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BACKGROUND: Home-based primary care promotes aging in place but is not immediately responsive to urgent needs. Community paramedicine leverages emergency medical services clinicians to expedite in-home care, though limited evidence supports this model. We evaluated the primary care and acute care use of older adults evaluated urgently by a community paramedic with telemedicine physician compared to a physician home visit model. METHODS: This prospective cohort study enrolled older adults in home-based primary care who requested an urgent evaluation. We allocated participants to the physician home visit model or physician home visit plus community paramedic model by ZIP code. We observed primary care and acute care use for 6 months following enrollment. The primary outcome was the median number of primary care and acute care visits per participant. Secondary outcomes included 30-day readmission rates, median wait times, and physician productivity. Data analysis included descriptive statistics, comparison of means and proportions, and negative binomial regression modeling reported as incidence rate ratios (IRR). RESULTS: We screened 255 participants, determined 203 eligible, allocated 199, and completed observation for 167 (84 community paramedicine, 83 physician home visit). Participants were mostly female, age 76-86 years, with 3-5 comorbidities, living in a home/apartment. Community paramedic participants had 29% more primary care visits (IRR 1.29, 95% confidence interval [CI] 1.06-1.57) and shorter wait times for urgent evaluations (1 vs. 5 days, p < 0.001) without increasing acute care use (IRR 0.75, 95% CI 0.48-1.18) or 30-day readmissions (IRR 1.32, 95% CI 0.49-3.55). Physician productivity increased 81% (40 vs. 22 visits/week, p < 0.001). CONCLUSION: Older adults evaluated by a community paramedic for urgent needs were seen sooner, used acute care similarly to patients evaluated by a physician home visit, and nearly doubled physician efficiency. This suggests that older adults may benefit from combining emergency medical services and primary care resources for urgent evaluations.

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BACKGROUND: Rural, remote, and underserved communities have often struggled to provide adequate access to family physicians. To bridge this gap in Renfrew County, a large, rural region in Ontario, Canada, a community- based, hybrid care model was implemented, combining virtual care from family physicians and in-person care from community paramedics. Studies have demonstrated the clinical and cost effectiveness of this model but its acceptability to physicians has not been examined. This study investigates the experiences of participating family physicians. METHODS: A mixed-methods study, combining physician questionnaire response data and qualitative thematic analysis of focus group interview data. RESULTS: Data was collected from n = 17 survey respondents and n = 9 participants in two semi-structured focus groups (n = 4 and n = 5 respectively). Physicians reported high satisfaction, driven by skills development and patient gratitude, and felt empowered to reduce ED visits, care for unattached patients, and address simple medical needs. However, physicians found it difficult to provide continuous care and were sometimes unfamiliar with local healthcare resources. CONCLUSION: This study found that a hybrid model of in-person and virtual care from family physicians and community paramedics was associated with positive physician experiences in two main areas: clinical impacts, especially avoiding unnecessary ED visits, and physician satisfaction with the service. Potential improvements for this hybrid model were identified, and include better support for patients with complex needs, and more information about local health-system services. Our findings should be of interest to policymakers and administrators seeking to improve access to care through a hybrid model of in-person and virtual care.

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OBJECTIVES: To compare health service utilization of patients interacting with a mobile integrated health care program consisting of advanced care paramedics delivering community paramedic care to people experiencing homelessness before and after their initial visit. METHODS: ED visits, physician claims, and pharmaceutical dispensations were compared in the year prior to and in the year following the initial community paramedic visit. Administrative databases were linked and utilization rates were calculated and analyzed between periods in this pre-post cohort study. RESULTS: The 1360 community paramedic patients included in this study had no significant change in ED visits (IRR: 1.02) following their initial visit. There were 17,699 ED visits in the pre-period and 18,398 visits in the post-period. There was an observed increase in rates of primary care physician claims (IRR 1.22) and pharmaceutical dispensations from community pharmacies (IRR 1.04). Patients who did not have pharmaceutical dispensations and those without physician claims in the pre-period were significantly less likely to not access these services in the post-period. CONCLUSIONS: In the year following the initial community paramedic visit there were small but significant increases in community-based care utilization of people experiencing homelessness. These data suggest that the continued development and implementation of paramedics as part of an interdisciplinary care team can increase access to care for a traditionally underserved population with complex health needs. Patients would likely benefit from the integration of community paramedics in community-based management that aim to improve access to care following ED visits.

