The house in Moose River where Skyler Carpenter pulls up in his Ford F-150 truck is familiar to him.
He went there on several occasions to draw blood from the owner of the house, Marcelle Lumbert, 91, to check her medication or to offer other medical treatment.
But he was back one freezing winter night because Lumbert had become dizzy and had fallen into his bathroom. Her two sons live nearby and found her on the ground when they stopped to check on her.
Carpenter sat across from Lumbert on the edge of his tub as he assessed him. She put her hands in her lap with black tape covering the left lens of her glasses due to a persistent eye problem.
Lumbert, who has lived her entire life in or near Moose River in Jackman, is lucky Carpenter is looking after her. Until recently, such a fall would likely have sent her to the nearest hospital – an hour and a half away, at Redington-Fairview General Hospital in Skowhegan.
Carpenter was EMT for Scarborough North East Mobile Health Services with over 20 years experience in the back of an ambulance. But he has just completed a broader level training which earned him the title of relay doctor.
He is now able to use heart machines, is familiar with serious heart events, and can make various medical decisions, either on his own or in consultation with an on-call doctor at a partner hospital. This is all the result of a program being rolled out called the Critical Access Physician Extender Program, which gives paramedics the hospital training needed to provide emergency care procedures.
The program is a response to the 2017 decision to end 24/7 emergency custodial care at the Jackman Community Health Center. It also reflects the transformation of rural health care as critical care centers close and are now commonly found in more populated areas.
The venture, funded in part by an initial federal grant of $1.2 million, is a partnership involving North East Mobile Health, Penobscot Community Health Care, the City of Jackman and Bangor-based St. Joseph Healthcare. It aims to provide a new model of healthcare delivery in rural areas for less money and better patient care.
Rick Bridges is a builder who has lived in Jackman for about 20 years, having moved there from southern Maine for its remote lifestyle and “slower pace”. He was taken to Jackman Community Health Center last year after sustaining a deep cut on his finger. He said the fledgling program is helping bring some stability and a sense of relief to the less than a thousand people who live in Jackman and a few hundred more in the wider area.
“I think for us and other people, it’s definitely a bit of security knowing that there’s someone out there who can at least sort you out and help you and possibly save your life, maybe save a member,” Bridges said. “Without that, I think there would be a lot less people in town… So having something, as far as medical care goes, will keep people safer, more secure and maybe alive longer. according to the situation.”
FALLING MEDICAL RESOURCES
The need for the program and its benefits can be explained from the perspective of three people: Dr. Patricia Doyle, based in Jackman; Dr Jonathan Busko, Medical Director of Service and Consult at Jackman Community Health Center and Emergency Physician at St. Joseph’s Hospital in Bangor; and Rick Petrie, director of operations for North East Mobile Health.
Doyle said a solution was needed to deal with dwindling medical resources in rural Somerset County.
“When I was hired, the model was that there were two vendors and we would share the office hours and the call. And the reason you needed both providers was because when you have 24/7 availability, you can’t have just one person doing it. It’s just not sustainable.
— Dr. Patricia Doyle
After medical school at Tufts University and a residency at the former Maine Dartmouth Family Medicine in Waterville, Doyle found his way north to Jackman in the mid-1970s on a National Health Service scholarship. to pay for medical expenses by working as a doctor in underserved areas. She and her husband liked the lifestyle, started a family, and decided to stay.
Jackman’s hospital delivered her last baby decades ago and then became a nursing home, which eventually closed in 2017 due to severe financial losses. As services dwindle and costs continue to rise, the city may end up having no clinics at all.
“When I was hired, the model was that there were two vendors and we would share office hours and calling,” Doyle said. “And the reason you needed both vendors was because when you have 24/7 availability, you can’t have one person to do it. It’s just not sustainable.
Enter Dr. Busko.
The CAPER program, which has been in the works for nearly four years, stems from Busko’s experience in Alaska.
He spent time in that state in the early 2000s and began to outline a program to meet the staffing needs for the delivery of health care to a rural population. One response was to expand paramedic training to provide a wider range of care, while giving paramedics access to telemedicine so doctors could be consulted on patient treatment.
“I knew what community health practitioners were capable of, I knew where the holes in their training were,” Busko said. “By giving a paramedic this extra training, you would have a very successful independent practitioner supported by telemedicine.”
He said the model makes financial sense: it’s hard to find doctors and medical assistants to work in rural settings, and paying them can be expensive, so giving paramedics better training and access to doctors for remote consultations can be a good solution.
Petrie, North East Mobile Health’s program director, said the Jackman program is driven by Busko’s ideas and experience.
“There is a very strong need to grow programs in rural areas like this to serve the underserved,” Petrie said. “He’s been the driving force here behind it all. And he acknowledges that in rural Maine…the health care system is not reaching a good number of people.
Petrie said the program is designed for locations “far from a primary care hospital with an emergency room.”
“That paramedic would have little to no role as it’s structured right now in Portland, for example, because they’re close to a hospital with a quick transport time,” Petrie said. “Now there are other things that Portland might be able to do in the sense of a kind of community paramedicine. But this model would not fit there.
“THERE IS ANOTHER WAY”
Paramedicine, which integrates paramedics into the delivery of emergency medical services, received a boost in Maine in 2012 with legislation allowing paramedic programs in places where health services lagged.
But Petrie said paramedic services haven’t taken off in Maine because there isn’t a stable funding mechanism for it. So the ambulance services that did, “did it out of the goodness of their hearts,” Petrie said. “And they were paying the price. And the thing is, eventually, the people who pay the bills will realize that a strong paramedic program can save them a lot of money while providing better service to patients.
He explained that the traditional reimbursement model for emergency medical services is based on transporting patients by ambulance to a hospital.
“Medicare and Medicaid are the primary payers in the state of Maine and nationally, and their reimbursement is probably in the 85% range of what it costs to make a call,” Petrie said. “So it’s very difficult to pay EMS providers what they’re worth and it also makes it difficult to retain them.”
And this is especially problematic in rural areas which typically see a dwindling number of EMS workers and aging all-volunteer EMS stations.
“A model like this, we can tell a community, we can provide it to you, but we factor the increased pay rates into those costs so that the paramedics and EMTs who work on those projects can get paid. more money,” Petrie said.
“And I think those kinds of opportunities really suddenly open the door for people to say, ‘Oh wow, there’s another way. I can go there when I’m young and energetic and work in an ambulance and make those calls and make those trips. But once I get some experience, here are some alternative routes,” he said.