Rationale and methods of an Evaluation of the Effectiveness of the Community Paramedicine at Home (CP@home) program for frequent users of emergency medical services in multiple Ontario regions: a study protocol for a randomized controlled trial

Effectiveness of the community paramedicine at home (CP@home) program for frequent users of emergency medical services in Ontario: a randomized controlled trial

OBJECTIVE

To evaluate the impact of the Community Paramedicine at Home (CP@home) program, a community paramedicine home-visit intervention, on reducing emergency medical services (EMS) calls among frequent users.

DESIGN

A 6-month, open-label, pragmatic, randomized controlled trial with parallel intervention and control arms. An online automated platform (randomizer.org) was used to randomly allocate participants using a 1:1 allocation sequence.

SETTING

In homes of frequent EMS users in four paramedic services and regions across Ontario, Canada.

PARTICIPANTS

Eligible participants were frequent callers (≥ 3 EMS calls within six months and ≥ 1 EMS call within the previous month), or had ≥ 1 lift assist call within the previous month, or were referred by paramedics.

INTERVENTION

Community paramedics conducted risk assessments, provided health education, referred appropriate resources, and reported to family physicians for up to three home visits. The control arm received usual care.

PRIMARY OUTCOME MEASURE

EMS calls in 6 months during intervention.

RESULTS

Two thousand two hundred eighty four eligible participants were randomly allocated to the intervention and control groups, with 265 participants lost to follow-up due to inability to retrieve participant records from EMS databases. There were 1025 intervention participants (52.7% female, mean age 69.65 years [standard deviation (SD) = 19.98]) and 994 control participants (52.0% female, mean age 69.78 years [SD = 19.09]). In the post-intervention intention-to-treat analysis (zero-inflated negative binomial regression), the EMS call rate was not significantly lower in the intervention group compared to the control group (incidence rate ratio [IRR] = 0.88, 95% confidence interval [CI]: 0.76, 1.01). In the subgroup analysis, the intervention had a significant effect in the lift assist caller subgroup (IRR = 0.73, 95% CI: 0.58, 0.92), but no significant effect among the frequent caller subgroup (IRR = 0.97, 95% CI: 0.82, 1.14). The sensitivity analyses found a similar association for the lift assist caller subgroup. There was a significant subgroup effect (p-value for interaction < 0.01).

CONCLUSIONS

CP@home had a significant impact on reducing EMS calls for those with a lift assist call but not for the overall sample. This program filled a healthcare gap by shifting primary care delivery, which could reduce the disproportionate number of EMS calls, thus reducing healthcare costs.

TRIAL REGISTRATION

Registered with ClinicalTrials.gov NCT02835989 on July 14, 2016.

Community Paramedicine Program in Social Housing and Health Service Utilization: A Cluster Randomized Clinical Trial

Importance

Community Paramedicine at Clinic (CP@clinic) is a chronic disease prevention program that decreases 911 calls for emergency medical services, but its wider system effects are unknown.

Objective

To evaluate the effects of CP@clinic vs usual care on individual-level health service utilization outcomes.

Design, Setting, and Participants

This open-label, pragmatic cluster randomized clinical trial evaluated all residents 55 years or older in 30 social housing buildings in Ontario, Canada, that had (1) a unique postal code, (2) at least 50 apartments, (3) 60% or more residents 55 years or older, and (4) a similar building for pairing (15 intervention and 15 control buildings, pair-matched randomization). The 12-month intervention had a staggered start date from January 1, 2015, to December 1, 2015, and ended between December 31, 2015, and November 30, 2016. Administrative health data analysis was conducted in May 2022.

Intervention

CP@clinic was a health promotion and disease prevention program led by specially trained community paramedics who held weekly drop-in sessions in social housing buildings. These paramedics conducted 1-on-1 risk assessments, provided health education and referrals to relevant community resources, and, with consent, sent assessments to family physicians. Control buildings received usual care (universal health care, including free primary and specialty medical care).

Main Outcome and Measures

Individual-level health service utilization was measured from administrative health data, with ED visits via ambulance as the primary outcome; secondary outcomes included ED visits for any reason, primary care visits, hospitalizations, length of hospital stay, laboratory tests, receipt of home care, transfer to long-term care, and medication initiation. Generalized estimating equations were used to estimate intervention effects on individual-level health service utilization, accounting for trial design and individual-level baselines.

