Evaluation of a community paramedicine health promotion and lifestyle risk assessment program for older adults who live in social housing: a cluster randomized trial

Chronic disease prevalence and preventive care among Ontario social housing residents compared with the general population: a population-based cohort study

BACKGROUND

Older adults living in social housing report poor health and access to healthcare services. This study aimed to estimate the prevalence of chronic diseases, influenza vaccination and cancer screenings among social housing residents versus non-residents in Ontario, Canada.

METHODS

We conducted a population-based cohort study for all health-insured Ontarians alive and aged 40 or older as of 1 January 2020. Social housing residents were identified using postal codes. Validated health administrative data case definitions were used to identify individuals with diabetes, hypertension, chronic obstructive pulmonary disease, asthma, congestive heart failure and cardiovascular disease. Influenza vaccination and mammography, Pap and colorectal cancer screenings were identified among screen-eligible residents using health administrative data.

RESULTS

The prevalence of all chronic diseases was higher among social housing residents across all age groups: 40-59, 60-79 and 80+ years. Influenza vaccination rates in 2018-2019 were lower among social housing residents aged 60-79 and 80+ years. Mammography rates for women aged 50-69 years in 2018-2019 were 10-11% lower among social housing residents across all age groups compared with non-residents. Pap screening rates for women aged 40-69 in 2018-2019 were 6-8% lower among social housing residents. The percentage of colorectal screening in both women and men aged 52-74 was lower (9-10% in men and 6-7% in women) in social housing compared with the general population in 2019-2020.

CONCLUSION

There is a higher prevalence of chronic diseases and lower cancer screening rates among the growing population of older adults in social housing in Ontario, Canada.

Development and evaluation of a low-cost database solution for the Community Paramedicine at Clinic (CP@clinic) database

The Community Paramedicine at Clinic (CP@clinic) program is a community program that utilizes community paramedics to support older adults in assessing their risk factors, managing their chronic conditions, and linking them to community resources. The aim of this project is to design a low-cost, portable, secure, user-friendly database for CP@clinic sessions and pilot test the database with paramedics and older adult volunteers. The CP@clinic program database using the Microsoft Access software was first developed through consultation with the CP@clinic research team. Next, the database was pilot tested with two sets of older adults and one set of paramedics to assess user experience. Volunteers completed a survey regarding their perceptions of the level of difficulty when using the database. A computer-based database was the best option as it provided flexibility while reducing costs. The final database should perform calculations and summarize risk assessment data, provide recommended resources, generate automated reports, capture changes in medical and medication history, and ensure that the sensitive information is secure. During pilot testing, the older adult participants and the paramedics indicated that the database was easy to use. This low-cost, user-friendly and secure database captures initial and follow-up data, incorporates algorithms that guide the paramedics, and calculates risk factor scores for the participants. This solution to a healthcare database is translatable to other health research studies in which ongoing patient data is collected electronically and longitudinally.

Older adults in social housing: A systemically vulnerable population that needs to be prioritized

Older adults living in social housing are a vulnerable population with unique health challenges that often lead to poor health outcomes and high emergency service utilization. However, the needs of this population are frequently overlooked. This policy note describes the characteristics of older adults living in social housing in Canada and discusses why they are a vulnerable, underserved population in need of immediate attention and priority. Older adults in social housing have higher rates of chronic disease, lower quality of life, and lower health literacy and face challenges caused by various compounding social determinants of health. There is a large gap in research and tailored interventions focusing on this population. Based on these findings, the authors highlight the need for the allocation of resources to support this growing population, including dedicated funding, research, and programming. Proactively addressing the issues that exist in the health and social care of this high-needs population will also have larger implications for reducing healthcare system burden.

COVID-19 and social care screening for older adults in social housing: a CP@clinic adaptation

BACKGROUND

COVID-19 has changed healthcare access and delivery, especially impacting older adults. The Community Paramedicine at Clinic (CP@clinic) program is a chronic disease prevention, management, and health promotion program for community-dwelling low-income older adults. We investigated a telephone-based CP@clinic program adaptation during the pandemic.

