Should the Paramedics take on the role of Rural Home Health Nurse?

What do you think?
Earlier this week I attended a 3-hr of public hearing in Sacramento where a variety of speakers were debating a pilot program proposal for an increased role of PARAMEDICS in managing chronic care diseases when attending to home care needs of patients (in rural on inner city areas they say).

While I fully support the notion that something must be done with the dreadful state of CA public health, access to medical care and adherence to home care / discharge plans, with all due respect and deference to paramedics, to manage a chronic condition in a home setting takes fine tuning and years of studies and practice. Just because nobody is bleeding does NOT mean it is not critical, problematic or very complexed issue to deal with.
There is a reason new grad RNs are NOT hired for home health because you MUST have experience in dealing with the disease management before you will be even considered to be sent out there making decisions on location!

It is usually the patients who are not bleeding or vomiting or collapsing that are the biggest problem in a home health setting, those who sit quietly, those who if you don’t know what and how to ask OR if you don’t know what signs to look for – usually, they are the ones who don’t even tell you! They don’t wanna be a ‘bother’ – I’ve heard that SO MANY times from grandmas and grandpas
(Again, I am talking about chronic disease management in home care, not discharge home from tonsillectomy, for example)

To manage chronic care diseases, you must know and understand the disease process, the disease signs & symptoms, to know how it was managed in a hospital, what can be the side effects of any of the above, what to look for, how probable complications look like even before they become major problems…. And finally, you must understand how to fine-tune the care!
Again, paramedic are GREAT and FANTASTIC at what they do, which is the FIRST phase of giving emergency care, I worked with them for many years on 2 continents (and in Czech I worked in the department!), so my hats off to you, but to manage the last part so-to-speak of care such as COPD or CHF or HTN or DM – that takes years of training, learning and practice!

Also, I am NOT saying we, the nurses, are fine-tuning or managing the treatments, that’s why we have specialists such as fantastic pulmonologists, but we the nurses are fine-tuning the plans of care upon discharge, the follow ups and the adherence to those. At least that’s what the nurses should do – but we don’t have them!
WHY?
Because the State cut the budget in 2011 and DHS and DSS just don’t have the funding! Those positions got cut. …Now we see how much it actually cost us because just because you cut a position or access to care here does NOT mean those patients will not seek the treatment or medical attention elsewhere. Now, all those trips to ERs – they get very expensive for the State! And now with added millions of new patients via Obamacare – don’t get me even started!

While I fully support the need for a change and innovation in our roles and in health care system delivery overall, in fact I have been calling for it for some time now, I do not believe paramedics as chronic care managers or home health caregivers are the long-term solutions to our much bigger problem.
They are trained as ‘ready to go’ as first responders, and I believe they are the BEST in the WORLD, but not as chronic care or home health care giver, and 16-18 hours of added education will not change that.
… At the same time, I absolutely understand what they are trying to do or accomplish and WHY!
I get it, I understand.
But I don’t believe this is the right solution.

Is ‘population diversity & behaviors’ to blame for lower U.S. life expectancy…?

Government Spending

Government Spending (Photo credit: Tax Credits)

Last week I posted article asking a pertinent question “If U.S. Spending is so Outrageous, Are We Getting the BEST?”

https://marketahouskova.wordpress.com/2013/04/22/if-u-s-health-care-spending-is-so-outrageous-are-we-getting-the-best-2/

The answer is “kind of”.

We do have the best technological and medical advancements in the world, and our acute care and treatments can deliver miracles.  We don’t have to wait 4-6 month for a surgery, we mostly get timely care, good care, and we do have great outcomes. However, as wonderful as that is, it does not impact the overall measurements of ‘life expectancy’ as it falls under the category of ‘acute care’ and we do really well here.

It is injuries or conditions lasting more than 6 months that are considered ‘chronic’ and require ongoing management, ongoing medication, follow-up doctors visits, repeated test, etc… and that’s where the U.S. is seriously lacking. So yes, while we are very good at acute care, we lack in chronic care management – and that does impact the overall ‘life expectancy’ and quality of life.

Which brings me to the fact that even after spending over $8,000 per capita in overall healthcare expenditure in 2010 (the highest in the world) , the U.S. has a lower life expectancy compared to other OECD nations. Why is that? Is “healthcare”  to blame? Is “public health” to blame? Or is it due to our “population diversity and behaviors“?  I have heard many  blaming it on the “diversity & behaviors” part, but in that case a question remains –  isn’t it the health and life expectancy of the whole population, no matter what diversity groups it includes, that makes for ‘life expectancy’ studies, surveys and measurements?

I agree with you that our diverse population is an integral part of our society, however, it is 21st Century and everybody knows that if you want to live longer and have a good quality of life, when you are not feeling well or have certain episodes – you should go see a doctor. And this is where the crux of “it is population diversity & behaviors fault” argument weakens, as 50 million of low-income working Americans (yes, majority about 80% are working and 82% are legal citizens) DO NOT have options or access to a non-acute or preventive care, so they go without seeing a doctor, without taking medications, and without ongoing management of preventable conditions – NOT because of their population diversity or behaviors – but because under the current system they have no viable option for obtaining health plans!

This clearly and directly impacts the overall life expectancy and thus the overall quality of healthcare we as ‘all Americans’ get.
If 1 in 5 Americans don’t have access to health care – it seriously impacts all of us in terms of loss of economic potential, loss of productivity, and in the end, in an increase in overall health care spending.

I ask again, does $8,000 per capita (twice as much as others developed nations) deliver the best health care to our society? Does it…?

Now, since we established that “population diversity & behaviors” are not to blame for lower U.S. life expectancy, is it a fault of healthcare, or public health? The answer is “yes” as the status of U.S. health care and it’s overall total health care spending and expenditures is a direct result and implication of U.S. health policies implementations. States are responsible for health care but federal government plays its role in Medicare, Medicaid, CHIP & other programs.

Medicaid, for example, by covering health care needs of pregnant women and prenatal care is not only delivering health care, but also implementing a U.S. public health policy. Smoking cessation programs – public health issue, or health care issue? Both, as continued smoking leads to lung cancer, COPD, emphysema etc… and that is very costly in terms of health care spending. Public health programs are offering smoking cessation in order to prevent future health care spending, a clear integration of health care and public health policies.

Without proper public health policies we will not be able to deliver proper health care to our diverse population. Clear and simple.

P.S.

Yes, while certain “diverse” behaviors cause increase in health care spending (i.e. smoking, bad diet etc..), if we look at it closer – these behaviors span all socio-economic levels, not only diverse population often mentioned. So we are back at the beginning, why the U.S. has lower life expectancy that other OECD nations? The one clear answer is that it is not due to “population diversity and behaviors”.

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