plan outline is included in Appendix A. Again,

you need to develop and customize a Plan to t your community’s needs.

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MIH-CP BUSINESS PLAN FOR SUNSHINE COUNTY EMS

1. Introduction to Sunshine County Emergency Medical Services (Sunshine EMS)

Sunshine County Emergency Medical Services (Sunshine EMS) is a government entity that covers the entire county of

Sunshine, Florida. The EMS service operates 2 ambulances during the day and 1 at night. Their staff consists of 2 full time

and 1 part time Paramedics and 2 full time and 1 part time EMT’s. In addition, they have 2 volunteer Paramedics and 3

volunteer EMT’s.

They run approximately 2,500 calls per year. Of which, 35% of the 9-1-1 calls are by residents 65 years of age and older for

fall-related injuries.

Dr. Bea Good is the medical director for the EMS service.

Population Statistics:

Located in central Florida, rural Sunshine County has a population of 96,698 residents. Critical indicators of access to

healthcare are poverty, employment, insurance status, and education. The following is a summary of these indicators for

Sunshine County:

• 37% of the county’s residents are below 200% of the poverty level.

• 38.6% of families with related children under the age of 5 are living under the poverty level (this gure is over

56% higher than the state rate of 16.8%).

• 42.5% of families with a female head of household with children are living under the poverty level.

• The current unemployment rate of 15% (1st quarter 2018) is 45.6% higher than the state of Florida at 10.3%. The

highest areas of unemployment are in the towns of Orange, Lemon, and Lime.

• As many as 21,274 residents under the age of 65 are uninsured. This equates to 22% percent of that population

segment.

• The Hispanic population has the highest uninsured rate in the county at 41.9% for 2017. This is signicantly

higher than the rate of uninsured for the county and 27% higher than the state level.

• Between 2014-2017 only 16.6% of residents aged 25 years of age and older had a bachelor’s degree, signicantly

lower than the state rate of 26.4%.

• 32% of the population are 65 years of age and older compared to approximately 18% statewide.

• The Median Household income is $39,100, which is signicantly lower than the state level of $46,956.

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2. The Needs Assessment

After reviewing the county statistical data and the Sunshine EMS internal call and run report data, they have

identied the rate of falls among residents 65 years of age and older (35% of all calls) as a potential problem/need

that could be addressed by an MIH-CP program.

They searched for additional information on falls through the Florida Department of Health. This agency conducts

a Behavioral Risk Factor Survey that asks respondents to report if they had fallen in the three months before the

interview. The results of the survey indicate that individuals 65 years of age and older in Sunshine County reporting

a fall in the past three months was 8.32% compared to only 5.7% for Florida residents. Additionally, in 2016 the age-

adjusted death rate due to unintentional injuries for individuals 65 and older was 16 per 100,000 in Sunshine County

compared to 9.4 for the Florida population.

They also searched for information on falls in Florida CHARTS. The crude death rate due to unintentional falls among

the Sunshine County population 65 years of age and older is 90.13 per 100,000 compared to the Florida rate of 62.8.

The rate of falls among Sunshine County’s residents 65 years of age and older is 6.5% compared to a rate of 5.1% for

the comparable Florida population.

Community Make-Up:

• Mercy is the only hospital in the county. It has an emergency room.

• They have 2 primary care doctor oces, with a total of 4 doctors.

• There are no urgent care clinics.

• Sunnyside and Rosary are the 2 nursing homes.

• They have a hospice center aliated with the Rosary nursing home.

• There are 2 pharmacies, one aliated with a large chain, and a locally operated one.

• There are no home health services or mental health facilities in the county.

• There is a Florida public health department oce and a social services oce.

• They have 2 high schools and a satellite oce for a local community college. The satellite oce focuses

primarily on general studies, but the college does offer CNA, certications and degrees on the main campus.

• They have several civic/veteran’s organizations: Lions Club, VFW, and Kiwanis.

• There is a Senior Center which has meeting space, a game room, and provides inexpensive lunches Monday –

Friday.

• Together, the Non-Denominational, Baptist, Catholic, and Lutheran churches in the county operate a food pantry

on Thursday mornings.

