Remodeling the House

It was a time of social upheaval and racial discontent. Those in poorer areas didn’t have good access to medical care—certainly less than others elsewhere who were wealthier (and typically whiter). Neither did they have the same career opportunities. 

In Pittsburgh in the late 1960s and early ’70s, Freedom House Ambulance Service presented a pioneering answer to both problems, training residents of the city’s underserved areas as paramedics to deliver elite prehospital care back to neglected neighborhoods like their own. And while it lasted less than a decade, it demonstrated that with the right resources and will, pipelines could be built to craft worthy candidates in need of a chance into dedicated caregivers that returned quality help to their communities. 

Now it’s 50-plus years later, and variants of those same problems persist in cities across America. Against that backdrop, healthcare leaders in Pittsburgh have reimagined and revived the city’s legendary Freedom House program with a modern twist. 

“Clearly we’re going through a time of great social unrest,” says Kenneth Hickey, who’s leading the program for the University of Pittsburgh Medical Center (UPMC) and its health plan. “Several years ago we had a study that showed being Black in Pittsburgh, you had worse outcomes in health, education, employment—pretty much every outcome you could possibly have was horrible for the Black community. At the same time we had a great need for frontline workers and first responders. And we realized, Hey, Freedom House started here. With everything that’s going on, why not revive it? This is a great time for a program that helps against so many of the negative things we’re combating today.”

Similarities notwithstanding, a lot else has changed since the 1960s, not the least of which is the universal availability of EMS. Thus the new incarnation of Freedom House has some key differences. Most prominently, it takes a wider approach to preparing students not just as EMTs but for a broader variety of roles better prepared to address a range of nonacute needs across today’s complex healthcare environment. 

“When you look at the types of calls our 9-1-1 systems are dealing with, it’s clear we’re using models that were developed a long time ago that don’t really resonate with the types of calls we’re dealing with today,” says Dan Swayze, DrPH, MBA, MEMS, vice president of community services for the UPMC Health Plan and an early innovator of community paramedicine/mobile integrated healthcare concepts in EMS. 

“The concept with Freedom House 2.0 is specifically to say, ‘If we start to include a broader assessment—if we start to offer our providers more resources than just medical care or the emergency department as the explicit solution for these folks—can we transform the EMS system into something better able to respond to the types of emergencies we’re seeing today?’”

The returns will take time, but optimism is high. 

Freedom House: A Brief History

Before modern EMS systems, medical emergencies were answered by firefighters, police, and funeral home ambulances. In Pittsburgh as in many cities, responses to lower-income neighborhoods could be lacking. In 1967 Phillip Hallen, the president of a local charity, the Maurice Falk Medical Fund, conceived a solution involving Freedom House Enterprises, a nonprofit that assisted Black Pittsburghers with needs like finding jobs, registering to vote, and organizing politically. Hallen proposed expanding its job training to ambulance work. 

Freedom House Enterprises boss Jim McCoy agreed, and they approached UPMC’s predecessor, Presbyterian University Hospital, where they connected with resuscitation legend Peter Safar. Safar eagerly agreed to orchestrate the medical training in conjunction with a local ambulance service. Funding in hand, they hit the streets to find candidates. The resulting students had some checkered backgrounds—poverty, criminal histories, some Vietnam vets—but got cutting-edge training and support through academic titans like Safar and later Nancy Caroline that grew them into dedicated providers of the most advanced care found at the time. 

That’s a short history; for a fuller one see “The Forgotten Legacy of Freedom House.” Some of its key ideas recur in the sequel: Freedom House 2.0 also has nonprofit origins—essential funding came from Partner4Work, a local workforce-development organization—and is also drawing from a nontraditional student base and supplementing its clinical training with emphases in areas like life skills, professional skills, and personal resiliency to which many of its students haven’t been exposed. 

Program medical director Emily Lovallo, MD, an assistant professor of emergency medicine at the University of Pittsburgh, came to the city from Alameda County, Calif., where a program called EMS Corps reflects similar ideas. Its mission is to “increase the number of underrepresented workers in emergency medical services through youth development, mentorship, and job training.” There she worked closely with emergency physician Jocelyn Freeman Garrick, MD, MS, a leader of the Alameda County health system who’s helped drive EMS Corps and other local pipeline and mentoring programs for underserved communities.

In particular EMS Corps generated an offshoot program in the mid-2010s where students received additional training through the UC Berkeley School of Public Health and served as nursing and case management educators in emergency departments, where they initiated relationships with patients that continued for six months into the outpatient setting. “It really kind of built a bridge between EMTs, community health workers, case management, and health coaching,” says Lovallo. “There were a lot of incredible outcomes.”

Lovallo wanted to bring something comparable to Pittsburgh. She connected with Swayze, who’d led the successful local CONNECT community paramedicine project, and Hickey, and they began building the program. The grant funding came through last October, and classes started in January. The first two cohorts have now graduated. 

No Two the Same

The first two 10-person classes were recruited through a variety of outlets: community-based organizations, federally qualified health centers, churches, even daycares. Program leaders left flyers in hospital EMS and break rooms and gave them directly to workers in nonclinical positions and even patients. This helped generate more than 100 applicants. 

“We went to community organizations and said, ‘We’re looking for people who are dreaming of doing something bigger in the future, and we want to support them to get there,’” says Hickey. “We wanted grassroots people who wanted to achieve goals.”

