Whereas traditional EMS largely focuses on the provision of emergency care and the stabilization and management of patients during transport, out-of-hospital care agencies have long been interested in alternative frameworks of providing care that could expand the role and increase the value of EMS systems to the community, to patients, and to the health care system.1,2 The EMS Agenda for the Future published in 1996 envisions EMS treatment to be a part “of a complete health care program,” with “finances … linked to value.”3 In 1997, Neely et al. articulated the multiple option decision point model which allows for an EMS call to be responded to with a variety of transportation options and to a variety of destinations.4 In recent years, these ideas have become embodied within the term community paramedicine (CP), also known as mobile integrated health care.
Define community paramedicine and mobile integrated health care.
Discuss integration with the health care network.
Discuss medical direction considerations.
Describe examples of existing programs.
While the precise definitions of these two terms are not entirely agreed upon, we will use the terms interchangeably to describe a model of care in which the roles of EMTs, paramedics, and EMS systems are expanded to allow for greater flexibility and patient centeredness in emergencies, better clinical integration with hospital and health care systems, or for the prevention of emergencies before they begin. Any individual EMS agency might serve in a variety of different expanded roles depending on the needs of their community. We categorize these roles into three areas:
Patient-centered emergency response: Making 9-1-1 more flexible and adaptable to meet the needs of the patient including transporting to alternate destinations (primary care office, dialysis centers, urgent care centers, etc) and “treat and release” protocols.
Integration with coordinated health care systems: Extending a hospital’s or health system’s care model into the community through proactive out-of-hospital care programs and improved clinical coordination of care, including innovations in telemedicine. Adding value to routine patient interactions during non-9-1-1, interfacility, and discharge-associated ambulance transports.
Integration with the community and public health: Integrating out- of-hospital care systems into the public health infrastructure of a community. Vaccination programs, personal preparedness training, fall risk reduction are just a few of the ways that EMS can serve as the foot soldiers of the public health system.
Early community paramedicine programs were largely based in rural settings to help fill the gaps created by a scarcity of primary care and other health care resources. The state of Alaska has been implementing community paramedicine, with trained professionals called community health aides/ practitioners (CHA/Ps), since the 1950s in order to meet the health needs of those living in remote villages. In the mid-1990s, paramedics in New Mexico participated in the Red-River project in which they were trained to provide a range of primary care skills. The program successfully reduced emergency call volume but was discontinued due to concerns over inadequate supervision. Unlike modern CP initiatives in the United States, these programs both involved a change in the scope of practice.5
CP programs have also been successfully implemented in Canada, Australia, and the United Kingdom in a variety of different models. Canada has a range of pilot programs ongoing including emergency response models with the option to transport to non-ED destinations, programs like the Community Referrals by EMS (CREMS) program in Toronto where EMS has an enhanced ability to connect patients to social services, and programs like the one in Nova Scotia where EMS providers bridge the gap with primary care by offering more complex care. In the United Kingdom, the most well-known program is a specialized emergency care practitioner (ECP) model with certain advanced skills which are utilized in both urban and rural settings with the goal of treatment of minor conditions in the field.5 A study of Australian programs identified three service delivery models: the primary health care model, the substitution model, and the community coordination model.6