Results

The 30 social housing buildings had 3695 residents (1846 control and 1849 intervention participants; mean [SD] age, 72.8 [9.1] years; 2400 [65.0%] female). Intention-to-treat analysis found no significant difference in ED visits by ambulance (445 of 1849 [24.1%] vs 463 of 1846 [25.1%]; adjusted odds ratio [AOR], 0.97; 95% CI, 0.89-1.05) but found higher antihypertensive medication initiation (74 of 500 [14.8%] vs 47 of 552 [8.5%]; AOR, 1.74; 95% CI, 1.19-2.53) and lower anticoagulant initiation (48 of 1481 [3.2%] vs 69 of 1442 [4.8%]; AOR, 0.68; 95% CI, 0.53-0.86) in the intervention arm vs the control arm. CP@clinic attendance was associated with higher incidence of primary care visits (adjusted incidence rate ratio, 1.10; 95% CI, 1.03-1.17), higher odds of receiving home care (AOR, 1.07; 95% CI, 1.01-1.13), and lower odds of long-term care transfers (AOR, 0.32; 95% CI, 0.13-0.81).

Conclusions and Relevance

In this cluster randomized clinical trial of CP@clinic, the intervention did not affect the rate of ED visits by ambulance; however, there were increased primary care visits and connections to home care services, which may have increased antihypertensive medication initiation and reduced long-term care transfers from social housing. Health policymakers should consider CP@clinic's impact as an upstream approach to improve care for older adults with low income.

Trial Registration

ClinicalTrials.gov Identifier: NCT02152891.

Physician perspectives of the community paramedicine at clinic (CP@clinic) and my care plan app (myCP app) for older adults

BACKGROUND

Community Paramedicine (CP) is an emerging model of care addressing health problems through non-emergency services. Little evidence exists examining the integration of an app for improved patient, CP, and family physician (FP) communication. This study investigated FP perspectives on the impact of the Community Paramedicine at Clinic (CP@clinic) program on providing patient care and the feasibility and value of a novel "My Care Plan App" (myCP app).

METHODS

This retrospective mixed-methods study included an online survey and phone interviews to elucidate FPs ' perspectives on the CP@clinic program and the myCP app, respectively, between January 2021 and May 2021. FPs with patients in the CP@clinic program were recruited to participate. Survey responses were summarized using descriptive statistics, and audio recordings from the interviews thematically analyzed.

RESULTS

Thirty-eight FPs completed the survey and 10 FPs completed the phone interviews. 60.5% and 52.6% of FPs reported that the CP@clinic program improved their ability to further screen and diagnose patients for hypertension, respectively (in addition to their regular screening practices). The themes that emerged in the phone interviews were grouped into three topics: app benefits, drawbacks, and integration within practice. Overall, FPs described the myCP app as user-friendly and useful to improve interprofessional communication with CPs.

CONCLUSIONS

CP@clinic helped family physicians to screen and monitor chronic disease. The myCP app can impact health service delivery by closing the gap between primary, community, and emergency care through an eHealth information-sharing platform.

The role of community paramedicine in fall prevention: A SWOT analysis

BACKGROUND

Millions of older US adults fall annually, leading to catastrophic injuries, over 32,000 deaths and healthcare costs of over $55 billion. This study evaluated perceived benefits and limitations of using community paramedicine for fall prevention strategies from the lens of older adults, caregivers, and healthcare providers.

METHODS

Semi-structured focus groups were held with individuals from three stakeholder groups: (1) community-dwelling older adults (age ≥60), (2) caregivers, and (3) healthcare providers. The Strengths-Weaknesses-Opportunities-Threats (SWOT) framework was used to quantitatively analyze stakeholder perceptions of using community paramedicine for fall prevention strategies.

RESULTS

A total of 10 focus groups were held with 56 participants representing older adults (n = 15), caregivers (n = 16), and healthcare providers (n = 25). Community paramedicine was supported as a model of fall prevention by older adults, caregivers, and healthcare providers. Participants identified strengths such as visibility to the home environment, ability to implement home modifications, implicit trust in emergency medical services (EMS), and capacity to redirect resources toward prevention. Additionally, participants acknowledged opportunities such as providing continuity of care across the healthcare spectrum, improving quality and safety of care and potentially reducing unnecessary emergency department use. Participants endorsed weaknesses and threats such as funding, concerns of patients about stigma, and struggles with medical data integration.

