Healthcare systems worldwide and here, at home are facing delivery challenges. These challenges have been brought on by population growth, epidemiological demographic transitions, that is to say, the increasing burden of chronic diseases and population aging in addition to a shortage of healthcare providers [1 p. ii]. Paramedics have evolved and adapted from a one-dimensional practitioner who initially only responded to emergencies to become an indispensible member of a mobile integrated health team (MIHT). Community Paramedic program themselves are noted to, “provide a bridge between primary care and emergency care” [1 p. ii]. These programs have been developed to address the needs of low acuity patients who lack access to primary care, elderly patients without mobility as well as residents in rural and/ or remote areas [1 p. ii].
Community Paramedic Cost-Effectiveness
The economic analysis performed by the Institute of Health Economics found two studies, which assessed the cost-effectiveness of community paramedic programs and favourably concluded the implementation of these programs [1 p. iii]. The findings of these assessments revealed that community paramedicine programs were, “associated with an improvement in health outcomes, measured using self-reported Psychosocial Adjustment to Illness Scale (PAIS-SR) scores or quality adjusted life years (QALYs)” [p. 1 iii]. The Institute of Health Economics noted that in one study there was a diminished cost over a three-year period post-implementation of the program. While the other study examined revealed a slightly higher cost for Paramedics than ‘usual care’, the study proposed that, “community paramedicine programs were cost effective, given a relatively low incremental cost-effective ratio” [1 p. iii].
The Question of Specialized Education
The CSA Group, through Defense Research and Development Canada published the first edition of CSA Z1630-17 standard for community paramedicine program framework in 2017. This framework highlights the recognition and requirement for, “community paramedics to receive specialized education and continuing professional development appropriate to the program’s model of care” [2 p. 13]. Educational requirements should also provide these practitioners with foundational knowledge that is, “based on a recognized or approved curriculum” [2 p. 13]. In short, the chosen training should fit and satisfy the needs of the community as well as the learners and should be based on the healthcare gaps identified by way of a community assessment. While preference may lie with an educational program delivered by a post-secondary educational institution, the framework recognizes and supports the development of an in-house program or the opportunity to work collaboratively with a local educational institution for the development of a customized training program [2 p. 13].
However, enabling higher education is not without its own challenges. Predominately, there exists two such challenges identified in the work of Dr. O’Meara et al. (2014). Firstly, the current paramedicine program curricula are noted to, “already be at full capacity with respect to acute care topics and skills” [3 p. 6]. Secondly, there exists a prevalent complexity in convincing mainly young students that role of paramedics in the future will be more deeply rooted in community primary care practice versus answering emergency calls [3 p. 6]. According to Dr. O’Meara et al., there is support for paramedic programs to evolve and grow into a four-year Bachelor level degree course that would be comparable to other healthcare professions such as nursing for instance [3 p. 6]. With this shift to a Bachelor level degree program, community paramedicine could transition to becoming a specialist stream, which would incorporate subjects such as public health as well as specific procedural skills [3 p. 6]. The latter notion of incorporating public health topics is not new; in fact the United States has developed community paramedicine curricula that incorporates both public health teachings and specific procedural skills. Both Australia and New Zealand’s degree-level paramedicine programs incorporate public health topics as well. These programs have been well established, and provide higher education that includes a mix of three-year paramedicine degrees in addition to “some four-year double degrees in combination with Nursing or Public Health” [3 p. 6]. Traditional paramedic programs have been described as, “ narrowly focused” [3 p. 6]; as noted earlier their emphasis centered on emergency response, with little consideration for education in cultural safety, health promotion, aged and chronic disease while lacking to provide education in the social determinants of health and how the wider healthcare system performs according to the findings of O’Meara et al. [3 p. 6].
Dr. O’Meara et al. (2014) suggest that paramedic programs would benefit from expanding their curriculum to include:
- Generic health and social service education
- Social determinants of health, and other public health topics
- Acute and chronic mental health
- Chronic disease management
- Geriatric emergency medicine
- Wound care
- Understanding of community (sociology)
[3 p. 7]
Convincing students and stakeholders that community primary care content is in fact relevant to the practice of paramedicine within an integrated healthcare systems remains a challenge, and while the evolution of traditional paramedic education to a Bachelor-level program will take some time, Paramedics that wish to practice in the community paramedicine setting currently have limited resources for high education. In the research and material preparation phase for this article three Canadian programs stood out while one American program offering an opportunity at advance licensing stood out.
The first program examined was the Community Care Paramedic program offered through Ontario’s Centennial College located in Scarborough. The program is delivered over 9 weeks in a flexible format that combines both on-line and in-class education, allowing the student complete their community care education in a manner that best fits their schedule .
The program’s learning objectives are to noted to include the following:
- Utilize critical thinking and analysis in assessing, developing and applying community-based paramedic research and practice.
- Develop a variety of leadership techniques, critical thinking and decision-making skills to develop, apply and communicate best practices,
- Improve health outcomes and promote community-based paramedic initiatives.