• There is no dedicated transportation system in the county, but there is a taxi service.

• They have a re department and a law enforcement agency covering the county.

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Sunshine County Florida U.S. Benchmark

Length of Life Ranked 60th

Premature Death 10,012 6,893 5,200

Poor Physical Health Days 4.4 3.7 2.5

Poor Mental Health Days 4.6 3.8 2.3

Health Behaviors Ranked 35th

Adult Obesity 27% 26% 25%

Adult Smoking 24% 18% 14%

Physical Inactivity 26% 23% 20%

Injury Deaths 109 69 50

Social & Economic Factors Ranked 46th

Children in Poverty 29% 25% 13%

High Power/Low Interest

Mercy Hospital

State Government Representative

High Power/High Interest

Local Government Representative

Third Party Payors

Public Health Department

Primary Care Doctor Oces

Low Power/Low Interest

Educational Institutions

Vendors

Low Power/High Interest

Sunnyside and Rosary Nursing Homes

Rosary Hospice

Senior Center

Fire/Law Enforcement Agencies

Social Service Agency

Both Pharmacies

Civic /Veteran’s Organizations

All Churches

Taxi Service

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The Robert Wood Johnson Foundation provides county health ranking information. http://www.countyhealthrankings.org

They researched how Sunshine County ranks and discovered this:

Upon completion of the needs assessment, Sunshine EMS identied the problem of falls among Sunshine County residents

65 years of age and older as the focus of their MIH-CP program.

They decided to initially invite those in the High Power/Low Interest, High Power/High Interest, and Low Power/High Interest

categories to attend a presentation on their proposed MIH-CP program.

Sunshine County Health Rankings Compared to Florida and U.S. Benchmarks

3. Stakeholders

The next step was to identify the potential stakeholders they want to invite to participate in the development of their

program. Using the Power verses Interest Grid, they categorized the various community organizations/individuals to come

up with a list of potential stakeholders.

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4. Program Plan

After meeting with the potential stakeholders, Sunshine EMS developed the following:

Vision: Sunshine County will be free of all preventable illness and injury.

Mission: Our mission is to eliminate injuries and deaths to individuals 65 years of age and older from falls in Sunshine

County.

Goal: Reduce illness, disability, and death related in home falls among individuals 65 years of age and older.

Strategies:

Strategy A. Raise awareness

Develop partners to get home assessment information to the target market

Offer workshops on home assessments

Strategy B: Referral System

Set up a referral system with community partners

Strategy C. Education

CDC Check for Safety Tool

Strategy D. Programming to prevent falls

Matter of Balance classes

Tai Chi classes

Yoga classes

Strategy E. Home Assessments and Remediation

Develop partners to assist with remediation efforts

Strategy F. Medication Reconciliation

Develop partners to assist in reconciling conicting medications

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Objectives and Performance Measures

The following presents two key objectives for Strategy E and the associated performance measures:

Objective 1.1: To increase the number of client homes with individuals 65 years of age and older who have completed an

at-home risk assessment from 30% to 50% within the rst year.

• Performance Measure: The number of client homes with individuals 65 years of age and older who have

completed an at-home risk assessment from 30% to 50% within the rst year.

• Numerator: The number of at-home fall risk assessments that are completed in client homes with individuals 65

years of age and older.

• Denominator: The denominator is the number of client homes with individuals 65 years of age and older.

• Baseline: In the calendar year 2017, 30% of client homes with individuals 65 years of age and older had a

completed at-home fall risk assessment.

Objective 1.2: To reduce the number of fall related 9-1-1 calls by residents 65 years of age and older from 35% to 20%

within 1 year.

• Performance Measure: The number of fall related 9-1-1 calls by residents 65 years of age and older.

• Numerator: The number of fall related 9-1-1 calls by residents 65 years of age and older.

• Denominator: The denominator is the total number of 9-1-1 calls.

• Baseline: In the calendar year 2017, the number of fall related 9-1-1 calls by residents 65 years of age and older

was 35%.