METHODS

Community paramedics delivered CP@clinic via telephone to residents of 36 social housing buildings. They conducted screening for COVID-19, emergency preparedness, and social health factors. Community paramedics provided education on staying safe, self-isolating, self-monitoring, and preparing for pandemics using governmental infographics. Descriptive analysis was conducted on assessments completed between March and June 2020. Paramedic documentation was thematically analyzed to identify common themes.

RESULTS

All 191 participants had ≥ 1 telephone visit and 34.6% had ≥ 2 telephone visits, 82.8% were aged 65 years and older, 30.9% had internet access, and 57.9% had cable TV (limiting exposure to COVID-19 information). The CP@clinic program infrastructure provided a platform for paramedics to swiftly contact many vulnerable older adults to screen for COVID-19, educate on safe practices, and facilitate healthcare access. One-quarter of participants screened positive for social isolation. Thematic analysis described participants' experiences adapting to daily life in the pandemic, emotional experience during the pandemic, and paramedics supporting participants during the pandemic.

CONCLUSIONS

Public health interventions are needed for low-income or hard-to-reach older adults, especially during pandemics. Community paramedics were able to support vulnerable older adults living in social housing through the unique CP@clinic adaptation. This innovative program delivery increased vulnerable populations' access to public health services and information at a time of great health need.

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 emergency medical services approaches to fall prevention: a systematic review

BACKGROUND

Falls are a leading cause of morbidity and mortality among older adults in the USA. Current approaches to fall prevention often rely on referral by primary care providers or enrolment during inpatient admissions. Community emergency medical services (CEMS) present a unique opportunity to rapidly identify older adults at risk for falls and provide fall prevention interventions in the home. In this systematic review, we seek to assess the efficacy and qualitative factors determining success of these programs.

METHODS

Studies reporting the outcomes of fall prevention interventions delivered by EMS were identified by searching the electronic databases PubMed, Embase, Web of Science Core Collection, CINAHL and the Cochrane Central Register of Controlled Trials through 11 July 2023.

RESULTS

35 studies including randomised and non-randomised experimental trials, systematic reviews and qualitative research primarily from Western Europe, the USA, Australia and Canada were included in our analysis. Current fall prevention efforts focus heavily on postfall referral of at-risk community members. CEMS fall prevention interventions reduced all-cause and fall-related emergency department encounters, subsequent falls and EMS calls for lift assist. These interventions also improved patient health-related quality of life, independence with activities of daily living, and secondary health outcomes.

CONCLUSIONS

CEMS programmes provide an opportunity for direct, proactive fall prevention on the individual level. Addressing barriers to implementation in the context of current emergency medical systems in the USA is the next step toward widespread implementation of these novel fall prevention interventions.

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.

Actioning atrial fibrillation identified by ambulance services in England: a qualitative exploration

OBJECTIVES

To explore the acceptability and feasibility of detection of atrial fibrillation (AF) by emergency medical services (EMS) and identify potential barriers and facilitators to implementing a formal pathway to facilitate follow-up in primary care, which could reduce the risk of AF-related stroke.

DESIGN

Qualitative study using focus groups and one-to-one interviews guided by a semistructured topic guide.

SETTING

North East England.

PARTICIPANTS

Focus groups with 18 members of the public and one-to-one online interviews with 11 healthcare and service providers (six paramedics and five experts representing cardiology, general practice (GP), public health, research, policy and commissioning).

RESULTS

All participant groups were supportive of a role of EMS in identifying AF as part of routine assessment and formalising the response to AF detection. However, this should not create delays for EMS since rate-controlled AF is non-urgent and alternative community mechanisms exist to manage it. Public participants were concerned about communication of the AF diagnosis and whether this should be 'on scene' or in a subsequent GP appointment. Paramedics reported frequent incidental identification of AF, but it is not always clear 'on scene' that this is a new diagnosis, and there is variation in practice regarding whether (and how) this is communicated to the GP. Paramedics also focused on ensuring the safety of non-conveyed patients and a perceived need for an 'active' reporting process, so that a finding of AF was actioned. Field experts felt that a formal pathway would be useful and favoured a simple intervention without adding to time pressures unnecessarily.

