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RURAL OPERATIONS R ural emergency medical care in the Unit- ed States has been the backbone of the response paradigm since the National Academy of Sciences' 1966 EMS white paper. That paper, Accidental Death and Disability: The Neglected Disease of Modern Society, addressed the need for national education on first aid and a coordinated transportation and communications system to increase survival on the nation's highways, many of which were rural in nature. We still have lots of rural stretches of highway, but several other things have changed since 1966. We now have fewer physicians practicing in rural areas. 1 EMS services that utilize volunteers are decreasing in num- ber, 2 and rural patients use EDs more and follow up post-discharge less. 3 All of these seem like great reasons to start a rural community paramedic program. Eagle County, CO, is an interesting place. We are home to world-class skiing in Vail and Beaver Creek. We are bisected by Interstate 70 and have many small towns that on any other byway would be very rural. The full-time population of Eagle County is nearly 53,000, over 1,684 square miles. That equates to 31 people per square mile. Many of our towns are bedroom communities for the resorts that bring in an estimated 1.1 million skier-days per year. This hardly seems like a place that's rural and in healthcare crisis. But we are severely underserved in our community. More than 21% of our people are un- or underinsured (the national average is 13%). 4,5 This number is post-Affordable Care Act. We have had an increase in Medicaid patients of 200% since Janu- ary 2014, and we have few providers in the community who will see our Medicaid or uninsured populations. In 2009, when we created the first rural community paramedic (CP) program in the United States, we were dubious about the impact it would have on the rest of paramedicine and healthcare. We wanted to create a lasting program built on facts from our local public health agency to serve patients in all areas of need (medi- cal, social service, mental health and prevention). At the same time we wanted to create a program that would further the profession of paramedicine. Finally we knew our program wouldn't last if we didn't collaborate and create new pathways for communication and care in the health system. Today this is called integrated healthcare. Many of the new CP programs that have started around the country are in rural environments. The NAEMT's recent survey identified 49% of programs as serving rural areas. 6 Making CPs the provider of choice in rural environments seems to capture the best of both worlds: They can see patients during downtime and be highly skilled advanced life support providers when emergencies arise. This is the exact vision for what the future of CP can be in rural areas of the U.S. Here are five key considerations our system faced in launching a program. Getting Started One of the questions we are often asked is, "How do I get started?" The idea-to- implementation curve varies. On average you can expect to invest 12–24 months in implementation and education of your paramedics and community. Creating processes and looking at how you will document visits will be high on your list. Those of us who live and work in rural areas know several things: We know how to innovate, we know how to get things done, and we know people don't like change. So how do you create a program that essentially 1 20 OCTOBER 2015 | EMSWORLD.com B eginning in January, EMS World launched a yearlong series that pro- vides readers with a road map for developing MIH-CP programs. This series addresses the following topics: • Planning for rapid implementation; • Data metrics and outcome measures; • Collaborations with home healthcare; • Updates on CMS Innovation Grants; • Accreditation of MIH-CP programs; • MIH Summit at EMS On The Hill Day; • Payer perspectives for MIH-CP services; • Choosing practitioner candidates; • Education of MIH-CP practitioners; • International models of MIH-CP. This month we discuss MIH programs in rural settings. Mobile Integrated Healthcare: Part 10 Considerations of a Rural CP Program What goes into operating outside the urban environment? By Christopher Montera