By the Ontario Community Paramedicine Secretariat (OCPS)
Established in 2018, the Ontario Community Paramedicine Secretariat (OCPS) mandate supports the community paramedicine network in Ontario, enabling and facilitating work on the creation and dissemination of standardized care processes, performance reporting and measurement activities, and aspects of knowledge translation and exchange. The OCPS Steering Committee has representation from multiple key stakeholders including Ontario Health, the Ontario Association of Paramedic Chiefs, and frontline community paramedics. The OCPS was established at a time of both regulatory change to paramedicine and administrative transformation across all sectors of health care in Ontario. One part of this process has been a consultation process regarding modernization of the Emergency Health Services (EHS) system that has been led by the Ministry of Health (1). The consultation process has sought input from all stakeholders in Ontario about how “pre-hospital” care can play an active role in ending “hallway healthcare.” The Ministry of Health identified five areas of focus for the consultation process: Outdated dispatch technologies, Lengthy ambulance offload times and delays in transporting medically stable patients, Lack of coordination among EHS system partners, Need for innovative models that improve care, and Health equity, or access to services across regions and communities (1).
New strategies in community paramedicine programs should be part of a modern Emergency Health Services (EHS) system that will address hallway healthcare by helping patients overcome barriers or challenges in accessing timely coordinated care. Community paramedicine programs are demonstrating effective and efficient ways to provide short-to-midterm episodic care to underserved patient populations (2–11). The OCPS will continue to support planning and implementation of community paramedicine programs and future reporting on the impacts of these programs related to improved health outcomes, patient and provider experience, value, and improved system performance which has broader impacts on the whole population. Here are responses to some of the questions currently being discussed in Ontario as part of the consultation process on EHS Modernization and the role that community paramedicine programs can contribute to these efforts.
1. How would community paramedicine programs be part of a larger effort to modernize Ontario’s ambulance dispatch system?
A modern EHS system should be focused on providing excellent patient-centred care and this should include dispatch. One of the highest priority actions should be to include the clinical experience of community paramedics within the communication centres and to facilitate the technological capabilities of a common electronic medical record so that patient care can begin as soon as a call for help is placed. Right now, patients are able to speak directly with a community paramedic through a number of community paramedicine programs, freeing up 9-1-1 lines, improving efficiency of paramedic resources, and enabling care “in-place.” Examples of these kind of community paramedicine programs have been included in the OCPS 2019 Report on the Status of Community Paramedicine Programs in Ontario (12).
2. What role would community paramedicine have to help reduce ambulance offload delays?
Ambulance offload times are a symptom of a hospital and long-term care system that is functioning over capacity. Community paramedicine programs supporting hospital discharge transitions of care, alternate level of care patients, and patients waiting for long-term care can help address system capacity that contributes to the offload time challenge. Community Paramedicine-Specialist Response Units (CPRUs) mobilize community paramedic-led case management that could be applied to new models of care for 9-1-1 patients. CPRUs can back up or replace responding emergency transport vehicles when transport is not needed as well as provide follow-up after non-transport to ensure patient safety and effective case management. Case management approaches to integrated care through paramedic participation in Ontario Health Teams can further expand access to care 24/7 and delivery of care outside of the emergency department, possibly further reducing the offload delay challenge. Community paramedicine programs work to pre-empt or prevent the need for patients to be transported to hospital as well as support patients as they transition out of hospital—both contributing solutions to ending hallway healthcare.
3. What are other opportunities for the case management approach used in community paramedicine programs to improve navigation of the healthcare system?
Community paramedics facilitate case management to coordinate patient care with health system partners. Where appropriate, community paramedics can arrange transportation to the appropriate destination (not necessarily the closest destination) through a case management approach. Improved integration and leveraging improved technologies can ensure better coordination of patient care. The municipal basis for the provision of paramedic services make them uniquely positioned to implement solutions within and between Ontario Health Teams, expanding on and modernizing the concept of “seamless” service that already exists. Many community paramedicine programs incorporate point-of-care diagnostics like ultrasound and bloodwork as well as treatments that can be provided “in-place” through extended scope of practice. Improved utilization of portable diagnostic technologies can also address the need to transfer patients for these services.
4. With an aging population and the resulting increase of pressures on ambulance services what specific actions ensure modern, responsive pre-hospital services?
There are multiple examples across Canada and internationally where emergency health systems have been modernized. In six of ten provinces, paramedics are now governed as regulated health professionals. The evolution of paramedicine in these systems has seen greater alignment with other health care sectors to improve delivery of patient care and streamline access to the appropriate health system partners. Ontario Health Teams represent an important step towards this goal in Ontario. Community paramedicine programs across Ontario are improving access to primary, urgent, and/or specialized healthcare through scheduled or unscheduled visits to underserved patient population groups. Incorporating community paramedicine programs as part of the development of Ontario Health Teams aligns with the vision of Ontario Health and will have impacts on the increasing demands for responsive out-of-hospital integrated care. The 2019 Report on the Status of Community Paramedicine in Ontario describes a number of community paramedicine programs that have already spread and can be scaled accordingly (12).
