Community Paramedic Programs

beaucait

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I am interested in learning more about the Community Paramedic programs out there. I was recently asked to help out with PR type of stuff, and also helping out with the Community Paramedic program.

What are some things that a Community Paramedic program does? Does your CP program have anything that other companies don't offer? What is something you enjoy most about CP programs?
 

WolfmanHarris

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Our Community Paramedicine programs cover a few different areas and all are currently linked to research or pilot projects:

- Enhancing Paramedicine in Communities (EPIC) started a few years back as a two cohort before and after study looking at the effects of Paramedic home visits on patients with hypertension, CHF and diabetes within a large family health team. Paramedics perform regular check-ups as well as short notice visits for exacerbations and remain in regular contact with the Pt's MD. Showed good results in preliminary research, final paper not yet published. The province just gave a grant to continue this program outside the study.

Great patient care but my issue is that this study was done outside the 911 system (our service but outside of regular ops) so the eventual impact on EMS is still a bit tenuous.

- Shelter visits. Our staff in the Community Paramedicine and research unit partner with the social services staff at the local shelters to provide assessments and arrange referrals to appropriate services for those staying in shelters. Examples of interventions include arranging prescription refills and delivery, referral to walk-ins or calling in a unit for transport to ED when required.

- Community Referral by EMS. This is integrated into our ePCR system. When Paramedics in ops in the course of a call ID issues (fall risks, system navigation, mental health, LTC placement, etc) we complete an additional tab in ePCR which faxes the chart along with our referral to the Community Care Access Centre who assign a case worker for follow-up.

- High risk patient visits. Similar to shelters and CREMS Paramedics in regular operations ID high risk or repeat callers who then get a home visit from a CP often with a social worker to attempt to direct to more appropriate care.

- IMPACT (can't remember the acronym) is our newest and biggest CP study. It's looking at patient disposition, assessments and treatments done in the ED and discharge to identify new care pathways for 911 patients. Currently in phase 1 this approx 4-5 year trial will eventually see Paramedics doing greater assess, treat and refer (non-transport) or transport to alternative destinations like urgent care. This is the first CP project that will have profound impacts on front line operations; and in my opinion isn't mission creep into the realm of home care nursing. (I'm not adverse to this work but I think enhancements here can be made more efficiently within the existing providers)
 
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beaucait

beaucait

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I definately had the same thoughts regarding the home care nursing, and how it seems so similar.

When Paramedics in ops in the course of a call ID issues (fall risks, system navigation, mental health, LTC placement, etc) we complete an additional tab in ePCR which faxes the chart along with our referral to the Community Care Access Centre who assign a case worker for follow-up.

I think that is how our program works. We take high risk patients and check up on them and make sure that everything is safe, and that patients are taking meds etc. I am hoping to find out more about it soon!
 

SpecialK

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The local equivalent would be "Sierra" where calls requiring a physical response (i.e. cannot be closed over the phone) but with a statistically low need for transport (or for whom standard transport would most likely to be suitable) are responded to by a Paramedic or ICP in a car in Auckland, Wellington, and Christchurch.

Although the Sierra officer has the same options for referral as do all paramedics it is the targeting of specific types of calls with a more efficient resource than sending a fully crewed ambulance.

From memory something like 30% of pts nationally (so about 120,000 per year) are treated on scene and/or referred to other than ED, including something like 3% who are taken somewhere else other than ED e.g. mental health unit or A&M clinic.
 

WolfmanHarris

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From memory something like 30% of pts nationally (so about 120,000 per year) are treated on scene and/or referred to other than ED, including something like 3% who are taken somewhere else other than ED e.g. mental health unit or A&M clinic.

Those are fantastic numbers! I hope our program sees similar results when it hits its stride. Better for the system and faster more appropriate care for the patient.
 

Alan L Serve

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Isn't this the exclusive domain of nurses such as the VNA (Visiting Nurses Association) and home health nurses? Seems to me they have the actual training the education to provide such services.
 

Tigger

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Isn't this the exclusive domain of nurses such as the VNA (Visiting Nurses Association) and home health nurses? Seems to me they have the actual training the education to provide such services.
It is not.

We have very little home healthcare in our area. Our paramedics also received additional, college accredited education to handle these patients. We also provide "mobile-crisis response" to mental health patients either accessed via the state crisis hotline or through more traditional means.
 

Alan L Serve

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It is not.

We have very little home healthcare in our area. Our paramedics also received additional, college accredited education to handle these patients. We also provide "mobile-crisis response" to mental health patients either accessed via the state crisis hotline or through more traditional means.
Please elaborate in great detail. I am not above admitting I am wrong but the requirements are high when you are trying to convince me that an emergency-trained provider can offer equivalent services to an RN.
 

SpecialK

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Those are fantastic numbers! I hope our program sees similar results when it hits its stride. Better for the system and faster more appropriate care for the patient.

These numbers are for all Ambulance Officers generally, not specific to Sierra paramedics. The non-transport rate for Sierra is much higher given that target those calls with a high likelihood of non-transport. To do this, you really need options other than taking somebody to ED and it is not always easy to implement particularly in areas where there are no after-hours options other than ED.
 

