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Guo B, Corabian P, Yan C, et al. Community Paramedicine: Program Characteristics and Evaluation [Internet]. Edmonton (AB): Institute of Health Economics; 2017 Sep.
This section presents information regarding the following research question:
The main literature search identified a number of documents, systematic reviews, or general reviews that described various community paramedicine programs. Whenever necessary, information from primary studies is also used to supplement this section. A detailed description of these programs is provided in Appendix D.
It has been suggested that a more fundamental and simple classification of low-acuity service delivery models into two discernible paradigms is required to limit the rapidly expanding nomenclature in community paramedicine.6 One paradigm is aligned with a “preventative/follow-up” model of care to reduce the incidence of unscheduled/emergent care, by working collaboratively with physicians and other primary care services in areas such as chronic disease management, health promotion/education, and early intervention. The common term for a paramedic employed in this model of care is community paramedic or, for those employed in the Mobile Integrated Health Care model in the United States, community paramedicine provider.6
The other paradigm is a “reactive” model, in which paramedics respond to calls for unscheduled care and are usually dispatched by ambulance control centres through traditional notification systems, such as calls to 000 in Australia or 999 in the United Kingdom. A patient is treated in their own residence, most often for a low-acuity presentation, and, if necessary, is referred for follow-up care, likely with the patient’s general practitioner. Common terms for a paramedic employed in this model of care (particularly in Australasia and the United Kingdom) include extended care paramedic, paramedic practitioner, and emergency care paramedic.6
In general, Australia emphasizes rural and remote paramedics, whereas Canada, the United Kingdom, and the United States implement the expanded paramedic practice within different environments including rural, remote, regional, and metropolitan settings.13
In Australia, there are some differences in paramedic practice between urban and rural areas. Rural paramedics adopt a whole community approach rather than a case dispatch approach, have multidisciplinary team members rather than operating mainly within ambulance teams, take additional responsibility as a teacher and manager for volunteers, and are highly visible members of the community rather than relatively anonymous.14
There are several current community paramedicine programs that have been developed to meet the needs of rural and remote communities in Australia (for details, see Appendix D, Table D.1). Blacker and Walker grouped these programs into three broad categories: the primary health care model, the substitution model, and the community coordination model (see Table 1).15
Community paramedicine program models in Australia.
The primary health care model was developed in Queensland and New South Wales in response to challenges including increased ambulance demand, an aging population, rising prevalence of chronic disease, and decreased accessibility for unpredicted care and out-of-hours care. Collaborating with other healthcare professionals, paramedics in this model extend access to primary health services to promote disease and injury prevention while continuing to provide pre-hospital emergency care.
The substitution model has been implemented in some country hospitals in South Australia in response to the physician shortage there, as well as in the emergency department of the Alice Springs Hospital (the main acute care hospital for Central Australia) in response to the nurse shortage there. Paramedics in this model provide leave coverage for medical and nursing staff. Contracts or official agreements between paramedics and hospitals/health departments have been developed to permit paramedic practice in these settings.
The community coordination model has been implemented in South East Victoria, Tasmania, and Western Australia, with focuses on recruiting, retaining, and supporting existing volunteers while providing support to existing health services when needed.
O’Meara et al. described the key characteristics, roles, and expected outcomes for a Rural Expanded Scope of Practice (RESP) model.16 The key feature of the RESP model is a capacity to integrate existing paramedic models with other health agencies and health professionals to ensure that paramedic care is part of a seamless system that provides patients with well-organized and high quality health care. Adoption of the RESP model requires paramedics to have the following activities as core components of their expanded role: rural community engagement, emergency response, situated practice, and primary health care. This expansion of the scope of practice of paramedics offers the potential to improve patient care and the general health of rural communities.
Based on interviews with paramedics, volunteer ambulance officers, and other health professionals from four rural regions of South East Australia with existing innovative models of rural paramedic practice, O’Meara et al. found that, in small rural communities, paramedics are increasingly becoming first-line primary healthcare providers and developing additional professional responsibilities throughout the cycle of care.
A nurse practitioner-paramedic-physician model has been developed and implemented in the islands of Long and Brier, two isolated islands approximately a 45-minute drive away from the small town of Digby, Nova Scotia, with access restricted to passenger car ferries.17 With approximately 1,240 residents and 50% of them over 65 years old with increased healthcare requirements, it was challenging for rural communities to provide accessible health care to residents on the islands.17
In the first phase of the nurse practitioner-paramedic-physician model, 24 hours a day/7 days a week emergency paramedic coverage on the islands was established. Community paramedics started services such as administering flu shots, holding clinics, checking blood pressures, and answering phone calls from residents for non-emergency services, such as checking for diabetes. Policies, procedures, and protocols regarding safe care delivery were developed by Emergency Health Services (EHS). Through collaboration with a nurse practitioner and a physician, community paramedics expanded their services and were able to complete more complex care to the island residents, such as providing wound care and immunization, and participating in community health promotion and injury prevention sessions, such as fall prevention for seniors. EHS established community paramedic competencies in 2005, which include congestive heart failure assessment, fall prevention and home safety assessment, venipuncture/phlebotomies, urinalysis by dip stick, suture/staple removal, wound care, immunizations, medication compliance, diabetic assessment, glucose checks, blood pressure checks, antibiotic administration, B12 injections, helmet safety fitting, car seat installation, CPR and First Aid instructor status, and health promotion activities (see Appendix D, Table D.2).18
The Toronto EMS Community Paramedicine program was developed in 1999 in Toronto, Ontario. It is a non-emergency, community-based service with a focus on health promotion, system navigation, and injury prevention in the urban area.19 The mission of this program is to help patients in the community solve some of their medical and care problems before they become real emergencies. Services offered by this program include heat surveillance, window and balcony safety, vaccinations (influenza, hepatitis A, meningitis C, and streptococcal pneumonia), infection prevention and control, and Community Referrals by EMS (CREMS) (see Appendix D, Table D.2).