CONCLUSIONS

There is support for the development of a formal pathway to ensure follow-up for people with AF that is incidentally detected by EMS. This has the potential to improve anticoagulation rates and reduce the risk of stroke.

Health-promoting behavior and its determinants towards non-communicable diseases among adult residents of the Gedeo zone, South Ethiopia: the application of the health belief model

Background

Non-communicable diseases are becoming a challenge for the health care system in Ethiopia, which has suffered a double burden from infectious and rapidly increasing non-communicable diseases. However, there is little information on health-promoting behavior in the study settings. Thus, the purpose of this study was to determine health-promoting behaviors and its associated factors among adult's residents of Gedeo zone.

Methods

A cross-sectional study was conducted among 705 adult residents of Gedeo zone, south Ethiopia, selected using a multi-stage sampling technique. Interviews administered through a structured questionnaire were used to collect the data. The data were entered using Kobo Collect and analyzed using Stata version 17. The baseline characteristics of the participants were summarized using descriptive statistics. The independent sample t-test and one-way ANOVA were used to compare two groups and more than two groups, respectively. Stepwise multiple linear regression analysis was used to identify the potential determinants of health-promoting behavior and its components. Statistically significant factors were declared at p-value of less than or equal to 0.05.

Results

The overall means score for health-promoting behavior was 73.88 ± 16.79. Physical activity and spiritual growth had the lowest and highest mean scores, respectively. The variables: gender, marital status, education, family history of NCDs, health insurance status, perceived health status, knowledge of NCD risk factors, risk perception of NCDs, expected outcome, cues to action, and self-efficacy showed a statistically significant difference in overall health-promoting behavior. The total health-promoting behavior score was associated with age, gender, perceived health status, marital status, family history of NCDs, health insurance, knowledge of NCD risk factors, perceived threat, expected outcome, self-efficacy, and cues to action.

Conclusion and recommendations

In the study, the mean score of health-promoting behaviors was low. Socio-demographic and economic variables, family history of NCD, perceived health status, knowledge of NCD risk factors, perceived threat, expected outcome, self-efficacy, and cues to action affect health-promoting behaviors. Therefore, the study suggests establishing health promotion programs to increase residents' awareness of health-promoting lifestyles, empower them to adopt healthy lifestyles, and improve health outcomes by increasing self-efficacy, providing education, and creating supportive environments.

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.

Cardiometabolic risk factors in social housing residents: A multi-site cross-sectional survey in older adults from Ontario, Canada

OBJECTIVE

This study describes cardiometabolic diseases and related risk factors in vulnerable older adults residing in social housing, aiming to inform primary care initiatives to reduce health inequities. Associations between sociodemographic variables, modifiable risk factors (clinical and behavioural), health-related quality of life and self-reported cardiometabolic diseases were investigated.

DESIGN, SETTING, AND PARTICIPANTS

This was a cross-sectional study with an interviewer-administered questionnaire. Data was collected from residents aged 55 years and older residing in 30 social housing apartment buildings in five regions in Ontario, Canada.

OUTCOME MEASURES

The proportion of cardiometabolic diseases and modifiable risk factors (e.g., clinical, behavioural, health status) in this population was calculated.

RESULTS

Questionnaires were completed with 1065 residents: mean age 72.4 years (SD = 8.87), 77.3% were female, 87.2% were white; 48.2% had less than high school education; 22.70% self-reported cardiovascular disease (CVD), 10.54% diabetes, 59.12% hypertension, 43.59% high cholesterol. These proportions were higher than the general population. Greater age was associated with overweight, high cholesterol, high blood pressure and CVD. Poor health-related quality of life was associated with self-reported CVD and diabetes.

CONCLUSIONS

Older adults residing in social housing in Ontario have higher proportion of cardiovascular disease and modifiable risk factors compared to the general population. This vulnerable population should be considered at high risk of cardiometabolic disease. Primary care interventions appropriate for this population should be implemented to reduce individual and societal burdens of cardiometabolic disease.