FiremanMike

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Please elaborate in great detail. I am not above admitting I am wrong but the requirements are high when you are trying to convince me that an emergency-trained provider can offer equivalent services to an RN.

It doesn't take a nursing pathway to know that a heroin addict may want help getting into rehab, that a patient taking 3 BP meds may want to follow up with a single PCP to check for potentiation and adjust, or that an aging elderly who's having trouble getting around may like to have the phone numbers for mobility resources.

Our CP has 16 years on the truck, an associates in EMS, and went to 80 hours of classroom and 240 hours of clinicals that were guided by functional CP programs. He does all of the above case follow ups and then some and is currently activated solely on in house referrals from EMS runs.

A CP should be hand picked, as it takes a different temperament to do that job than is typically found in this line of work. I know the stories he tells me about his interactions, which he loves, would bore me quicker than watching paint dry..
 

Summit

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Our paramedics also received additional, college accredited education to handle these patients.
How many credit hours?

We also provide "mobile-crisis response" to mental health patients either accessed via the state crisis hotline or through more traditional means.
What kind and how much mental health crisis training do they receive?
 

Summit

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It doesn't take a nursing pathway to know that a heroin addict may want help getting into rehab, that a patient taking 3 BP meds may want to follow up with a single PCP to check for potentiation and adjust, or that an aging elderly who's having trouble getting around may like to have the phone numbers for mobility resources.

Our CP has 16 years on the truck, an associates in EMS, and went to 80 hours of classroom and 240 hours of clinicals that were guided by functional CP programs.
Some EMS experience and one 5 credit class + lab and we have an applied associates degree provider functioning as a MS prepared LCSW and BSN prepared CHRN?

Well, not quite I guess not quite if all they do is hand out phone numbers and set up doctors appointments... I mean... why do we need a Paramedic for that? Lets create Expanded Practice Home Health Aids and CNAs and save some money!
 

Bullets

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Isn't this the exclusive domain of nurses such as the VNA (Visiting Nurses Association) and home health nurses? Seems to me they have the actual training the education to provide such services.

It depends on what kind of service they are providing. We are starting to just do home visits in my town with our paid staff. We are a municipal BLS agency and we have developed a policy within our scope to help people who either access us regularly or we notice needs on initial visits.We do fall assessments, looking for tripping hazards and other clutter, review discharge instructions and make the appointments, order meds and pick them or or arrange delivery, assess vitals, ect. While its not a whole lot, we have found that just by visiting these people it has reduced their calls and sometimes a little personal contact is what people need
 

WolfmanHarris

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I think the key to success in Community Paramedicine is keeping programs geared towards short-term assess, treat and refer. The goal of even these more sub-acute programs should be providing appropriate interventions (medical or social) with an eye to quickly transitioning these patients to more appropriate care such as Nursing. Too much mission creep and we go from filling a clearly identified gap between what are patients call for and the care we can provide into duplication of services.
 

WolfmanHarris

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How many credit hours?

Couldn't find the course outline for the EPIC education, but here's a research overview for EPIC which touches briefly on the 6 week (F/T) course the ACP's used in the program were sent to.

http://www.emergencymedicine.utoronto.ca/research/ptmr/CS/EPIC.htm

This outline also highlights my main problem with some of the current Community Paramedicine research, I don't believe it necessarily addresses a need better or more efficiently than other health care providers or what utility Community Paramedicine is for the 911 patient population. It's early days and I'm happy to withhold judgment while the research is done.


What kind and how much mental health crisis training do they receive?

I'd be interested to know as well. Our current MH program involves the tiering of a Crisis Worker from a local agency the way we would FD or PD (dispatch criteria) who then respond in their POV. There are huge capacity and geography issues with this program and we've been looking at proposing some better solutions using Paramedic de-escalation and risk assessment with delayed referral to community crisis. I worked on this project briefly and we were considering developing a certificate program with local Colleges based on their existing programs. Not sure where that's at now since I left HQ but I believe they have a Psychiatrist on retainer now to consult.
 

FiremanMike

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Some EMS experience and one 5 credit class + lab and we have an applied associates degree provider functioning as a MS prepared LCSW and BSN prepared CHRN?

Well, not quite I guess not quite if all they do is hand out phone numbers and set up doctors appointments... I mean... why do we need a Paramedic for that? Lets create Expanded Practice Home Health Aids and CNAs and save some money!

Before I really spend a good deal of time dissecting and answering your "question", I'm really curious to know what level of exposure you have to CP programs in your area and your knowledge base on what they are designed to do.
 
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beaucait

beaucait

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The thing about the community paramedic program in my area is that instead of the patient looking for help (such as a nurse or home health care) they are referred by a family member who feels like the patient is at high risk, or someone in the EMS community that feels that they see this patient too often for non-emergency visits. That way we already have all of the information we need for the patient and it is within the ambulance service. We are a private ambulance service, so it can be taxing to have 3 units out of 7 out on calls that are non ambulatory calls due to people just wanting attention. We have about 96 patients, and two community paramedics.
 

