The International Roots of Community Paramedicine

In January 2005, a single telephone call from Halifax, Nova Scotia, to Lincoln, NE, changed the face of EMS forever. That telephone call led to the creation of the International Roundtable on Community Paramedicine (IRCP).

Over the last 11 years, delegates from Australia, Canada, England, Germany, Ireland, Israel, Norway, Switzerland, the United Arab Emirates and the United States have met annually and participated in periodic conference calls to further the practice of CP around the globe.

While there is a lot of community paramedicine innovation occurring in the U.S. currently, all of our biggest innovations to date have been realized in other countries. In this article we will describe some program attributes that have been successful in Australia and Canada.

Australia

Generally there are two types of Australian programs that fall under a heading of the “paramedic practitioner” model. Health Workforce Australia invested $4 million AUD to fund five site trials in four states and territories that were loosely based on the U.K. extended-care paramedic (ECP) model. One limitation of the ECP model is that it focuses exclusively on emergency department avoidance.

In very remote states, the Aussies have used community paramedics not only to work closely with existing healthcare providers, but also to make volunteer EMS systems sustainable. The states of Tasmania and Victoria operate small programs using this model. Victoria also has one system that connects patients directly to community paramedics using the CooWee smartphone app, which links care teams across locations and technologies.

In the state of Western Australia, St. John Ambulance covers the largest area of any sole ambulance service in the world, nearly a million square miles (33% of the land mass of Australia). St John has 3,400 volunteers working in this area, and they transport only 32,000 people a year. Supporting the volunteers are 70 community paramedics stationed in 22 rural communities. The charge of the community paramedics is to collaborate with a variety of local healthcare providers and provide training, clinical and operational support to volunteers in the St. John system.

South Australia has invested $6 million AUD in a pilot integrating community paramedics into local public health networks. This program focuses on emergency department avoidance, reducing readmissions and reducing repeat 0-0-0 (Australia’s 9-1-1 equivalent) calls while increasing patient satisfaction and safety by integrating with local primary care providers.

Canada

The most innovation of new models of community paramedicine has occurred in Canada. A plethora of programs operates there; some paramedic services operate several different kinds of programs within one agency. Canada has done a good job with packaging programs so they can be delivered the same way in multiple areas.

Some unique program structures include focusing community paramedics on providing services in housing projects, integrating with social outreach workers, transitions of care for hospital-discharged patients, providing health education, conducting wellness fairs and clinics, remote home monitoring services, and community health assessment programs. In the York Region paramedics visit homeless shelters each week to provide health assessments and referrals to other healthcare agencies.

Renfrew County, Ontario, operates several programs throughout its region. One is called “Aging at Home,” which consists of a collaborative team including paramedics, housekeeping and maintenance services, personal support workers, an alert system and a support line available 24 hours a day.

The “Community Referrals by EMS” (CREMS) program developed by Toronto is now used across the country. This program focuses largely on creating referral pathways to community mental health services for frequent 9-1-1 callers.

Another popular program is called “Vitals, Safety, Inspections and Treatment,” or VISIT. This system is geared primarily toward medication compliance, fall risk assessments and referrals when needed.

One of the great contributions to community paramedicine by Canada is the “Paramedics Assessing Elders at Risk of Independence Loss” (PERIL) tool. This tool was developed and validated at Sunnybrook University and predicts patients who are at risk of needing community paramedic services. CP follow-up visits are automatically scheduled for the patient if they answer “yes” to two of these three questions:

1. Are there any problems in the home that would prevent safe discharge from the emergency department?

2. Before today’s issue, did the patient require help on a regular basis?

3. Has the patient made any 9-1-1 calls in the last 30 days?

Patients who score 3/3 on the PERIL tool have a 93% chance of having an adverse outcome (return to the emergency department, admission to the hospital or death) in the next 30 days. Patients who score 2/3 have a 54%–68% chance of having an adverse outcome in the next 30 days.

Multiple Ontario paramedic services are participating in a research project led by St. Michael’s Hospital known as the “Expanding Paramedicine in the Community” (EPIC) program. This IRB-approved study focuses on keeping patients with diabetes, CHF and COPD out of the hospital.

Several Canadian programs relate to primary care clinic settings. One notable long-standing program is on Long and Brier Islands. These islands off the Atlantic shore of Nova Scotia are served by a local clinic operated by a nurse practitioner (NP) and community paramedics, with offsite physician consultation as necessary. In this model the nurse practitioner and paramedics see patients in the clinic, and then patients with chronic conditions receive home visits by a community paramedic. There is no hospital on the island, and inpatient admissions are clumsy for the patients and their families due to the ferry ride and mainland travel to the closest hospital. This program has been successful in reducing ambulance transports by 25% and emergency department visits by islanders by 40%.

Another successful NP/CP  primary care model is the development and use of a “health bus” in Saskatoon. The bus is positioned in areas of the city where primary care is known to be underutilized. Each Monday the bus is in one location, on Tuesday another, and so on. The bus offers primary care evaluation and services, chronic disease management, wound care, flu shots and referrals.

Several paramedic services offer wellness clinics in the cities they serve. These programs generally focus on health promotion, injury prevention, health education, vital signs and risk evaluation. In Renfrew County alone paramedics see an average of 600 clients per month in their wellness clinic model.

Sharing Best Practices

Sharing among community paramedicine programs is important to both increase the use of best practices and avoid replication. While Canada used to be ahead of Australia and the U.S., the countries are now on more parallel pathways and should continue to learn from each other. Australia’s programs are largely in extremely isolated areas and somewhat focus on supporting volunteers, while Canada has produced some nice scoring tools (such as PERIL) and packaging of programs (such as CREMS) and the U.S. has lately been focusing on creating performance measures for outcomes and processes. Each of these approaches has so far been limited to development in a single country.

The sharing of international best practices in MIH-CP through organizations like the IRCP enhances the delivery models, outcomes and research related to this growing EMS service line. For more information, visit www.ircp.info.