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C o mmu n i t y Param edi ci n ei n C an adaCommu n it y Paramedi ci nein C an adaEm erg en cy m e d i cal s e r v i c e s c h i e f s o f can ada“EMS must pursue innovation and new models of service delivery to meet the community-defined needs.Collaboration of EMS and community organizations, social service agencies, and public safety groupswill enable innovative initiatives that have the potential to improve the level of health care within acommunity.”– EMSCC White PaperACKNOWLEDGEMENTSThis paper has been prepared with the invaluable input from Paramedic Services across Canada that are leadingthe way in developing innovative programs that have created the foundations of Community Paramedicine.We would like to thank the paramedics who have embraced the concept of Community Paramedicineand continue to provide excellence in care to their respective communities.From the Authors:Michael NolanPresident, Emergency Medical Services Chiefs of CanadaChief, County of Renfrew Paramedic ServiceOntarioTim HillierContributing Editor, EMSCCDirector of Professional Development,MD Ambulance, SaskatoonSaskatchewanCarmen D’AngeloWriter and Research Coordinator, EMSCCCommander, Hamilton Paramedic ServiceOntarioP A R A M É D E C I N E C O M M U N A UT A I R E A U C A N A D A57

CONTENTSIntroduction58Executive Summary59What is Community Paramedicine?59The Positive Outcomes of Community Paramedicine60Examples of Community Paramedicine in Canada and Internationally62The Cost Savings Achieved66Recommendations to the Standing Committee on Health67References68INTRODUCTIONIn the Emergency Medical Services Chiefs of Canada (EMSCC)White Paper entitled The Future of EMS in Canada, a Vision wasdeveloped that embraced EMS as a mobile health care service.Overall, as illustrated (right), the future of EMS in Canada is atthe centre of the community, providing primary health care in amobile setting.To achieve this Vision, the White Paper included elevenrecommendations that would strategically guide the leaders ofEMS and associated public policy. One of the recommendationswas that, “EMS must pursue innovation and new models of servicedelivery to meet the community-defined needs. Collaborationof EMS and community organizations, social service agencies,and public safety groups will enable innovative initiatives thathave the potential to improve the level of health care within acommunity.”This recommendation has been adopted by several ParamedicServices across Canada via programming entitled CommunityParamedicine. These initial programs, in association with theconcept of Community Paramedicine, were presented to theFederal Standing Committee on Health in 2011.The purpose of this document is to present the reader with anunderstanding of Community Paramedicine and create a basisfor the development of a national strategy.58C omm u ni t y P aramedicine in C anada

C o mmu n i t y Param edi ci n ei n C an adaEXECUTIVE SUMMARYEmergency Medical Services Chiefs of Canada (EMSCC)is working collaboratively with their international partnerson Community Paramedicine. The work is organized viathe International Roundtable on Community Paramedicine(IRCP) and thereby allows a dedicated forum wherevarious countries and regions can exchange informationand innovative programming. The goal of the IRCP is tofocus on exploring the promotion and delivery of improvedhealth care through the utilization of “traditional” and “nontraditional” models of care.(2)On November 28, 2011 the EMSCC President MichaelNolan presented “The Role of the Community Paramedic inCanadian Health Care” to the Federal Standing Committeeon Health relative to the management of chronic diseasesand ageing in Canada. As a primary provider of front-linehealth care, the EMSCC has identified two fundamentalproblems in the current health care system:(1) accessibility to primary health carea. in remote and rural Canada, andb. with seniors and marginalized members of thecommunity in urban centres; and(2) rising cost of institutional primary health care.It is the position of the EMSCC that CommunityParamedicine, in partnership with other community servicesand agencies, can improve the accessibility to health care andthe quality of life of Canadians. It has also been demonstratedvia existing programs that Community Paramedicine is a costeffective chronic disease management strategy for remote,rural and urban Canadian centres.WHAT IS COMMUNITY PARAMEDICINE?Traditionally, paramedics are educated to respond toemergency 911 calls, treat patients who are ill and injured, andtransport the patients to emergency departments for additionalacute care treatment. However, not all patients require transportto an emergency department. Many simply need basicassessment and referral to an appropriate community service.This is particularly evident with seniors, residents in rural andremote areas, and vulnerable members of the community.Representing just 14% of the current population, seniors use40% of hospital services in Canada and account for about 45%of all provincial and territorial government health spending. Asreported by the Canadian Institute for Health Information, onein four Canadians will be over the age of 65 representing 25%of the population by 2036, thereby placing further pressures onhealth care costs.(3)In Canada, 60% of Paramedic responses are for patients overthe age of 60. Upon further analysis, the EMSCC has identifiedthat patients over the age of 80 represent in excess of 27% of allrequests for assistance through 911. In a direct correlation, withan ageing population, the paramedic response call volume toseniors requesting health care assistance is increasing.In an effort to maximize efficiencies in patient care andresources, many paramedic services are finding innovativeprograms and best practices to address the non-emergentprimary care needs of seniors and other vulnerable membersof their respective communities. One such innovative programis Community Paramedicine; where paramedics are engaged innon-traditional roles to assist in the health care of the population.According to the International Roundtable, CommunityParamedicine is a model of care whereby paramedics applytheir training and skills in “non-traditional” community-basedenvironments, often outside the usual emergency responseand transportation model. The community paramedic practiceswithin an “expanded scope”, which includes the applicationof specialized skills and protocols beyond the base paramedictraining. With this expanded scope, the paramedic can belocated in communities where there is a shortage of other healthcare providers (such as in remote and rural areas of Canada). Thecommunity paramedic can also be viewed as the “canary in thecoal mine”, where the paramedics often find members of theP A R A M É D E C I N E C O M M U N A UT A I R E A U C A N A D A59