RéSUMé: OBJECTIFS: Comparer l'utilisation des services de santé des patients interagissant avec un programme de soins de santé mobile intégrés composé d'ambulanciers paramédicaux de soins avancés fournissant des soins paramédicaux communautaires aux personnes sans domicile fixe avant et après leur visite initiale. MéTHODES: Les visites aux urgences, les demandes de remboursement des médecins et les prescriptions pharmaceutiques ont été comparées dans l'année précédant et dans l'année suivant la visite initiale du personnel paramédical communautaire. Les bases de données administratives ont été reliées, et les taux d'utilisation ont été calculés et analysés entre les périodes dans cette étude de cohorte avant et après. RéSULTATS: Les 1 360 patients paramédicaux communautaires inclus dans cette étude n'ont pas connu de changement significatif dans les visites aux urgences (IRR : 1,02) après leur visite initiale. Il y a eu 17 699 visites aux urgences dans la pré-période et 18 398 visites dans la post-période. On a observé une augmentation des taux de demandes de remboursement des médecins de soins primaires (IRR : 1,22) et des dispensations de produits pharmaceutiques par les pharmacies communautaires (IRR : 1,04). Les patients qui n'ont pas bénéficié d'une dispensation de produits pharmaceutiques et ceux qui n'ont pas fait l'objet d'une demande de remboursement par un médecin au cours de la période précédente étaient significativement moins susceptibles de ne pas avoir accès à ces services au cours de la période suivante. CONCLUSIONS: Au cours de l'année qui a suivi la première visite du personnel paramédical communautaire, on a constaté une augmentation faible mais significative de l'utilisation des soins communautaires par les personnes sans domicile. Ces données suggèrent que le développement et la mise en œuvre continus des ambulanciers paramédicaux au sein d'une équipe de soins interdisciplinaire peuvent accroître l'accès aux soins pour une population traditionnellement mal desservie et présentant des besoins de santé complexes. Les patients bénéficieraient probablement de l'intégration des ambulanciers communautaires dans la gestion communautaire qui vise à améliorer l'accès aux soins après une visite aux urgences.

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Community paramedic (CP) units are becoming more popular in enhancing a person's access to the need for care assessment and treatment in acute but non-life-threatening health issues. Simultaneously CP units can reduce the strain on emergency departments (EDs) by treating patients effectively at home. The efficacy of CP units is proven in previous studies, but the details of conditions patients seek retreatment at the ED after a CP unit visit are largely unknown. This study aimed to categorize CP unit patients (n = 229) seeking retreatment after a CP unit visit and investigate links between CP unit actions and patients seeking retreatment. The study was based on a data set from a six-month CP unit pilot program in Finland. The main results show that 82% of the patients assessed and treated by the CP unit did not seek retreatment. Low back symptoms and nausea were the main problems patients presented to the ED within 96 h after the CP visit. On-call physician consultation (p = 0.335) or CP unit treatment time (p = 0.629) were not associated with the frequency of ED presentation. Further studies are needed in order to investigate which types of emergency medical missions are the most suitable for CP units. The findings of this study support the effectiveness of community paramedicine programs.

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OBJECTIVES: The aim of this study is to identify the types of community paramedicine programs and the training for each. METHODS: A systematic review of MEDLINE, Embase, grey literature, and bibliographies followed a search strategy using common community paramedicine terms. All studies published in English up to January 22, 2018, were captured. Screening and extraction were completed in duplicate by two independent reviewers. The Mixed Methods Appraisal Tool (MMAT) was used to assess studies' methodological quality (full methodology on PROSPERO: CRD42017051774). RESULTS: From 3,004 papers, there were 64 papers identified (58 unique community paramedicine programs). Of the papers with an appraisable study design (40.6%), the median MMAT score was 3 of 4 criteria met, suggesting moderate quality. Programs most often served frequent 911 callers (48.3%) and individuals at risk for emergency department admission, readmission, or hospitalization (41.4%); and 70.7% of programs were preventive home visits. Common services provided were home assessment (29.5%), medication management (39.7%), and referral and/or transport to community services (37.9%); and 77.6% of programs involved interprofessional collaboration. Community paramedicine training was described by 57% of programs and expanded upon traditional paramedicine training and emphasized technical skills. Study heterogeneity prevented meta-analysis. CONCLUSION: Community paramedicine programs and training were diverse and allowed community paramedics to address a spectrum of population health and social needs. Training was poorly described. Enabling more programs to assess and report on program and training outcomes would support community paramedicine growth and the development of formalized training or education frameworks.

