Defining Community Paramedicine

According to the Association of State and Territorial Health Officials (ASTHO), in most traditional models, the primary responsibility of emergency medical services (EMS) providers is to stabilize patients in crisis and then transport them to emergency healthcare services for treatment. Community paramedicine is an emerging model that enhances the role of EMS providers so they are partners in public health and community healthcare delivery.

There are two primary types of EMS employees: paramedics and emergency medical technicians (EMTs). Traditionally, paramedics and EMTs respond to emergency situations, conduct lifesaving measures, and transfer patients to healthcare settings for more advanced care. Paramedics are trained to a higher level and have a larger scope of practice than EMTs. The level of training for each role varies state by state.

Community paramedicine programs build on the existing skills and community relationships of paramedics and EMTs and provide additional skills to work in the community, such as motivational interviewing. A community paramedic may perform health screenings, home inspections, suturing, and other services while in the field or in the client's home. In their role, community paramedics address one or both of two main goals:

• Increasing access to primary care
• Reducing use of emergency care resources

These programs can align with a broader, system-wide expansion toward mobile integrated healthcare, a model of care in which healthcare professionals work in an expanded capacity outside of the clinical setting.

The National Association of Emergency Medical Technicians (NAEMT) reported in 2018 that over 200 community paramedicine programs operate in the United States, and many of them are located in rural areas. Some community paramedicine programs are focused on providing or connecting patients with primary care services.

The Centers for Disease Control and Prevention (CDC) explain that an individual may call 911 for help when it is not a medical emergency for reasons like a lack of access to other healthcare services or transportation. However, these calls can strain limited EMS resources and fill the emergency department (ED) with patients who could be better served by a different level of care. Nationally, an estimated 14%-27% of ED visits, according to a 2010 RAND Corporation report, are for non-emergency medical issues that could be addressed at a health clinic, saving $4.4 billion per year in healthcare costs.

In many cases, insurers will only provide reimbursement for emergency care and services to the EMS provider when a patient has been transported to a hospital. As a result, people who do not need to visit the hospital for higher-level or more comprehensive care — and could be treated effectively by paramedics at their current location — may be transported to the ED unnecessarily so the cost of their treatment is billable to insurance. This adds both burden to the healthcare system and stress for patients and their families.

Emergency Medical Services in Communities

EMS providers are front-line healthcare workers who are the first responders when emergency medical care is needed. Emergency Medical Services: At the Crossroads, a book from the National Academies of Sciences, Engineering, and Medicine, explains how the EMS system developed quickly in the U.S. in the 1960s and 1970s following research into clinical advances like cardiopulmonary resuscitation (CPR). This research provided proof of the life-saving potential of rapid response medical care, which stabilizes patients long enough to transport them to a location like a hospital with more sophisticated or comprehensive resources.

In the 1980s, federal funding for EMS programs declined, and local jurisdictions needed to develop their own systems for providing emergency medical care. As a result, there are several types of EMS agencies that provide services in different parts of the country.

Fire departments. EMS programs are most often affiliated with a fire department. Fire department-based EMS programs accounted for 40% of all EMS programs in the U.S. in 2011. This affiliation is common in rural areas because having a standalone EMS program may be too costly to maintain.

Standalone or third-party EMS. Some EMS programs are privately organized and not associated with a hospital. They may be run as nonprofit or for-profit entities. These programs accounted for 25% of all EMS services in the U.S. in 2011.

Government. Some local jurisdictions, like counties, have an EMS service that is separate from the fire department but still managed by government organizations. These agencies represented 21% of U.S. EMS services, with tribal EMS representing an additional 1% in 2011.

Hospitals. EMS programs affiliated with a hospital accounted for 6% of all EMS programs in the U.S. in 2011.

Rural areas rely heavily on a volunteer workforce. In a 2013 survey from the National Highway Traffic Safety Administration, which represents the best available national data, 43.8% of calls to rural EMS systems were managed by volunteers.

Types of Community Paramedicine Services

Community paramedics can receive training and provide a variety of different services depending on community needs and gaps in existing services.

Generally, a community paramedicine encounter will involve the community paramedic driving to a patient's home in a fleet vehicle, not an ambulance, dressed in their EMS uniform. Their activities while in the home may vary based on the patient's needs and health status. Programs typically have a set of protocols to navigate the health issues they are targeting in their patient population. After initial contact with the patient, community paramedics may continue to conduct in-home visits or may check in by phone or telehealth visit, depending on the program's protocols.