5. Alignment/Conict Evaluation:

After developing the program’s vision, mission,

goals, and strategies Sunshine EMS evaluated them

in the context of the organization’s vision, mission,

and goals for alignment. They are consistent with

the organization’s mission of providing the highest

quality of care to the citizens of Sunshine County.

The program aligns with the EMSSP, Strategic

Priority 5 by increasing the number of MIH-CP

programs in Florida and by increasing the number

of programs providing fall prevention programs in

Florida.

Also, they contacted each of the community

organizations who work with the 65 years of age

and older target market to verify the goals did not

conict or duplicate their efforts. Finding none,

they proceeded with the identied goals.

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zkes/Shutterstock.com

F l o r i d a M o b i l e i n t e g r a t e d H e a l t H c a r e - c o M M u n i t y Pa r a M e d i c i n e P r o g r a M g u i d e b o o k

6. Implementation Plan:

Sunshine EMS’s MIH-CP program will target the 65 years of age and older population, who has the highest rate of falls in

the county. Falls by the elderly has devastating effects on their length and quality of life, as well as burdening the county’s

emergency response system. Addressing this issue will have a positive impact on many lives and ease the use of the 9-1-1

system by this age group.

Standard Operating Procedures (SOP’s)

Dr. Bea Good has enthusiastically agreed to provide medical direction for the program. She will not charge any additional

fees for her services.

She has agreed to develop Standard Operating Procedures for the program, including general physical assessments, home

safety assessments, medication reviews and reconciliations, emergency situations, and MIH-CP enrollment and discharge

protocols. In addition, she will create a patient consent form which complies with the Health Insurance Portability and

Accountability Act for the clients and develop a quality assurance program for the protocols and program operation.

Operating Plan:

Launch Date: The MIH-CP launch date is planned for March 1, 2019.

Service Offerings:

Services will be provided to all Sunshine County residents 65 years of age or older, and shall include:

• Educational programs on fall prevention

• Programming to prevent falls

• Home assessments and remediation efforts

• Medication reconciliation

• Home health checks

• Patient navigation/advocacy

The evidence-based practices included in the program are found in the U.S. Department of Health and Human Services,

Centers for Disease Control and Prevention’s publication, Preventing Falls: A Guide to Implementing Effective Community-

Based Fall Prevention Programs.

Stang:

The MIH-CP program will have one paramedic wholly dedicated to the delivery of MIH-CP services; this includes all

administrative tasks associated with the job. The salary will be $42,000, plus benets. After consulting with the accountant

that handles payroll, the percentage of benets for this position is 22% of salary.

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President/CEO of Sunshine EMS

Earl Daring

Multidisciplinary Advisory Committee

To be determined

Medical Director

Dr. Bea Good

MIH-CP

Manager/Community Paramedic

To be hired

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Operations:

• It will operate Monday – Friday from 8am to 5pm.

• One small used SUV will be purchased to utilize

for the program – not to exceed $15,000.

Graphics will need to be ordered and placed on

vehicle at a cost of $500.

• Insurance on the additional vehicle and

malpractice will be $1,800/year.

• No additional space will be necessary. Will

use current oce administrative support and

supplies. A new cell phone and laptop computer

will be purchased, including all Microsoft

software.

• Uniform allocation of $500 for a new employee,

and $100/year thereafter for replacement.

• Some additional medical supplies and minor

equipment will be required to stock the vehicle at

a cost of $2,000.

• Mercy Hospital, a primary care doctor, and Rosary

Nursing / Hospice have agreed to provide funding

to support ½ the annual salary of the CP and will

provide referrals to the program.

• The local pharmacist has agreed to work with

the CP and medical director on medication

reconciliation as needed and provide referrals to

the program.

• The local public health department will work in

conjunction with the CP on vaccinations, and sign

a Memorandum of Agreement.

• The Senior Center has offered space to hold

educational sessions at no cost.

• The taxi service has offered to provide discounted

rides to medical appointments for the population.

Organization Chart:

Multidisciplinary Advisory Committee:

A multidisciplinary advisory committee will be established. It will consist of a primary care physician, a hospital l

representative, a social services representative, a nursing home or hospice representative, a pharmacy representative, a

public health representative, a member of either the re or law enforcement community, and at least one lay person from

the community.