CONCLUSIONS

The results of this study illuminate the opportunity to leverage community paramedicine to address a variety of perceived barriers in order to design and implement better solutions for fall prevention efforts.

Challenges in recruiting frequent users of ambulance services for a community paramedic home visit program

BACKGROUND

The Community Paramedicine at Home (CP@home) program is a health promotion program where community paramedics conduct risk assessments with frequent 9-1-1 callers in their homes, with a goal of reducing the frequency of 9-1-1 calls in this vulnerable population. The effectiveness of the CP@home program was investigated through a community-based RCT conducted in four regions in Ontario, Canada. The purpose of this current recruitment study is to examine the challenges met when recruiting for a community randomized control trial on high frequency 9-1-1 callers.

METHODS

Eligible participants were recruited from one of four regions participating in the CP@home program and were randomly assigned to an intervention group (n = 1142) or control group (n = 1142). Data were collected during the recruitment process from the administrative database of the four paramedic services. Whether they live alone, their parental ethnicity, age, reason for calling 9-1-1, reason for not participating, contact method, and whether they were successfully contacted were recorded. Statistical significance was calculated using the Chi-Squared Test and Fisher's Exact Test to evaluate the effectiveness of the recruitment methods used to enroll eligible participants in the CP@home Program.

RESULTS

Of the people who were contacted, 48.0% answered their phone when called and 53.9% answered their door when a home visit was attempted. In Total, 110 (33.1%) of people where a contact attempt was successful participated in the CP@home program. Most participants were over the age of 65, even though people as young as 18 were contacted. Older adults who called 9-1-1 for a lift assist were more likely to participate, compared to any other individual reason recorded, and were most often recruited through a home visit.

CONCLUSIONS

This recruitment analysis successfully describes the challenges experienced by researchers when recruiting frequent 9-1-1 callers, which are considered a hard-to-reach population. The differences in age, contact method, and reason for calling 9-1-1 amongst people contacted and participants should be considered when recruiting this population for future research.

Understanding the role of the paramedic in primary care: a realist review

BACKGROUND

Since 2002, paramedics have been working in primary care within the United Kingdom (UK), a transition also mirrored within Australia, Canada and the USA. Recent recommendations to improve UK NHS workforce capacities have led to a major push to increase the numbers of paramedics recruited into primary care. However, gaps exist in the evidence base regarding how and why these changes would work, for whom, in what context and to what extent. To understand the ways in which paramedics impact (or not) the primary care workforce, we conducted a realist review.

METHODS

A realist approach aims to provide causal explanations through the generation and articulation of contexts, mechanisms and outcomes. Our search of electronic databases was supplemented with Google and citation checking to locate grey literature including news items and workforce reports. Included documents were from the UK, Australia, Canada and the Americas-countries within which the paramedic role within primary care is well established.

RESULTS

Our searches resulted in 205 included documents, from which data were extracted to produce context-mechanism-outcome configurations (CMOCs) within a final programme theory. Our results outline that paramedics are more likely to be effective in contributing to primary care workforces when they are supported to expand their existing role through formal education and clinical supervision. We also found that unless paramedics were fully integrated into primary care services, they did not experience the socialisation needed to build trusting relationships with patients or physicians. Indeed, for patients to accept paramedics in primary care, their role and its implications for their care should be outlined by a trusted source.

CONCLUSIONS

Our realist review highlights the complexity surrounding the introduction of paramedics into primary care roles. As well as offering an insight into understanding the paramedic professional identity, we also discuss the range of expectations this professional group will face in the transition to primary care. These expectations come from patients, general practitioners (family physicians) and paramedics themselves. This review is the first to offer insight into understanding the impact paramedics may have on the international primary care workforce and shaping how they might be optimally deployed.