Tigger

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Please elaborate in great detail. I am not above admitting I am wrong but the requirements are high when you are trying to convince me that an emergency-trained provider can offer equivalent services to an RN.
We are not providing equivalent services to an RN. Your words were "exclusive domain," and that is the untrue part. Our program does not seek to replace home health care, but rather help fill the limitations of home health care in our region.

Currently our biggest aspect is responding to mental health calls. The governor established Colorado Crisis Services, and our local Medicaid contractor provides mental health crisis response, to include mobile response and freestanding "psych ERs." They in turn subcontract to us to provide mobile response to our district, as we are rural there is very little in the way of existing mental health infrastructure. Our paramedics respond to crisis hotline activations, 911 calls for non-violent behavioral disturbances, and law enforcement requests. The paramedic responds alone in an SUV and along with the patient and their medical health professional (if one exists), determines a plan. Often times this is transport to the Crisis Stabilization Unit (pysch ER). A checklist was developed jointly between the CSU and our staff. This includes a significant medical assessment in which patient's receive a typical EMS assessment, BAC, saliva drug screen, and lab draw utilizing a CSU provided iStat. Provided the patient meets assessment criteria and are voluntary, they are transported by the single paramedic to the CSU or inpatient psych unit. Sometimes, in consultation with their own therapist, we are able to leave patients at home. And of course sometimes patients are still transported by ambulance to the ED, though are numbers of psych transports by ambulance have been reduced by over half. Patients are charged a base fee in the 100-140 dollar range plus mileage, which certainly beats an ambulance bill.

At no point was the VNA (which we don't even have here) or any other nursing entity providing or attempting to provide similar service. There was nothing but EMS transporting to the ED. Our paramedics received a week long mental health assessment program from one of our paramedics who is also a psychologist. They also receive a motivational interviewing program and spend 24 hours of clinical time at various psych facilities. Certainly this is not a tremendous amount of education. But look closely at what are people doing: resource navigation. There is no need for us to take the role of psych professional. Our goal is to be able to get patients the proper destination beyond the ED if possible. We developed a program and are making a significant cost savings for the patient, service, and system.

Our program also seeks to identify patients who burden the 911 system. Between the paramedics and medical director, patient specific care plans are developed to deal with chronically ill patients who use the 911 system to manage their chronic illness. In addition to communication and community resource education, our paramedics receive additional pharm education, fall prevention strategies, and workshops on various chronic conditions (CHF, DM, etc). But again, most of the job is centered around resource navigation. We set patients up with home health and/or hospice. We'll find them a doctor, a clinic for their disease, or even a skilled nursing facility. We'll talk to their physician and/or home health to come up with a plan that usually does not involve a transport to the ED. Most of our over-users can be divided by those that do not follow their discharge instructions and those that have no idea what resources are available. By partnering with other healthcare interests we can be the "boots in the house" that actually sit down with the patient and work on a plan.

And our local home health nurses love us. They have very limited staffing, and we can argument that, especially at night. Our people are not the ones writing the plans for these patients, and we do not intend to. We just want to help the patients stick to their care plans and keep them out of the hospital. Of note, we also work with hospice for after hours response. We're able to provide pain management until their staff arrives and determine if the patient should/needs to be transported to an ED for treatment that is not related to their "hospice condition."

Eventually we hope to directly partner with hospital networks to assist in their readmission prevention programs, though this will require more education and a willingness from the hospital to try something new. Currently neither of the hospital networks have any sort of local presence to provide in-home follow up care, so it would seem they have little to lose.

The one thing I cannot stress about our program is that we are primarily there to assist patients in navigating the healthcare system. The extra education helps ensure that we determine patients are properly eligible for certain resources, and to think that this is only a job for nurses makes little sense to us, especially considering their exceptionally limited local resources.

I hope I have elaborated in great detail for you.

I will happily post the program syllabus for you when/if I receive one from the community college whose website is just terrible. ETA: The program is about four months long when done on duty.
 
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luke_31

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I think Tigger hit the nail on the head with what a Community Care Paramedic should be. Too many people want to focus on skills or treatments, when it is all about connecting resources. Being that we are in the field and see the patient in their own environment, having the tools to know what resources are available can greatly impact the patient by helping them to get the resources they need. Some patients can't adequately express what they need or how their living situation is, but having a paramedic who was there to see first hand can help other medical providers with understanding of the individual patient situation, that might result in them ordering a different care plan then what they were originally going to order.
 

Tigger

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Some EMS experience and one 5 credit class + lab and we have an applied associates degree provider functioning as a MS prepared LCSW and BSN prepared CHRN?

Well, not quite I guess not quite if all they do is hand out phone numbers and set up doctors appointments... I mean... why do we need a Paramedic for that? Lets create Expanded Practice Home Health Aids and CNAs and save some money!
Because we are already there. Our fulltime paramedics all receive this training. That way the process can begin on the initial call.

Not to mention our mental health program falls under our CP/Mobile Integrated Health initiative, and that needs some paramedic level education. For our purposes.
 
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