The main targets were young adults 18–24 or those who’d lost jobs due to COVID, though some in the first group fell outside those parameters. The second class was younger, Lovallo says, “folks with positions that were helping them make ends meet but not really what they wanted to do.”

Candidates needed a high school diploma or GED, and an important criterion was lived experience: Freedom House wanted people who’d been through poverty, adversity, and health and personal challenges who could be empathetic to the potential plights of patients. 

That they got: The first cohort had dealt with obstacles like addiction and job loss, and during classes students endured multiple deaths of family members, along with family, health, and other issues. But attrition was minimal, and the mission kept students galvanized.

“Once I saw the opportunity, I knew it was something I couldn’t pass up,” says Tashina Hosey, a single mom of children ages 1 and 3 who came to the program after leaving a job with the postal service and was one of the top-performing students in the first class. “Then once the classes started and I started learning things, I became really interested. We had two days where we went on ride-alongs with EMTs and paramedics, and that was kind of like an epiphany—a lightbulb just went off: This is what I want to do. Every call I went one was definitely different than the last—there were no two the same.”

Extra Support

The first of the students’ 10 weeks of class is devoted to the skills of academic success: time management, scheduling, note-taking, how to study. EMT education occupies the next seven weeks—the National Standard Curriculum delivered through Pitt and the Center for Emergency Medicine of Western Pennsylvania—then a week of expanded training for community paramedic/community health worker roles. 

“Throughout the course and specifically in the last week, we look at how to deal with social determinants of health,” says Swayze. “The broadened assessment skills: how to use motivational interviewing, how to incorporate trauma-informed care into interactions with people to better understand why they’re calling and not just what the medical presentation is.”

This includes alternatives to emergency departments and connections to other resources and sources of care. The final week then focuses on job preparedness—familiarization with the ED and other parts of the hospital and healthcare system, as well as skills  like resume-writing, dressing for success, and interviewing. 

What truly distinguishes the effort is its degree of student support. The program covers uniforms and equipment and even provides a financial stipend to help replace job income. It pays graduates’ National Registry testing fees. Students get enhanced study time and support; expanded access to instructors; a mentoring component that matches them with experienced guides in their areas of interest; and counseling services, including for families. Program personnel also make sure students are connected to other social services or benefits for which they’re eligible.

“They provided everything we could possibly need: laptops, bus passes for people who didn’t have transportation, breakfasts and lunches, supplies—basically everything,” says Hosey. “There was nothing I feel like I needed to be successful that they didn’t provide for us, and I think we’d all say the same thing.” 

Mental health and trauma resiliency emphases are woven throughout. “Embedded in this is that we’re trying to teach them coping skills, which are sorely lacking from traditional EMT training,” Swayze adds. “Many have had trauma in their lives, so how do they deal with that? We try to give them skills to increase their resiliency—something we think will be helpful.”

Toward Bigger Goals

Graduates of the Freedom House course are qualified to work as EMTs, patient care technicians, or community health workers—three high-demand occupations that made the program attractive to Partner4Work. UPMC doesn’t have an ambulance service in Allegheny County but guarantees interviews for PCT, CHW, or one of its few in-house EMT roles. If graduates want to go elsewhere to work on ambulances, it will also assist them with that. 

Students have been interested in a range of healthcare careers. Hosey had been trained as a medical assistant and has nurses in her family. She was intrigued by the role of the community health worker. “It’s more of a long-term type of connection, and for whatever reason I related to that field the most,” she says. She hopes to work as a CHW and an EMT. 

That kind of job placement—immediate and as a first step toward longer-term careers—is a big part of what will measure the program’s success. “Obviously we don’t want you to sit through the program and not get hired somewhere,” says Hickey. “But to me it’s also that you’re giving back to the community.” 

“We want this to be a step toward their bigger goals. And if we can help them get there, then to me that’s a success,” adds Lovallo. “Where they are right now—with this accomplishment and being role models for their families and communities, being able to say they’re coming to Freedom House and learning the things they’re learning—that’s success.”

Interest in the project has been high. Other EMS systems and national organizations have reached out. That breeds hope that on a bigger scale, the broader approach of Freedom House 2.0 might help drive EMS education into some of those newer directions that better address modern patient needs. 

Safar’s vision for the original Freedom House Ambulance was to drive advanced medical interventions—intubation, defibrillation, pushing meds—from hospitals out into communities, where people were dying of reasons such skills could impact. Now they’re dying of different things—and extrahospital training and care models need to adapt. 

“We really haven’t kept pace with changes to the 9-1-1 system, and as a result we’re seeing frustrated medics who were trained to be clinicians but are now dealing with these other types of calls,” says Swayze. “It’s not just about the medical crises we’re called to intercede with anymore. It’s crises of all kinds of issues—behavioral health issues and social-determinants-of-health issues. Yet when we’ve gone through various exercises looking at the EMS education curriculum and the models we use, we often end up just trying to fine-tune old content. 

“I hope this program is something agencies will realize can help in a number of ways to deal with the burnout and frustrations our current workforce can have with the types of calls we’re getting and making the next generation of EMS students better prepared to handle those types of emergencies.” 

John Erich is the senior editor of EMS World. Reach him at john.erich@emsworld.com.