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The coronavirus was not the first challenge to the Jackman region’s ability to keep offering around-the-clock medical care, but for a moment, it looked like it might be the last.
Jackman Community Health Center announced in April that it would stop providing medical care outside of normal business hours because of “unprecedented” challenges from the pandemic and “fragile” conditions that had preceded it, all of which had made it harder to staff the clinic, which serves a small population spread out over an area larger than Rhode Island.
Without overnight service, residents suffering urgent medical issues past normal business hours in one of the most remote areas in Maine and all of the northeastern U.S. would have to travel at least 50 miles to hospitals in Skowhegan or Greenville on their own or in an ambulance.
But northern Somerset County officials and a group of organizations avoided the cuts by fast-tracking the rollout of a program that was being developed before the coronavirus. Inspired by an approach used in remote Alaskan villages, it could preserve health care access long after the pandemic is over and serve as an example for rural areas facing similar problems.
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The program has been costly to launch, but it has appealed to many residents who recognize the importance of swift care for heart attacks, logging injuries and other emergencies that could strike at any time, Jackman Selectman Alan Duplessis said.
“It’s kind of a no-win situation,” he said. “We’ve got to do something.”
Jackman’s new model stands out as the coronavirus has endangered hospitals and clinics by forcing them to cancel nonessential services that typically bring in a large chunk of revenue amid staffing shortages and shrinking patient numbers. Bankrupt hospitals in Lincoln and Calais have already warned they could close because of the new challenges.
The initiative, which is being partly funded by local taxpayers, has addressed the clinic’s immediate needs by recruiting paramedics from an outside company, North East Mobile Health Services of Scarborough, to work there under the direction of its doctors. That has allowed the clinic to keep offering on-call overnight care, and the paramedics have also embedded with the local volunteer ambulance service to help improve its coverage.
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If the second part of the initiative goes forward next year, the paramedics would play a larger role in that care. After receiving extensive training in everything from wound care to anesthesia, they would take direction from doctors working remotely at St. Joseph Hospital in Bangor to treat patients or prepare them for transport to a hospital. The doctor would appear over a video conferencing program in an approach commonly called telemedicine.
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Communities already use paramedics to fill in gaps in primary health care coverage. Telemedicine has become more common during the pandemic. But combining the two as a way to expand urgent care would make for a unique approach if it can win approval from state officials and get more funding.
By shifting the clinic’s overnight care to paramedics and the emergency room doctors who would remotely oversee them, the approach could make it easier to recruit more primary care providers to the rural area.
“This is a unique and interesting model,” said John Gale, a rural health expert at the University of Southern Maine who has followed the initiative. “A place like Jackman, or remote and frontier areas in Montana and North Dakota, they need different models than exist for more populated areas. I think this has some possibility to make the pieces of the system work better.”
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With modifications, Gale said the “team-based” approach could be replicated in other remote sections of Maine such as Washington County, where hospitals have also struggled to fill positions and are hard to access during a snowstorm.
If it succeeds, the Jackman initiative would also demonstrate the importance of rural health care institutions listening to and winning buy-in from their communities. This past week, Jackman voters agreed to pay up to $175,000 over the rest of 2020 to get the program started. The nearby communities of Moose River and Dennistown Plantation must also approve it.
The town is urging Maine’s congressional delegation to sponsor federal legislation allowing the paramedics to be reimbursed by insurance programs at the same level as nurse practitioners or physician assistants, which could offset some local cost, Duplessis said.
The challenges of rural medicine have been particularly acute in Jackman, a town of just over 800 people that had its own hospital until the 1970s. After the organization that is now MaineGeneral Health took over the hospital that decade, it stopped offering inpatient services and was converted into a nursing home and outpatient clinic.
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The latest erosion of the institution came three years ago, when MaineGeneral Health closed a nursing home whose nurses had provided the overnight staffing at Jackman Community Health Center. Since then, the clinic’s parent organization, Penobscot Community Health Care, has scraped together enough staff to stay on call throughout nights and weekends.
But over time, the stress of that arrangement has made it harder to recruit workers. It finally became untenable after the pandemic arrived, according to Dr. Patricia Doyle, the clinic’s medical director who has worked there since the 1980s.
“Finding a provider to take over the primary care practice will be easier if they don’t have to be on call 24-7,” she said. “For most primary care providers coming out of training now, being on call isn’t really a thing unless you’re doing deliveries.”
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North East Mobile Health Services is now waiting for Maine’s emergency medical services office to approve the pilot project, which could start in the first half of 2021. The group’s paramedics are now able to stay in apartments that have been created in the former nursing home.
The model could also help the EMS industry retain workers by giving paramedics room to grow in their careers, said Nate Yerxa, a director at North East Mobile Health Services who is overseeing the Jackman initiative. Duplessis, a former emergency medical technician himself, said that he has heard of one advanced EMT who lives about 20 minutes away in West Forks and wants to work at the Jackman clinic once she gets certified as a paramedic.
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Dr. Jonnathan Busko, the medical director of St. Joseph Hospital’s emergency department who has been working as an independent consultant on the Jackman initiative with grant funding from the Maine Health Access Foundation, said that there are few U.S. precedents for the model.
In some cases, he said, commercial shipping vessels and isolated Alaskan villages have relied on lower-level health workers to provide care with guidance from physicians far away. The resort town of Red River, New Mexico trained paramedics to provide some urgent and primary care services in the 1990s, but that approach had poor outcomes because it lacked appropriate medical oversight, said Busko.
Besides making it easier to recruit new workers, Busko said the Jackman initiative could also improve the region’s ambulance coverage by bringing in paramedics with more training than the local volunteers and give patients quality emergency care through the telehealth arrangement.
The Jackman area has demonstrated interest in supporting its local clinic at a time when many rural communities have ceded local control of medical facilities to larger systems that have absorbed them, Busko said. One county over, for example, the regional hospital in Dover-Foxcroft recently became the 10th hospital to join the Northern Light Health network.
“This project has empowered the community to decide what level of service it wants and what it’s willing to pay,” Busko said. “It’s something that health care consolidation has taken away from a lot of communities, but it’s incredibly valuable.”
Watch: The risks associated with reopening rural parts of the state