urban community who cannot access - or are unaware how toaccess - both health care and social services.By expanding the role of paramedics, and workingcollaboratively with other community agencies, paramedicscan manage patients who do not require transportation to anemergency department. Via an expanded paramedic scope ofpractice, paramedics can manage and subsequently refer thepatient to the most appropriate community agency (such as thepatient’s family doctor, community care access centre, familyhealth team, home care, public health, mental health, addictionservices, and/or domestic violence services). At times, it may onlyrequire the Paramedic assisting the patient to contact a familymember or friend to attend their home to provide basic supportor monitoring. By referring the patient to the most appropriatecommunity agency or family/friend, there will be a significantreduction in visits to emergency departments, hospitalizations,re-admissions. The referral also defers the need for the need forplacement in a long-term care facility.Research FocusPERIL Study - Paramedics assessing Elders at Risk forIndependence Loss (Sunnybrook Research Institute)BackgroundWhile the majority of the elderly are independent, frail olderpeople are a sub-group at increased risk for preventable eventssuch as falls, delirium or functional decline: 20% of people over65 and 44% of those over 85 lack the support they need tofunction daily. A minor change can trigger a chain of eventsleading to adverse outcomes. For example, being trapped onthe floor after a fall, developing skin breakdown and becomingdelirious may ultimately require admission to a nursing home.Interventions that prevent adverse outcomes exist, but they areeffective only when they are appropriately targeted to highrisk groups. Older adults are the highest users of ambulanceor emergency medical services (EMS), and are five times morelikely than younger adults to need an ambulance. Because oftheir social isolation and lack of support and timely access toprimary care, frail older people frequently depend on EMS tofunction as a safety net and the proportion of non-urgent callsparadoxically increases with age. Consequently, paramedics areuniquely positioned to observe older persons in their homesand identify those at risk for adverse outcomes.THE POSITIVE OUTCOMES OF COMMUNITY PARAMEDICINEDue to advancements in technology, training delivery, andevidence based research – the scope of paramedic clinicalpractice can be easily increased to meet the community needs.Paramedics are already educated in advanced patient careassessments and skills, including: 12-Lead ECG acquisitionand interpretation, blood glucose testing, obtaining oxygensaturation levels, wound care, intravenous therapy andmedication administration. This can be complimented withphlebotomy, expanded drug administration, antibiotic therapy,and delivery of vaccinations. An expanded scope of practicein paramedics leads to the ability to initiate a CommunityParamedicine program.Community Paramedicine will assist in alleviating the increasingpressure on our health care system. Overall, as evident with manyinnovative programs across Canada and globally, CommunityParamedicine will achieve significant savings in health care by:Reducing the volume of 911 callsBy entering designated communities - such as in Saskatoonwith the innovative Health Bus - patients can access medicaladvice and care rather than calling 911 for assistance. Thiswill directly reduce the 911 call volume, take pressure ofthe 911 system, and allow 911 call takers to manage otherpriority emergency calls. A reduction in emergency calls also reduces the need ofTiered Responses by allied emergency services (police, fireand EMS). This decrease in tiered response allows alliedemergency services to focus on other priority calls, and,increases community safety by reducing emergency vehiclesneedlessly traveling rapidly through neighbourhoods withlights and sirens. Reducing emergency department visitsWith paramedics referring patients to appropriate communityagencies, there is a decrease in need of transporting thesepatients to local emergency departments. Reducing emergency department visits will lessen theburden of overwhelmed hospitals and the associated waittimes for patients to see an emergency physician. Reducing the visits to emergency departments will also assistin decreasing ambulance off-load delays (where patients ObjectiveThe goal of the current study is to complete the empiricderivation of the PERIL clinical prediction tool, using paramedic’sobservations in the homes of older people to identify those athigh risk for adverse outcomes after an EMS encounter.60C omm u ni t y P aramedicine in C anada

C o mmu n i t y Param edi ci n ei n C an ada cannot be transferred from paramedics to emergencydepartment staff because there are no emergency bedsavailable). During off-load delays, paramedics are confinedwith their patients at the hospital waiting for an emergencybed, rather than be available for other 911 emergency callsin the community. This “off-load delay” problem has beennegatively affecting EMS system performance globally.An example of this positive outcome is evident in NovaScotia, on Long and Brier islands. With this communityparamedicine program, trips to the mainland hospitalemergency department fell by 40% over a five year period.Reducing hospitalizationsBy the early detection of medical problems with seniorsand other vulnerable members of the community, medicalconditions can be prevented from advancing into furthercomplex cases and/or emergencies. With early detection,and associated health promotion, the wellness of acommunity’s population is increased. With the reduction in hospitalization via early detectionand health promotion, there is an improvement in hospitalcapacity and alternate level of care availability. The “Ageing at Home” initiative, involving the County ofRenfrew Paramedic Service and their community partners,is an example of a Community Paramedicine program thathas reduced hospitalizations. In a 16-month period, of thepatients assessed by Paramedic and Personal SupportWorkers, only 34% required transportation to an emergencydepartment and subsequent admission to hospital.Technology Focus Reducing the demand on long-term care bedsBy providing seniors with the ability to stay at home longer– supported by family, friends, home care, EMS and othercommunity agencies – there will a decrease in demand onlong-term care (LTC) beds. From reducing the demand on LTC beds, there is associatedreduction in seniors held idle at hospitals due to the lack of Many paramedic services have implemented theinfrastructure to capture and distribute healthinformation via electronic reporting. This e-Healthinformation can then be shared with other healthcareand social organizations in the continuum of patientcare.Significant advancements have been made in mobilediagnostic equipment (such as cardiac monitoring,ultrasound, oximeters, and glucometers) therebyenabling paramedics to conduct mobile clinicalassessments.Advancements in c