- Enhance the physical, psychosocial and emotional well-being of diverse individuals, families and communities by applying principles and
- Concepts of health promotion, ageing, social determinants of health, pharmacology and pathophysiology.
- Analyze and perform advanced assessments, diagnostic techniques and health promotion strategies to develop, apply and communicate
- Personalized healthcare plans in a therapeutic manner.
- Develop strategies for personal and professional development to enhance personal practice level as a community paramedic. 
The second program examined was the Community Paramedic Advanced Certificate offered by Saskatchewan Polytechnic (formerly Saskatchewan Institute of Arts and Science or SIAST for short) located in Saskatoon, Saskatchewan. The 30-week program is offered by combining on-line learning and 53 hours of hands-on lab/clinical practice.
The program focuses on enhancing education, whether the practitioner is a Primary care or advanced care. Topics covered include prevention, client/patient education, geriatrics, palliative care, mental health as well as addiction and chronic disease management .
The third Canadian program examined was the Community Paramedic Extension Certificate offered by Mount Royal University in Calgary, Alberta. This program was developed in collaboration with Alberta Health Service’s Emergency Medical Services Mobile Integrated Healthcare (also referred to a the Community Paramedics Program). Students of the programs may complete the program in as little as two years and take as long as six years. The certificate program is comprised of seven online courses totally 225 hours of didactic education and 2 field experience components totally 150 hours. The content of Mount Royal’s program focus is on, “the application of primary care healthcare strategies within inter-professional environments” . Benefits of this program are noted to include:
- The offer of professional development opportunities for Advanced Care Paramedics and currently practicing Community Paramedics
- Opportunity to gain in-depth theoretical knowledge and extensive experience in a variety of healthcare settings
- Become an integral part of the solution to Canada’s growing healthcare concerns through the development of professional strategies in response to healthcare issues, ethics, and inter-professional communication challenges
- Apply learned knowledge beyond the traditional emergency response role into the community setting, such as: assisted living sites, long term care homes, private residences, etc.
- Further develop inter-professional collaborative skills to manage continuity of care and resource allocation for patients with complex conditions
- Create care programs for patients to allow for continued independent living 
Lastly, the American program examined was the Certified Community Paramedic Review course offered by Southern Columbia University based in Orange Beach, Alabama. This on-line program was developed in partnership with the International Association of Flight & Critical Care Paramedics (IAFCCP) and is recognized as a review course for the advanced certification exam offered by the International Board of Specialty Certifications for the Community Paramedic Certification (CP-C) designation. The course is offered over 10 weeks and is self-paced with open enrollment. In the event that students are not able to complete the program in the prescribed time frame, an extension will be granted . Learning objectives for this program as described as:
- Apply knowledge of the principles of mobile integrated healthcare.
- Recognize the role of community paramedics in addressing community-based needs.
- Identify the variables that can affect patient care and health status.
- Identify components commonly found in a patient’s plan of care.
- Recognize the imperative for interdisciplinary collaboration to provide proper patient care.
- Distinguish strategies for effective patient-centric care.
- Recognize the factors that affect the monitoring and management of the chronic disease patient.
- Identify strategies for preventative care. 
Seeking Advanced Certification
In general, certification is a, “mechanism in which the public and employers are able to identify practitioners who have met certain standards in their particular specialty” .
The exams and subsequent certification offered by the IBSC are specific to speciality Paramedic practice, measuring a defined body of knowledge that is pertinent to a particular specialty. Specialty areas of practice covered by the IBSC include the following:
- Community Paramedic Certification (CP-C)
- Tactical Paramedic Certification (TP-C)
- Flight Paramedic Certification (FP-C)
- Critical Care Paramedic Certification (CCP-C) 
The IBSC notes that, “a role delineation study is conducted approximately every five years to assure the examinations reflect current specialty paramedic practice” . While IBSC exams are recognized around the globe, they have been based on best practices and scope of practice commonly found in the United States .
For the short-term outlook of the profession, the notion of “up-skilling” [3 p. 7] can and is noted to be a convenient method for current Paramedics who are broadening their care path towards a role in community paramedicine. Unfortunately, this does not tackle the strong underpinning of education for all Paramedics faced with an evolving role of the profession as seen in community paramedicine, extended care and remote areas [3 p. 7].
While the concept is not yet well established in North America or Canada, degree-level Paramedic programs exist in considerable numbers elsewhere in the world. This would be considered a sustainable long-term approach to broadening Paramedic education that would provide comparable education to that of other health professions, such as Physicians, Nurses and Social Workers to name a few [3 p. 7].
Community paramedicine has a wider requirement to ensure that its role is clearly defined, understood and acknowledged within paramedicine, amongst other healthcare professions as well by the institutions that fund as well as regulate the provision of health services which constitute the “distinctive activities and responsibilities of Community Paramedic” [3 p. 7].
Conflict of Interest
The author declares he does not have any conflict of interest with the educational programs highlighted or with the International Board of Specialty Certifications (IBSC)
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