For more information, visit JEMS.com/rs and enter 8.
access to such care. The Red River project ultimately failed for many
reasons, among them a lack of close medical director oversight, and
it was discontinued several years after its inception. 5 Studies of more
recent rural MIH-CP programs have shown that rural programs can
succeed in patient outcome measures and financial savings, like their
big city counterparts. 6
Like the Laguna Pueblo, many Native American reservations are
classified as rural or frontier and medically underserved—but they
also have a mobile health infrastructure upon which an MIH-CP
program can be built.
ORIGINS OF THE PROGRAM
The Indian Health Service (IHS) is the agency within the U.S. Public
Health Service Department of Health and Human Services responsible for providing federal health services to the 2. 2 million American
Indians and Alaska Natives who belong to 567 federally recognized
tribes. In 1968, IHS established the Community Health Representative (CHR) program. Since then, CHRs have operated on American Indian reservations as paraprofessionals that attend to the general
health needs of tribal members.
CHRs visit patients in their homes and help with general health
maintenance, health promotion and advocacy, and often help with
health-related transportation. They also work closely with patients
and their primary care providers (PCPs) to further healthcare outside
of regular doctor’s office visits. Patients are referred to the program
by local hospitals, patients’ physicians and by word of mouth, which
is perhaps one of the more powerful and reliable means of referral
into the program.
The Laguna Community Health and Wellness Department has
five CHRs who work together to follow a total of 100–150 unique
patients yearly for their various medical needs. The CHR scope of
practice is limited, however, and doesn’t allow representatives to provide many medical treatments.
In late 2015, the Laguna CHRs realized that although many of their
patients had relatively simple medical needs, their patients regularly
required long trips to Albuquerque for specialist appointments. Having identified the need, the CHRs approached Laguna Fire Rescue
about adding paramedics to the team to help address simple medical
needs in patients’ homes. The CHRs, Laguna Fire Rescue Administration, two of the Laguna Fire Rescue paramedics, and the Laguna
Fire Rescue medical director, held a meeting, and the Laguna Community Paramedicine Program (LCCP) was born.
INITIATING PATIENT CARE
Though they hadn’t performed a formal needs assessment, the CHRs’
intimate knowledge of their community suggested that care of poorly
healing wounds was a top priority. Many of their geographically isolated, elderly patients had wounds that were slowly worsening, and
getting regular care was challenging. Specialized wound care appointments were usually in Albuquerque, and because round-trip travel
alone could sometimes take three hours, many patients were missing
appointments and languishing in their homes.
Before patients could be treated, community paramedics (CPs) had
to learn the logistics of the CHR program. The first phase of the program involved CPs shadowing CHRs on their daily rounds, focusing
primarily on the patients with chronic wounds.
Though paramedics are very familiar with visiting patients in their
homes, arriving with the CHRs helped introduce the paramedics to
patients and allowed the paramedics better to understand the pace and
goals of the non-emergent home visit. CPs soon began accompanying patients and CHRs to wound care appointments, helping them
to develop rapport with the patients and the specialists.
To further their wound care skills, both CPs were sent to Oklahoma
City, Okla., to become certified wound care providers by the American
Society of Wound Care Professionals. This training gave them more
than just skills—it gave them the vocabulary to discuss wounds and
wound care at a professional level with patients’ wound care clinicians,
and gave those clinicians the confidence in the CPs to include them
in more complicated home care regimens.
Upon their return, and after they became comfortable with the
CHR-style workflow, the CPs began visiting patients on their own.
This level of professional cooperation has allowed several patients to
increase the amount of time between specialist visits.
Soon after becoming comfortable with wound care, the CPs began
offering medication management services as well, helping patients and
their families understand medications and their indications, effects
and side effects. Given that most common medications are familiar
to paramedics, this required minimal training; any questions that they
couldn’t answer could be looked up or discussed in real time with the
program medical director.