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.
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, it has been estimated that a significant portion of ED visits for non-emergency medical issues could be addressed at a health clinic or other non-emergent setting, potentially saving over $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.
The book also notes that 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. Approximately 40% of all registered fire departments in the U.S.-provide EMS response. 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.
Government. Some local jurisdictions, like counties, have an EMS service that is separate from the fire department but still managed by government organizations.
Hospitals. EMS programs affiliated with a hospital account for the smallest portion of all EMS programs in the United States.
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 patients. 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 patients. 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.