CREMS was implemented in 2006 as a pilot project, and has been fully operational across Toronto since 2008. Referrals are made by paramedics who respond to 911 calls based on a determination that a patient is in need of additional healthcare/support services. These referrals are made to the appropriate Community Care Access Centre (CCAC) for further assessment and determination of the type(s) of service most appropriate for the patient; all referrals are collected by Toronto Central and then forwarded to one of the five CCACs within Toronto, based on the patient’s residence or the facility the patient was transported to.19 The core services provided by the CCACs include nursing, personal support, physiotherapy, occupational therapy, speech language therapy, and extreme cleaning; secondary services include social work, nutritional counselling, medical supplies/equipment, connecting the patient with healthcare services, and long-term care placement.19
As of 2014, more than half of Ontario residents have access to community paramedicine programs in their communities, with approximately 13 community paramedicine programs currently operating in the province. Ten additional municipalities and EMS providers are planning to implement community paramedicine initiatives.iii
Alberta has an EMS Palliative and End-of-Life Care “Assess, Treat and Refer” program through which patients can access urgent, acute palliative care services in their homes or in the community. This service is available to any palliative patient in Alberta experiencing a medical emergency (for example, shortage of breath, nausea, delirium, or increasing pain), and can be activated by any registered healthcare professional or triggered by a routine 911-call. The program is staffed by Alberta Health Services (AHS) EMS paramedics, who can deliver palliation and rehydration therapy, and can administer medications (analgesics). These EMS paramedics work with the patient’s attending clinician (that is, physician, registered nurse, nurse practitioner, licensed practical nurse, physiotherapist, occupational therapist, or respiratory therapist) to ensure that the emergency treatment delivered aligns with the overall care plan. In other jurisdictions, this model of extended care may be known as “treat-and-release” (T&R). T&R protocols have been considered as an approach (in Alberta and elsewhere) to relieve emergency department overcrowding and to decrease rates of emergency department admissions, inpatient admissions, and clinic visits. However, there are concerns about the use of the T&R protocol in terms of patients’ optimum care and potential benefit from transport to a healthcare facility.20
Currently, AHS community paramedics provide at-risk patients with immediate access to health care in the community by collaborating with available family and specialized physician services.iv These specially-trained paramedics, in consultation with physicians, bring a broad range of medical services to the home, and can reduce 911-calls and the need for emergency department visits. Services that community paramedics can provide include: immediate assessment followed by physician-facilitated diagnosis and treatment; advanced assessment such as respiratory, cardiac, or environmental; on-site diagnostics including specimen collection, ECGs, blood glucose, oxygen saturation, and CO2 levels; and immediate on-site intervention including IV rehydration, pain management, suturing, medication administration, and facilitated prescription orders. This program is for patients with chronic health concerns that prevent them from accessing available healthcare services, and currently operates 365 days a year, 16 hours per day (from 6:00 a.m. to 10:00 p.m.).
AHS is working with the various education institutions to broaden the education that paramedics and emergency medical technicians (EMTs) receive, so that they have a wider understanding of long-term care health issues.
There are also a number of scalable programs ongoing in Alberta, where paramedics play expanded roles within their existing scope of practice in their communities (AHS, personal communication, 2017):
The Primary Health Bus project, a pilot project that integrates paramedics with primary health care, was launched in Saskatchewan in August 2008.21 With support from the Ministry of Health, this project was designed to reduce barriers faced by people who are geographically, socially, economically, or culturally isolated in accessing healthcare services, by bringing services to them via bus. The project operates year-round, eight hours a day, seven days a week; registered nurses (nurse practitioners) and paramedics provide various services to residents of core neighbourhoods in Saskatoon.21 The mobile Primary Health Bus serves many populations, including First Nations, Métis, children, older adults, immigrants, refugees, and those with chronic diseases, with services including health promotion, education, treatment, follow-up care, and referral.22 Staff have been building strong and positive relationships with community residents, and the project has successfully facilitated inner city residents to access healthcare services; as of February 2009, almost 1,000 patients have accessed services on the bus.21
In British Columbia, a community paramedicine program has recently been initiated, implemented by British Columbia Emergency Health Services (BCEHS) in partnership with the Ministry of Health, regional Health Authorities, the Ambulance Paramedics of British Columbia, the First Nations Health Authority, and others. The objective of the initiative is to address two challenges rural and remote communities in British Columbia face, namely recruiting/retaining paramedics, and issues in accessing health care due to distance of the nearest healthcare facility and recruiting/retaining healthcare professionals.
