Expansion of community paramedicine one step in meeting the needs of struggling health-care systems

About one-fifth of Canada’s population is 65 years or older. More than one-third of them have at least two of the 10 most common chronic diseases, a number that increases to almost half of individuals 85 and older. Meanwhile, many Canadians do not have a regular primary health-care provider (e.g., family doctor or nurse practitioner) and emergency departments (EDs) are pressed to provide timely access to care.

Community paramedicine, in which paramedics play a more active role in treating patients without transferring them to hospital, is a widely accepted solution that has been successfully implemented across the country.

In the traditional emergency-based response model of paramedicine, the goal is to stabilize patients and transfer them to an acute-care facility. However, there is a disconnect in how this model was designed and the current state of health care. Canadians have one of the highest rates of ED visits among OECD (Organization for Economic Co-operation and Development) countries. Patients turn to emergency services because they cannot get care elsewhere (e.g., inadequate access to primary care, medical imaging and urgent care options in the community). Research shows that 41 per cent of Canadians reported visiting an ED for a condition that could have been treated in a doctor’s office or clinic.

“People have changed how they use paramedic and emergency services over the past few decades,” says Amir Allana, a paramedic with experience working in Ontario and British Columbia, and a fellow with the McNally Project for paramedicine research.

“Really, it’s because people have a need, and that need is not being met by the health system. And when we see it that way, the question becomes do we try to ask the public to use services in a way that the services were designed, or do we adapt those services to the public’s need?”

Paramedics, trained in managing emergent and critical cases such as cardiac arrests, strokes and major traumas, are uniquely positioned to fill gaps in care for those with chronic health conditions through an expansion in their role.

“A lot of the patients that we’re seeing in our normal caseload, even through 911, are patients that require different kinds of care,” says Melissa Vose, an advanced care paramedic working in British Columbia. “It’s starting to become a lot more apparent where paramedicine can make impacts in the health-care system, and a lot of that includes programs throughout the country that are termed community paramedicine.”

Community paramedicine emphasizes a more proactive and preventative approach to care to reduce the number of calls to 911 and transportation to an ED. These non-traditional roles may include scheduled home visits to assess, monitor and support patients with chronic health conditions.

“Care models have historically been based on emergency medicine, which really focuses on what [paramedics] can intervene in right now, (instead of) zooming out and saying, what is the social and health context that an individual is living in,” says Allana.

Community paramedicine programs across Canada have shown that they can improve health outcomes and reduce the use of emergency services.

A model consisting of nurse practitioners, paramedics and physicians piloted in Nova Scotia in 2009 delivered services in two isolated communities with approximately 1,240 residents, 50 of whom were 65 or older. The program resulted in a 40 per cent decrease in ED visits, 28 per cent fewer general practitioner visits and a significant decrease in medication prescription among adults over 40 with at least one chronic disease. The pilot’s success led to the program being officially launched in 2018 and expanding to other areas in the province.

It’s because people have a need, and that need is not being met by the health system.

That same year, British Columbia Emergency Health Services completed the implementation of a community paramedicine program with 104 paramedics providing primary care services in remote and rural communities. The program serviced almost 1,600 patients and conducted more than 19,600 home visits over a three-year period. The target population was individuals aged 65 or older with heart failure, chronic obstructive pulmonary disease, diabetes or at risk for falls. Patients reported an improved ability to navigate the health-care system and increased confidence in self-management, resulting in 52 per cent of patients improving or maintaining their health. Since then, the program has expanded to include community paramedicine positions in 100 communities across the province.

Broadening paramedics’ ability to assess and treat patients at home has shown potential in palliative care. Healthcare Excellence Canada and the Canadian Partnership Against Cancer have teamed up to spread and scale an innovative model to better support patients receiving palliative care. In this model, paramedics work with the patient’s health-care team to ensure that emergency care services match the patient’s overall care plan. When paramedics respond to patients who have a complaint related to a palliative diagnosis, including worsening pain, delirium and breathing problems, they can provide symptom management without transport to hospital, often working with an on-call physician or other members of the patient’s care team.

“So, historically, if you called 911, and paramedics arrived, we would take you to hospital,” says Cheryl Cameron, a paramedic working in Alberta and the director of operations with Canada Virtual Hospice. “That approach really doesn’t jive with patients (whose) whole care plan is really organized around staying at home.”

While the final evaluation has not been completed, preliminary results show improvements in symptom control and quality of life at home, fewer ED visits and high satisfaction among families.

“It’s a piece that I think pushed the profession because it has broken down some of those legislative barriers in some jurisdictions about allowing paramedics to treat patients in the community and then leave them at home, and to not transport patients to acute care centres,” says Cameron.

These programs demonstrate that community paramedicine can be tailored to the type of community (e.g., rural or urban) and provide a range of services. In fact, even in cases in which patients were transported to EDs, the majority of cases (60 per cent) were non-emergent, meaning that no immediate life-sustaining interventions were required at the time of triage.

“Generally speaking, [community paramedicine] has paramedics doing things that are not purely trauma and acute emergencies,” says Allana. “But I would argue that that’s 95 per cent of the job anyway.”

Further, community paramedicine is popular among Canadians. An online poll conducted in 2023 by Abacus Data of 3,150 participants showed that 83 per cent of Canadians support the idea of community paramedicine.

However, significant barriers to the broader implementation of community paramedicine models of care still exist.

First, the adoption of these programs requires securing permanent funding to ensure their sustainability.

Second, these programs typically require paramedics with additional training; given the diverse scope of community paramedicine, the type of education and competencies required may be unique to each program. Third, programs need to build complex, integrated clinical pathways and communication networks between community paramedics, primary care clinics and EDs. However, there is a lack of standardization for the implementation of governance structures and medical oversight.

Approaches to overcome these barriers include having strong community and stakeholder engagement, robust interprofessional relationships, and effective recruitment and retention strategies. Community engagement is critical to the development and advocacy for these programs, and to tailor these programs to the specific unmet needs of a region.

Additionally, implementers need to communicate and demonstrate the benefits of community paramedics within the system and clarify the roles among different professions involved in these programs to avoid interprofessional conflicts and inefficiencies. Flexible work environments that allow paramedics to rotate between community and emergency roles are needed.

Finally, legal and operational frameworks that were designed for the traditional emergency-based response model likely require modifications to enable these changes while ensuring appropriate safety standards are maintained.

Vaidhehi Veena Sanmugananthan, Science Writer for the Raw Talk Podcast, and Atefeh Mohammadi, Co-Executive Producer at Raw Talk Podcast, contributed to this article.

To learn more, we invite you to check out Raw Talk Podcast episode #115 “The Future of Paramedicine” to hear from our guests Melissa Vose, Cheryl Cameron and Amir Allana. Also, do check out the links embedded in this article, as well as some interesting resources the teams have compiled in the episode show notes, wherever you get your podcasts.