California's Office of Statewide Health Planning and Development piloted different community paramedicine programs through the California Emergency Medical Services Authority (EMSA) that demonstrate how these services could be offered to different patient populations. The populations and services provided in these pilots included:

Post-discharge. Community paramedics visited patients with chronic conditions who were recently discharged from a hospital. These visits can provide an opportunity to introduce patients to techniques to manage their health conditions and reduce hospital readmission.

Frequent emergency medical services users. Individuals who frequently call 911 or use emergency services for non-emergent issues were provided case management to connect them with more appropriate services including primary care, behavioral health, housing, and social services.

Directly observed TB therapy. In an attempt to prevent the spread of tuberculosis (TB), patients with TB were given directly observed therapy (DOT) by community paramedics and local public health officials who provided patients with medication and monitored the patients to ensure they took their medication properly.

Hospice. Community paramedics provided services to hospice patients in their homes to decrease their need to call emergency services and avoid difficult or unwanted hospital stays.

Alternate destination – mental health. Community paramedics identified and evaluated patients who needed mental health services rather than emergency medical care and transported them directly to a mental health crisis center rather than to the hospital emergency room.

Alternate destination – sobering center. Community paramedics transported 911 callers with acute alcohol intoxication who did not need emergency medical or mental health services to a sobering center.

More information about different types of community paramedicine programs implemented in rural communities can be found in Module 2.

Mobile Integrated Healthcare

Mobile integrated healthcare (MIH) is a term that is often used to describe community paramedicine programs but also refers more broadly to the practice of providing patient-centered healthcare services outside of the hospital or traditional clinical environment. NAEMT explains that a variety of organizations and providers can participate in MIH and are administratively or clinically linked with local EMS services, while community paramedicine is a service provided by EMS agencies that are administratively and clinically linked with the broader healthcare system. This relationship can allow MIH providers to offer services like chronic disease management, referrals to other care providers, and telephone advice instead of immediate dispatch of EMS services to 911 callers. Some agencies may also prefer to use the term “mobile integrated healthcare” to describe their program, particularly if their providers have not been required to complete advanced community paramedic training.

Resources to Learn More

Community Paramedic Toolkit
Document
Provides guidance for healthcare organizations developing or expanding a community paramedic program in Minnesota. Includes information on education and training, program planning, models of care, hiring, financing, quality measurement, and evaluation.
Organization(s): Minnesota Department of Health
Date: 12/2016

Community Paramedicine in California
Website
Provides information on a series of community paramedicine pilot programs conducted in California. Includes information about implementation and evaluation of the pilots, along with a report on the impact of the pilots on the state budget.
Organization(s): California Health Care Foundation

Handbook on Mobile Integrated Healthcare
Document
Provides information and resources for fire department chiefs wanting to develop a mobile integrated healthcare (MIH) program in their department. Includes information about the organizational benefits, reimbursement mechanisms, working with policymakers, and financial sustainability. Offers considerations for volunteer departments relating to the implementation of an MIH program.
Organization(s): International Association of Fire Chiefs Date: 6/2017

Mobile Integrated Healthcare and Community Paramedicine (MIH-CP): A National Survey
Document
Reports the results of a 2014 survey on the development, characteristics, and status of mobile integrated healthcare and community paramedicine (MIH-CP) programs operating in the U.S. Includes information about clinical services, funding and payment mechanisms, evaluation and quality measures, and lessons learned.
Author(s): Zavadsky, M., Hagen, T., Hinchey, P., McGinnis, K., Bourn, S., & Myers, B.
Organization(s): National Association of Emergency Medical Technicians (NAEMT)
Date: 2015

Mobile Integrated Healthcare/Community Paramedicine (MIH/CP) Primer
Document
An introduction to the mobile integrated healthcare and community paramedicine (MIH-CP) models of coordinated, community-based care for people working in emergency medicine. Includes the history, organizational variability, state regulations, medical direction authority, scope of practice issues, specialized training, and financing or reimbursement considerations related to the MIH-CP program of care.
Organization(s): American College of Emergency Physicians, Mobile Integrated Healthcare/Community Paramedicine Task Force
Date: 6/2016

Vision Statement on Mobile Integrated Healthcare (MIH) & Community Paramedicine (CP)
Document
Outlines how emergency medical services (EMS) agencies can convert to a mobile integrated healthcare (MIH) system. Includes a list of key components useful for the development of MIH programs and services.
Organization(s): American College of Emergency Physicians