The function of the committee shall be to provide guidance on the quality of the services, the service offerings, and growth

opportunities.

Marketing/Public Relations:

The target market for our program are individuals 65 years of age and older. Our marketing approach will be two-fold.

First, direct marketing to the target population. We want people to be proactive in preventing falls.

Second, marketing to groups who work closely with the target population as a source of referrals.

A full marketing plan will be developed to implement each marketing approach. It is estimated to cost $10,000 to develop

the plan and materials to implement it.

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Area of Focus Key Action Steps

Person

Responsible

Date of

Completion

Comments

A. Focus Area: Personnel and Procedures for the MIH-CP Program

A.1. Hire Community Paramedic Develop a job description Earl Daring CEO Jan. 31st 2019

Must be a licensed

Florida paramedic

Complete new employee

orientation

Earl Daring CEO Feb. 28th 2019

A.2. Establish Procedures and

Forms for Program

Develop SOP’s for the new

service offerings

Dr. Bea Good Feb. 28th 2019

Will be evaluated by

the MIH-CP Manager

after hiring

Develop quality control

measures for program

Dr. Bea Good Feb. 28th 2019

Develop HIPAA compliant

patient consent forms

Dr. Bea Good Feb. 28th 2019

A.3. Integration of Program

Evaluate the organization’s

current policy and procedures

manual for program

compliance or modications

needed

MIH-CP Manager Feb. 1st 2019

Evaluate current EMS data and

billing software systems for

use with the program

MIH-CP Manager Feb. 1st 2019

Revise the Medical Director’s

contract to include the

additional responsibilities

Earl Daring CEO Feb. 1st 2019

B. Focus Area: Multidisciplinary Advisory Committee

B.1. Establish a Multidisciplinary

Advisory Committee

Develop By-laws or Guidelines

for an Advisory Committee

MIH-CP Manager Jan. 15th 2019

Be sure to include the

meeting structure

Recruit Advisory Committee

members

MIH-CP Manager Jan. 31st 2019

Hold the rst meeting MIH-CP Manager Feb. 15th 2019

B.2. Advisory Committee

Recruitment

Develop a plan for building

new advisory members

MIH-CP Manager March 31st 2019

B.2. Maintain Advisory

Committee

Develop a system for

continuous communication

with your Advisory Committee

MIH-CP Manager Ongoing

C. Focus Area: Marketing

C.1. Marketing to Target Market

Develop a market plan for

reaching the 65 years of age

and over target market

MIH-CP Manager Nov. 15th 2018

Include timelines

& materials to be

developed

Hire a marketing company

to develop materials for the

target market

MIH-CP Manager Dec. 1st 2018

C.2. Marketing to Partners

Develop a market plan for

partners regarding reaching

the 65 years of age and over

target market

MIH-CP Manager Dec. 1st 2018

Hire a marketing company

to develop materials for the

target market

MIH-CP Manager Dec. 1st 2018

C.3. Public Relations Events

Plan a Grand Opening

community event

MIH-CP Manager March 1st 2019 Date of launch

F l o r i d a M o b i l e i n t e g r a t e d H e a l t H c a r e - c o M M u n i t y Pa r a M e d i c i n e P r o g r a M g u i d e b o o k

Implementation Work Plan:

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Community Paramedic Program Budget Template

Categories Year 1 Year 2

Revenue

Internal Sourced Funds $ 46,000 $ 67,914

Patient/Client Payments $ - $ -

Grant/Foundation Funding $ 40,620 $ -

Partner Funding $ 25,620 $ 26,388

Total Revenue $ 112,540 $ 94,302

Expenses

Payroll Expenses

Salaries of Leader & Staff $ 42,000 $ 43,260

Percentage of Salaries for Benets $ 9,240 $ 9,517

Overtime $ - $ -

Percentage of Overtime for Benets $ - $ -

Total Payroll Expenses $ 51,240 $ 52,777

Operations Expenses

Administration

Dues & Subscriptions $ - $ -

Insurance (Facilities, Vehicles, Directors and

Ocers, Liability, Malpractice)