OBJECTIF: L'étude visait à relever les différents types de programmes de paramédecine communautaire et à décrire la formation donnée dans chacun d'eux. MÉTHODE: Une revue systématique des bases de données MEDLINE et Embase, de la documentation parallèle ainsi que de bibliographies a été entreprise à la suite d'une stratégie de recherche élaborée à l'aide de termes utilisés souvent en paramédecine communautaire. Ont été saisies toutes les études publiées en anglais jusqu'au 22 janvier 2018. Le tri et l'extraction des données ont été faits en double, par deux examinateurs indépendants. L'évaluation de la qualité méthodologique des études a été réalisée à l'aide de l'instrument Mixed Methods Appraisal Tool (MMAT) (description complète de la méthode dans PROSPERO : CRD42017051774). RÉSULTATS: Sur 3004 articles relevés, 64 ont été retenus (58 programmes distincts de paramédecine communautaire). Le score médian MMAT des articles présentant un plan d'étude susceptible d'évaluation (40,6%) était de 3 sur 4 quant au respect des critères établis, résultat évocateur d'une qualité moyenne. Les programmes avaient surtout pour cible les usagers fréquents du service 911 (48,3%) et les personnes susceptibles d'admission ou de réadmission au service des urgences, ou encore d'hospitalisation (41,4%); 70,7% des programmes portaient sur les visites préventives à domicile. Les services fréquemment offerts étaient les évaluations à domicile (29,5%), le contrôle de la pharmacothérapie (39,7%) et l'orientation ou le transport des malades vers des services communautaires (37,9%); 77,6% des programmes incluaient un volet de collaboration interprofessionnelle. La formation en paramédecine communautaire a été décrite par 57% des programmes et étendu sur le champ de pratique habituel de la paramédecine traditionnelle et visait l'acquisition de compétences techniques. Enfin, il n'a pas été possible de procéder à une méta-analyse en raison de l'hétérogénéité des études. CONCLUSION: Les programmes de paramédecine communautaire et la formation afférente sont diversifiés et permettent, de ce fait, aux professionnels du domaine de répondre à un large éventail de besoins sociaux et de besoins en matière de santé de la population. Pour ce qui est des descriptions de la formation donnée, elles étaient insuffisantes. Si les responsables de programmes étaient tenus d'évaluer les programmes et la formation offerte et de faire état des résultats obtenus, cela favoriserait le développement de la paramédecine communautaire et l'élaboration de cadres structurés d'études ou de formation.

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BACKGROUND: Since the beginning of 2000, the primary healthcare services around the globe are challenged between demands of home care and number of staff delivering it. The delivery of healthcare needs new models to reduce the costs, patient's readmission and increase their possibilities to stay at home. Several paramedicine programmes have been developed to deliver home care as an integral part of the local healthcare system. The programmes varied in nature and the concept of Community Paramedicine (CP) has not been established, demanding clarity. The aim of this review was to identify and describe the core components of CP, and identify research gaps for the further study. METHOD: A scoping review was performed using five electronic databases: Medline; CINAHL; Academic Search Premier; PubMed and the Cochrane Library for the period 2005 - June 2018. The references of articles were checked, and papers were assessed against inclusion criteria and appraised for quality. RESULTS: From 803 initial articles, 21 met the criteria and were included. Inductive content analysis was carried out. The four core components of Community Paramedicine emerged (a) Community engagement, (b) Multi-agency collaboration, (c) Patient-centred prevention and (d) Outcomes of programme: cost-effectiveness and patients' experiences. CONCLUSION: The Community Paramedicine programmes are perceived to be promising. However, Community Paramedicine research data are lacking. Further research is required to understand whether this novel model of healthcare is reducing costs, improving health and enhancing people's experiences.

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BACKGROUND: Older adults are more likely to access the emergency department, which suffers from overcrowding and congestion, for conditions that could potentially be treated in other settings. Older adults living in long-term care centers have access to healthcare resources in their residence, and several programs have been created with the intent of treating medical conditions on-site. The aim of this study is to identify and systematically review programs and interventions at long-term care centers that aim to treat patients on-site, avoiding unscheduled transportation to the emergency department. METHODS: We will follow the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. We will perform a comprehensive search of Embase, MEDLINE, CINAHL, ClinicalTrials.gov , PROSPERO, and the Cochrane Central Registry of Controlled Trials using a broad search strategy. Two independent reviewers will assess titles and abstracts against inclusion criteria, and we will further evaluate relevant full-text articles for inclusion. We will assess the risk of bias using the Newcastle-Ottawa scale for included non-randomized studies and the Cochrane Risk of Bias tool for randomized trials. We will present a narrative synthesis of results and complete a meta-analysis only if enough homogeneity is found. We will create funnel plots to evaluate possible reporting bias and use The Grading of Recommendations Assessment Development and Evaluation (GRADE) methodology to assess the confidence in cumulative evidence. DISCUSSION: As pressure on the healthcare system continues to rise, many areas are looking for alternative models of care. Several programs have been put in place in long-term care centers that seek to avoid transportation to the emergency department by providing enhanced care on-site. These programs are quite variable, and, to date, there is no standardized program or model of care. SYSTEMATIC REVIEW REGISTRATION: PROSPERO ( CRD42018091636 ).

