Community Paramedicine Models for Referrals for Social Services

In addition to performing critical primary care functions, community paramedics often provide support to patients through care navigation and linkage to the social services sector. Because community paramedics are in the patient's home, they can ask questions or identify issues that are otherwise not visible to a provider in a clinic but which may have an impact on the patient's health and well-being. Community paramedics can be the “eyes and ears” of the healthcare system within a patient's home. In addition, for homebound or socially isolated people, community paramedics can be an important connection to the outside world.

Community paramedics can build relationships with other human and social services organizations in the community and develop detailed lists of contacts, referral options, and resources. Because of their deep understanding of the local social services landscape, community paramedics may be able to leverage their relationships with these organizations to help their clients secure services. They may also be able to provide support navigating eligibility requirements or applications for services, which can be particularly difficult for people with poor internet connectivity, low literacy skills, or limited English proficiency.

Depending on patient need and the availability of community services, community paramedics may be able to offer a variety of referrals to services, including:

Nutrition – Meals on Wheels, food pantries, Supplemental Nutrition Assistance Program (SNAP) applications
Phone/internet assistance
Substance use treatment or support groups
Medical or non-medical transportation
Older adult services – Area Agency on Aging, Alzheimer's support groups, senior centers
Legal services
Housing assistance
Healthcare coverage, such as applications for Medicaid

For more information about addressing social determinants of health in rural communities, please visit the Social Determinants of Health in Rural Communities Toolkit.

Examples of Referrals for Social Services from Rural Community Paramedicine Programs

Tri-County Health Care EMS in Wadena, Minnesota, provides home visits to patients at high risk of readmissions and works with clients who are frequent emergency medical service users. The program also receives referrals from providers who have identified patients needing additional support obtaining health resources. Every two weeks, program clients receive a visit from a multi-disciplinary team that includes a social worker, who is able to further tailor their care plan or make additional referrals as needed.
The Flagler County Fire Rescue Community Paramedicine Program works with Access Flagler First, a community coordinating entity, to develop and update detailed lists of available resources in their community. These directories can be used to provide referrals to clients with human or social services needs. Partnerships with these organizations are strengthened through regular, quarterly meetings to share experiences, update one another on new programs or resources, and case-conference about shared clients.

Considerations for Implementation

Compared to urban areas, rural communities have a limited human or social services sector, though need is still often present for supports that help people live healthier and more productive lives. Community paramedics can be important advocates for their clients to access limited resources, making strong relationships with human and social services organizations very beneficial.

If possible, EMS agencies should participate in or convene meetings of key local stakeholders. Case conferencing and regular partner meetings can be particularly useful for linking individual patients to needed resources and identifying gaps in care.

In rural areas, faith-based organizations are often important stakeholders and provide many social and community services. Community paramedicine programs can partner with other non-traditional organizations that may facilitate access to resources for their patients.

Program Clearinghouse Examples

Resources to Learn More

Patient Health and Wellbeing Questionnaire
Document
An initial intake form listing a variety of social services needs related to mental health, social isolation, substance use, and ability to accomplish activities of daily living. Patients can select areas for which they need assistance and community paramedics can use the form for developing a case management plan. Form can be modified to reflect available services in the target community.
Organization(s): Cranberry Township EMS (CTEMS)