$ 1,800 $ 1,980

Legal Fees $ - $ -

License Fees of Staff $ - $ -

Marketing/Public Relations $ 10,000 $ 3,000

Medical Direction Contact Fees $ - $ -

Oce Supplies & Postage $ - $ -

Telephone/Internet $ - $ -

Utilities $ - $ -

Total Administration Expenses $ 11,800 $ 5,025

Facilities

Building Repairs/Maintenance $ - $ -

Communications Equipment $ 1,000 $ -

Computer Equipment $ 2,000 $ -

Lease Payments $ - $ -

Total Facilities Expenses $ 3,000 $ -

Vehicles

Fuel $ 27,000 $ 30,600

Repairs & Maintenance $ 2,000 $ 3,000

Lease Payments $ - $ -

Maintenance Contracts $ - $ -

Total Vehicle Expenses $ 29,000 $ 33,600

Miscellaneous Expenses

Meals $ - $ 200

Medical Equipment (disposable) $ 300 $ 300

Supplies (Operational) $ 500 $ 500

Supplies (Patient/Client) $ - $ -

Training (Initial) $ - $ -

Training (Continuing) $ - $ 1,500

Transportation Expenses $ - $ -

Travel $ - $ 500

Uniforms $ 500 $ 100

Other

Total Miscellaneous Expenses $ 1,300 $ 2,900

Total Operating Expenses $ 45,100 $ 41,525

Capital Expenses

Capital Purchases (Vehicles) $ 15,000 $ -

Renovations/Construction $ - $ -

Medical Equipment (non-disposable) $ 1,200 $ -

Other $ - $ -

Total Capital Expenses $ 16,200 $ -

Total Expenses $ 112,540 $ 94,302

Total Revenue After Expenses $ - $ (0)

Budget:

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F l o r i d a M o b i l e i n t e g r a t e d H e a l t H c a r e - c o M M u n i t y Pa r a M e d i c i n e P r o g r a M g u i d e b o o k

Budget Narrative:

Revenue Year 1

Internal sourced funds come from an infusion of monies by participation in the Public Emergency Medical Transportation

Supplemental Reimbursement Program for Medicaid ($28,289) and government funds ($18,011).

Grant funding from the American Health Care Association for purchase of the vehicle and ½ cost of 1st year CP salary/

benets.

Partners have committed to provide the other ½ cost of CP salary.

Expenses Year 1

Benets are 20% of salary.

Marketing includes professional design, printing cost of materials, grant opening event and other public relations events,

and vehicle graphics.

Fuel is calculated at 15,000 miles/month at 20 miles/gallon at $3/gallon

Revenue Year 2

Internal sourced funds come from an infusion of monies by participation in the Public Emergency Medical Transportation

Supplemental Reimbursement Program for Medicaid ($29,822) and government funds ($38,092).

Partners have committed to provide ½ cost of CP salary/benets.

Expenses Year 2

Salary increase 3% cost of living.

Benets are 20% of salary.

Insurance increase 10%.

License renewal for CP.

Marketing includes materials and public events.

Fuel is calculated at 17,000 miles/month at 20 miles/gallon at $3/gallon

Meals are for conferences for recertication.

Training (Continuous) is for conferences for recertication (every 2 years).

Travel includes hotel costs for recertication.

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MEMORANDUM OF AGREEMENT (MOA)

Sunshine County Emergency Medical Services as the primary EMS provider for Sunshine County (EMS Provider) and Dr.

Bea Good, Medical Director for the EMS Provider (Medical Director) enter into this Memorandum of Agreement with the

Department of Health, Sunshine County (County Health Department) to encourage more effective utilization of the skills

of emergency medical technicians and paramedics by enabling them to perform, in partnership with local county health

departments, specic additional healthcare tasks that are consistent with the public health and welfare.

Notwithstanding any other provision of law to the contrary, the parties agree as follows:

1. EMS Provider paramedics or emergency medical technicians may perform health promotion and wellness activities

and blood pressure screenings in a nonemergency environment, within the scope of their training, and under the

direction of the medical director. “Health promotion and wellness” means the provision of public health programs

pertaining to the prevention of illness and injury.