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BACKGROUND: Mental health patients wait lengthy periods in emergency departments for disposition. This delay is secondary to the process of medical clearance and then placement in an appropriate psychiatric specialty center. ACEP clinical policy questions the necessity of laboratory investigation for medical clearance and favors history and physical exam to determine safe disposition to mental health facilities. This manuscript explores if specially trained paramedics can effectively employ triage algorithms to determine proper disposition of patients suffering an acute mental health crisis in a 9-1-1 system. METHODS: Six paramedics working for AMR in Stanislaus County, California underwent 180 hours of specialized training to become Mobile Integrated Healthcare Paramedics (MIHPs). Their training detailed the use of two algorithms designed to identify patients that require evaluation in an emergency department versus those that can be triaged directly to a licensed mental health facility. Patients aged 18-59 with a suspected mental health crisis who are encountered via the 9-1-1 system, law enforcement or who walk in to the mental health facility for treatment were eligible. All patients in the study were evaluated with the well person algorithm (WPA). Those that passed the WPA were evaluated using the mental health clearance algorithm (MCHA). MIHPs directed patients to either the ED or the mental health facility based upon the evaluation results of the WPA and MHCA. RESULTS: 1006 patients were evaluated between September 2015 and December 2017. 404 patients failed one or more components of the WPA or MHCA. 326 patients passed both the WPA and the MHCA, but were ultimately transported to a local emergency department, most often because of lack of available psychiatric beds in the community. 276 patients were transported directly to a psychiatric facility. Of these, 10 returned to the emergency department within 6 hours, but none of the 10 were admitted for a previously unidentified medical or traumatic condition. CONCLUSION: Specially trained paramedics can effectively employ triage algorithms to screen and select patients experiencing an acute mental health crisis for transport directly to psychiatric treatment facilities.

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Background: Mobile Integrated Healthcare (MIH) is a novel, patient-centered approach to population management. This concept creates a needs-matched, time appropriate assignment of one or more members of a multi-professional clinical team to care for patients on a scheduled or unscheduled basis. The selection of the site of care for scheduled interventions is driven by patient choice and, most often occurs in the patient's home; unscheduled interventions are guided by a 5-point triage system and, based on acuity, may be treated in the home, primary care office, urgent care or, rarely, in an emergency department. Methods: An MIH team was assigned to deliver a care coordination program for a Medicare Advantage PPO (MAPPO) population (55% female, 71.2 years mean age), with risk assignment and interventions designed to affect potentially avoidable utilization of Emergency Medical Services (EMS), emergency department, and medical inpatient admissions. Patients participating in the MIH program were compared with contemporaneous, risk-matched non-participants as well as to actuarially expected cost and utilization based on historical claim experience. Results: All measured trends demonstrated favorable results for patients participating in the MIH program when compared against a matched cohort: 19% decrease in emergency department per member per month (PMPM) cost, 21% decrease in emergency department utilization, 37% decrease in inpatient PMPM cost, 40% decrease inpatient utilization, all measures reached statistical significance. Member experience satisfaction scores and patient activation measures also showed favorable preliminary trends. Conclusion: This initial impact analysis of a MIH care coordination program for this MAPPO population demonstrates promising trends regarding utilization, cost, member experience and patient activation. These preliminary findings indicate both that implementation of such a program is feasible and strongly suggest meritorious impacts upon the health, experience and cost of care for the population.

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BACKGROUND: Paramedicine is a rapidly evolving health profession with increasing responsibilities and contributions to healthcare. This rapid growth has left the profession with unclear professional and clinical boundaries. Existing defining frameworks may no longer align with the practice of paramedicine or expectations of the public. The purpose of this study was to explore the roles paramedics in Canada are to embody and that align with or support the rapid and ongoing evolution of the profession. METHODS: We used a concurrent mixed methods study design involving a focused discourse analysis (i.e., analysis of language used to describe paramedics and paramedicine) of peer reviewed and grey literature (Phase 1) and in-depth one-on-one semi-structured interviews with key informants in Canadian paramedicine (Phase 2). Data from both methods were analyzed simultaneously throughout and after being merged using inductive thematic analysis. RESULTS: Saturation was reached after 99 national and international grey and peer reviewed publications and 20 in depth interviews with stakeholders representing six provinces, seven different service/agency types, 11 operational roles and seven provider roles. After merging both data sets three framing concepts, six roles and four crosscutting themes emerged that may be significant to both present-day practice and aspirational. Framing concepts, which provide context, include variable contexts or practice, embedded relationships and a health and social continuum. Roles include clinician, health and social advocate, team member, educator, professional and reflective practitioner. Crosscutting themes including patient safety, adaptability, compassion and communication appear to exist in all roles. CONCLUSIONS: The paramedic profession is experiencing a shift that appears to deviate or at least place a tension on traditional views or models of practice. Underlying and evolving notions of practice are resulting in intended or actual clinical and professional boundaries that may require the profession to re-think how it is defined and/or shaped. Until these framing concepts, roles and crosscutting themes are fully understood, tested and operationalized, tensions between guiding frameworks and actual or intended practice may persist.

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