5. How can community paramedicine programs improve the provision of healthcare services in First Nations, rural and northern communities?
Community paramedicine programs use paramedics to provide immediate or scheduled primary, urgent, and/or specialized healthcare to vulnerable patient populations by focusing on improving equity in healthcare access across the continuum of care. First Nations, rural, and northern communities face unique challenges and barriers to healthcare access. By taking a “community paramedicine” approach to the design and delivery of emergency health services, focusing on integration of care, and maximizing available technologies, community paramedics in First Nations, rural, and northern communities can act as extensions of primary care providers who may not be locally available while also supporting safe transitions of care back to these communities when patients are admitted to hospitals far from home. The emergency response capabilities of a community paramedic provide added value and the ability to interface with the broader healthcare system outside of a local community when a patient’s condition worsens or if there is a medical emergency. (13).
The OCPS has gathered a great deal of information about the present state of community paramedicine programs in Ontario. Additional resources about community paramedicine are available on our website, http://www.ontariocpsecretariat.ca. As the Ministry embarks on EHS Modernization, the OCPS is ready to act as an advisor on community paramedicine according to the mandate that it was provided. Community paramedicine programs can play a larger role in the delivery of “out-of-hospital” care and contribute to the EHS modernization process.
- Ontario Ministry of Health. Discussion Paper : Emergency Health Services Modernization. 2019.
- Verma AA, Klich J, Thurston A, Scantlebury J, Kiss A, Seddon G, et al. Paramedic-Initiated Home Care Referrals and Use of Home Care and Emergency Medical Services. Prehospital Emerg Care [Internet]. 2017;0(0):1–6. Available from: https://doi.org/10.1080/10903127.2017.1387627
- Agarwal G, Angeles R, Pirrie M, McLeod B, Marzanek F, Parascandalo J, et al. Reducing 9-1-1 emergency medical service calls by implementing a community paramedicine program for vulnerable older adults in public housing in Canada: A multi-site cluster randomized controlled trial. Prehospital Emerg Care [Internet]. 2019;0(0):1–16. Available from: https://www.tandfonline.com/doi/full/10.1080/10903127.2019.1566421
- Agarwal G, Angeles R, Pirrie M, McLeod B, Marzanek F, Parascandalo J, et al. Evaluation of a community paramedicine health promotion and lifestyle risk assessment program for older adults who live in social housing: a cluster randomized trial. Cmaj [Internet]. 2018;190190(21):638–47. Available from: www.cmaj.ca/lookup/doi/10.1503/cmaj.180642
- Choi BY, Blumberg C, Williams K. Mobile Integrated Health Care and Community Paramedicine : An Emerging Emergency Medical Services Concept. Ann Emerg Med [Internet]. 2016;67(3):361–6. Available from: http://dx.doi.org/10.1016/j.annemergmed.2015.06.005
- Rasku T, Kaunonen M, Thyer E, Paavilainen E, Joronen K. The core components of Community Paramedicine – integrated care in primary care setting: a scoping review. Scand J Caring Sci [Internet]. 2019; Available from: http://doi.wiley.com/10.1111/scs.12659
- Leyenaar M, Mcleod B, Chan J, Tavares W, Costa A, Agarwal G. A scoping study and qualitative assessment of care planning and case management in community paramedicine. Irish J Paramed. 2018;3(July):1–15.
- Gregg A, Tutek J, Leatherwood MD, Crawford W, Friend R, Crowther M, et al. Systematic Review of Community Paramedicine and EMS Mobile Integrated Health Care Interventions in the United States. Popul Health Manag [Internet]. 2019; Available from: http://ovidsp.ovid.com/ovidweb.cgi?T=JS&PAGE=reference&D=medp&NEWS=N&AN=30614761
- Agarwal G, Lee J, Mcleod B, Mahmuda S, Howard M, Cockrell K, et al. Social factors in frequent callers: a description of isolation, poverty and quality of life in those calling emergency medical services frequently. BMC Public Health [Internet]. 2019; 19(684):1–8. Available from: https://doi.org/10.1186/s12889-019-6964-1
- Patterson DG, Coulthard C, Garberson LA, Wingrove G, Larson EH. What Is the Potential of Community Paramedicine to Fill Rural Health Care Gaps? J Health Care Poor Underserved [Internet]. 2016; 27(4A):144–58. Available from: https://muse.jhu.edu/article/634884
- Nejtek VA, Aryal S, Talari D, Wang H, O’Neill L. A pilot mobile integrated healthcare program for frequent utilizers of emergency department services. Am J Emerg Med [Internet]. 2017;35:1702–5. Available from: http://dx.doi.org/10.1016/j.ajem.2017.04.061
- Leyenaar MS, Strum R, Haque M, Nolan M, Sinha SK, Ontario Community Paramedicine Secretariat Steering Commitee. Report on the Status of Community Paramedicine in Ontario [Internet]. 2019. Available from: https://www.ontariocpsecretariat.ca/resources
- Ashton CW, Leyenaar MS. Health Service Needs in the North : A Case Study on CSA Standard for Community Paramedicine. 2019.