The prototype phase of this program included eight community paramedicine projects in nine rural communities, selected based on community need and the supportive level of BCEHS and Health Authority infrastructure. In April 2016, the British Columbia Health Minister announced the first 73 rural and remote communities that will have the services of community paramedics, including these prototype phase communities.v
Among the various community paramedicine models in the United Kingdom, the Emergency Care Practitioner (ECP) program is the most impactful, implemented widely in the United Kingdom since 2003.23 ECPs come from nursing and paramedical backgrounds; the role of ECPs is occupying the space between the physician, the nurse, and the paramedics, and most ECPs in the United Kingdom are recruited from paramedics. The aim of this non-traditional, community-based program is to provide assessment and treatment of patients with minor illness/injury within the community, without necessarily transporting the patient to the hospital. With additional training in assessment, examination skills, and management of long-term conditions, ECPs are capable of undertaking many activities traditionally carried out by physicians, including an initial assessment of patient status and deciding whether to deliver simple treatments or initiate referral to an appropriate clinical team (see Table 2 and Appendix D, Table D.3).24–26
Scope of practice of ECPs in the United Kingdom.
ECPs are primarily employed by United Kingdom Ambulance Services trusts, and work in a variety of urban and rural settings including general practitioner surgeries, minor injuries units, and emergency departments. Clinical support and supervision is provided from Ambulance Services or host providers.23
In the United States, the term community paramedicine was first used in 2001 as a potential model of improving rural community health care.11 Many existing programs expand the role of EMS personnel while staying within the skill level of their scope of practice; personnel in such programs are usually called community paramedics or community health paramedics. Other programs expand the scope of practice of EMS personnel; those in such programs are called advanced practice paramedics.
Community paramedicine in the United States is an evolving method of community-based health care in which paramedics function outside their customary emergency response and transport roles in ways that facilitate more appropriate use of resources and enhance access to primary care for underserved populations.9 A community paramedic is a paramedic or EMT who already operates in their service area or community, and who has taken advanced didactic and clinical education in a number of areas, enabling them to identify the healthcare needs in underserved communities.10 These areas can include: health and wellness, health screening assessments, health teaching, administering immunizations, monitoring diabetic patients, monitoring post-myocardial infarction patients, advanced mental health issues and referral, wound care, and safety programs.10 Target populations may include frail and/or elderly patients, patients with lack of transportation, patients with cognitive/mental problems, 911 “superusers” (for example, people who suffer from homelessness and/or mental health problems), and patients who need follow-up after being discharged from an emergency department or hospital.9
There are community paramedicine programs in varying stages of development in more than 20 states (such as North Carolina, Colorado, Minnesota, Maine, and Texas) and more than 150 communities.9, 28 There are also 12 pilot projects underway in California beginning with paramedic training in 2015, with independent evaluation expected in 2017.7, 9 The majority of these pilot projects have paramedics providing transportation to destinations other than an emergency department, such as a mental health clinic, an urgent care clinic, a physician’s office, or a sobriety centre. Some of these pilot projects also allow paramedics to provide follow-up care after discharge from an emergency department/hospital.9
To address an issue of highly frequent paramedic transports for a small group of 911-callers, in April 2008, San Diego EMS initiated a pilot project, the Resource Access Program (RAP). RAP uses EMS system surveillance, case management, and referral to identify and modify medical and psychosocial factors associated with repeated 911 calls.5 The RAP Coordinator (an experienced paramedic) contacts (by phone or in-person) individuals with more than 10 EMS transports within the past 12 months as well as other high users referred by fire and EMS personnel, and identifies factors associated with their excessive use of acute care resources for primary care conditions (for example, lack of transportation, social support, and/or health literacy). The Coordinator also liaises with primary care physicians, homeless services agencies, street outreach teams, hospital social workers, case managers, and adult protective services personnel. RAP clients receive education regarding appropriate use of EMS, and are connected with resources including equipment, transportation, housing, social services, mental health services, and primary care (see Appendix D, Table D.4).
There was a lack of information regarding funding within the studies included in this review.
In Alberta, AHS EMS has used operational funding to run community paramedic and other expanded role paramedic programs such as the ATR program (Alberta Health EHS unit, personal communication, May 2017).
In 2014, the Ontario Ministry of Health and Long-Term Care announced the allocation of $6 million to support the expansion of community paramedicine programs.3
Most of the community paramedicine programs in the United States up to 2016 were developed out of grants or other short-term funding. Some of the programs have shut down because they were not economically viable in the long term.9
For more information, see: news.ontario.ca/mohltc/en/2014/01/ontario-expanding-community-role-for-paramedics.html.
For details, see: www
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