2. EMS Provider paramedics may administer immunizations in a nonemergency environment, within the scope of their

training, and under the direction of the Medical Director. Appendix A, attached to this agreement, describes the

established protocols, policies, and procedures under which the paramedic will operate.

a. Medical Director will verify and document that a paramedic has the sucient training and experience

to administer immunizations. EMS Provider will maintain the training and experience verication and

documentation on the most current forms provided by the County Health Department and will make the

documentation available to the County Health Department upon request.

3. This agreement will replace any earlier documents or oral agreements between the parties as it pertains to these

specic provisions.

4. Either party must notify the other party of any necessary changes or modications to the agreement to keep the

agreement current, such as changes in the County Health Department training and experience documentation forms,

a change in the Medical Director, or modications to the protocols, policies, and procedures described in Appendix A.

5. This agreement will be effective from the date of the signature by all parties and remain in effect until one party

provides 30 days written notice to others that they desire the agreement to be cancelled.

The terms of this Memorandum of Agreement are understood and agreed upon by the EMS Provider, the Medical Director,

and the County Health Department.

EMS Provider:

_________________________________________________________________________________ Date: _______________

Earl Daring, CEO

Sunshine County EMS

Medical Director:

_________________________________________________________________________________ Date: _______________

Dr. Bea Good, Medical Director

County Health Department:

_________________________________________________________________________________ Date: _______________

Department of Health, Sunshine County

Title: _______________________________________

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TEMPLATE OUTLINE FOR BUSINESS PLAN

1. Introduction

Organization

Population Statistics

Community Make-up

2. Needs Assessment

3. Stakeholders

4. Program Plan

Vision

Mission

Goals

Strategies

Objectives

Performance Measures

5. Alignment/Conict Evaluation

6. Implementation Plan

Standard Operating Procedures

Operating Plan

Launch Date

Service Offerings

Stang

Operations

Organization Chart

Multidisciplinary Advisory Committee

Marketing/Public Relations

Implementation Guide

7. Budget

Budget Narrative

Appendix A

a p p e n d i x

Community Paramedic Program Budget Template

Categories Year 1 Year 2

Revenue

Internal Sourced Funds

Patient/Client Payments

Grant/Foundation Funding

Partner Funding

Total Revenue

Expenses

Payroll Expenses

Salaries of Leader & Staff

Percentage of Salaries for Benets

Overtime

Percentage of Overtime for Benets

Total Payroll Expenses

Operations Expenses

Administration

Dues & Subscriptions

Insurance (Facilities, Vehicles, Directors and

Ocers, Liability, Malpractice)

Legal Fees

License Fees of Staff

Marketing/Public Relations

Medical Direction Contact Fees

Oce Supplies & Postage

Telephone/Internet

Utilities

Total Administration Expenses

Facilities

Building Repairs/Maintenance

Communications Equipment

Computer Equipment

Lease Payments

Total Facilities Expenses

Vehicles

Fuel

Repairs & Maintenance

Lease Payments

Maintenance Contracts

Total Vehicle Expenses

Miscellaneous Expenses

Meals

Medical Equipment (disposable)

Supplies (Operational)

Supplies (Patient/Client)

Training (Initial)

Training (Continuing)

Transportation Expenses

Travel

Uniforms

Other

Total Miscellaneous Expenses

Total Operating Expenses

Capital Expenses

Capital Purchases (Vehicles)

Renovations/Construction

Medical Equipment (non-disposable)

Other

Total Capital Expenses

Total Expenses

Total Revenue After Expenses

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Appendix B

a p p e n d i x

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Appendix C

__________________________ EMS as the primary EMS provider for ________________, County, (EMS Provider) and ___________________

Medical Director for the EMS Provider (Medical Director) enter into this Memorandum of Agreement with the Department

of Health, ____________________ County (County Health Department) to encourage more effective utilization of the skills of

emergency medical technicians and paramedics by enabling them to perform, in partnership with local county health