Exploring the potential for social prescribing in pre-hospital emergency and urgent care: A qualitative study

There is a sustained increase in demand for emergency and urgent care services in England. The NHS Long Term Plan aims to reduce the burden on emergency hospital services through changing how pre-hospital care operates, including increased delivery of urgent care. Given the recognised potential of social prescribing to address wider determinants of health and reduce costs in other settings, this study aimed to understand the role that social prescribing can play in pre-hospital emergency and urgent care from the perspectives of staff. Semi-structured interviews (n = 15) and a focus group (n = 3) were conducted with clinical staff (n = 14) and non-clinical health advisors (n = 4) from an English Ambulance Service covering emergency (999) and non-emergency (111) calls. Data were analysed using a pre-defined framework: awareness of social prescribing; potential cohorts suitable for social prescribing; and determinants of social prescribing. Awareness and knowledge of social prescribing was limited, though when social prescribing was explained to participants they almost universally recognised its benefits for their role. Social prescribing was considered to be most beneficial to those calling for reasons relating to mental health, loneliness or social isolation, in particular older people and frequent users of 999 and 111 services. Determinants of social prescribing were identified across the micro (patient and staff acceptability of social prescribing), meso (triage and referral pathways) and macro (commissioning and funding) levels of analysis. This is the first empirical study to explore social prescribing in pre-hospital emergency and urgent care services, which suggests that it has potential to improve quality of care at the point of people accessing these services. There is a pressing need to address the micro, macro and meso level determinants identified within this study, in order to support staff within pre-hospital emergency and urgent care services to socially prescribe.

Paramedics working in general practice: a scoping review

Background: The term ‘paramedic’ has traditionally related to a healthcare professional trained to provide pre-hospital emergency care; however, paramedics are increasingly taking on novel additional non-emergency roles. General practice is facing unprecedented demand for its services related to rising expectations, an aging society and increased prevalence of chronic disease. Paramedics may be recruited to work in general practice to meet some of these demands. We undertook a scoping review to map the current literature considering paramedics working in general practice and inform follow-on research. Methods: We employed the six-stage scoping review framework developed by Arksey and O’Malley. Our research question was ‘to identify the scope of practice, nature of training/qualifications, challenges faced, and impacts of paramedics working in general practice’. Results: After searching PUBMED (Medline, n = 487), EMBASE (n = 536) and the Cochrane Library (n = 0) in June 2020, we identified eleven full-text articles that met our inclusion criteria. The literature suggests that paramedics have diverse skills that enable roles within general practice, some of which are context specific. Additional training is considered necessary to facilitate the transition from emergency care to general practice. We found no research that quantitatively assessed the impact of paramedics working in general practice on healthcare expenditure or patient health outcomes. Conclusions: There is a paucity of empiric scientific literature considering paramedic working in general practice. Further research is needed to inform training pathways, the structure of clinical practice and to measure outcomes.

Tracing frequent users of regional care services using emergency medical services data: a networked approach

OBJECTIVES

This study shows how a networked approach relying on 'real-world' emergency medical services (EMS) records might contribute to tracing frequent users of care services on a regional scale. Their tracing is considered of importance for policy-makers and clinicians, since they represent a considerable workload and use of scarce resources. While existing approaches for data collection on frequent users tend to limit scope to individual or associated care providers, the proposed approach exploits the role of EMS as the network's 'ferryman' overseeing and recording patient calls made to an entire network of care providers.

DESIGN

A retrospective study was performed analysing 2012-2017 EMS calls in the province of Drenthe, the Netherlands. Using EMS data, benefits of the networked approach versus existing approaches are assessed by quantifying the number of frequent users and their associated calls for various categories of care providers. Main categories considered are hospitals, nursing homes and EMS.

SETTING

EMS in the province of Drenthe, the Netherlands, serving a population of 491 867.

PARTICIPANTS

Analyses are based on secondary patient data from EMS records, entailing 212 967 transports and 126 758 patients, over 6 years (2012-2017).

RESULTS

Use of the networked approach for analysing calls made to hospitals in Drenthe resulted in a 20% average increase of frequent users traced. Extending the analysis by including hospitals outside Drenthe increased ascertainment by 28%. Extending to all categories of care providers, inside Drenthe, and subsequently, irrespective of their location, resulted in an average increase of 132% and 152% of frequent users identified, respectively.

CONCLUSIONS

Many frequent users of care services are network users relying on multiple regional care providers, possibly representing inefficient use of scarce resources. Network users are effectively and efficiently traced by using EMS records offering high coverage of calls made to regional care providers.