Factors Impacting the Implementation of Mobile Integrated Health Programs for the Acute Care of Older Adults

OBJECTIVE

Emergency services utilization is increasing in older adult populations. Many such encounters may be preventable with better access to acute care in the community. Mobile integrated health (MIH) programs leverage mobile resources to deliver care and services to patients in the out-of-hospital environment and have the potential to improve clinical outcomes and decrease health care costs; however, they have not been widely implemented. We assessed barriers, potential facilitators, and other factors critical to the implementation of MIH programs with key vested partners.

METHODS

Professional and community-member partners were purposefully recruited to participate in recorded structured interviews. The study team used the Practical Robust Implementation and Sustainability Model (PRISM) framework to develop an interview guide and codebook. Coders employed a combination of deductive and inductive coding strategies to identify common themes across partner groups.

RESULTS

The study team interviewed 22 participants (mean age 56, 68% female). A cohort of professional subject matter experts included physicians, paramedics, public health personnel, and hospital administrators. A cohort of lay community partners included patients and caregivers. Coders identified three prominent themes that impact MIH implementation. First, MIH is disruptive to existing clinical workflows. Second, using MIH to improve patients' experience during acute care encounters is key to intervention adoption. Finally, legislative action is needed to augment central financial and regulatory policies to ensure the adoption of MIH programs.

CONCLUSIONS

Common themes impacting the implementation of MIH programs were identified across vested partner groups. Multilevel strategies are needed to address patient adoption, clinical partners' workflow, and legislative policies to ensure the success of MIH programs.

Promoting Sustainability in Housing with Services: Insights From the Right Care, Right Place, Right Time Program

Despite the widely-acknowledged potential of housing with services for improving the lives of low-income older adults, ensuring their financial sustainability has been challenging. This study aimed to address this issue, drawing on 31 key informant interviews and three focus groups with payers, housing providers, and community partners involved in the Boston-area Right Care, Right Place, Right Time Program, which enrolled about 400 older adults. Transcripts were qualitatively analyzed using thematic coding. Participants agreed on the program's value, but there was little consensus on mechanisms for securing ongoing funding. The broadly distributed responsibility for individuals in housing sites, which involves health insurers, hospitals, and community service providers, provides little incentive for investment by these entities. Findings suggest that governmental mechanisms, probably at the federal level, are needed to channel funding toward these supportive services. Without such reliable funding sources, replication of supportive housing models for low-income older people will prove difficult.

Adapting the Community Paramedicine at Clinic (CP@clinic) program to a remote northern first nation community: a qualitative study of community members' and local health care providers' views

The views of community Elders and health care providers in a rural remote First Nation community in Ontario, Canada on their health care landscape and adapting the Community Paramedicine at Clinic (CP@clinic) Program to their community are presented. Key informant interviews took place between September 2020 and March 2021, and were thematically analysed using the Framework Hierarchical Analysis. There were seven themes that emerged with many subthemes: available services in the community, health care access, health challenges in community, causes of frailty, health care and community appreciations, community-specific benefits of CP@clinic, and CP@clinic program considerations for adaptation. CP@clinic program considerations for adaptation included defining the role of CP, refining referral processes to capture the target population, advertising and promoting, ensuring community awareness, determining clinic setting and composition, focusing on advocacy and timely continuity, adding to the program through time, managing resistance, engaging community and partners, deploying cultural training and language accommodations, leveraging community assets, and ensuring sustainability. Focusing on continuity, engagement, and leveraging available resources may support the success of the CP@clinic program implementation. Findings from this study may be useful to other underserved communities in Canada seeking health programming.

Perceived value and benefits of the Community Paramedicine at Clinic (CP@clinic) programme: a descriptive qualitative study

OBJECTIVES

Community Paramedicine (CP) is increasingly being used to provide chronic disease management for vulnerable populations in the community. CP@clinic took place in social housing buildings to support cardiovascular health and diabetes management for older adults. The purpose of this study was to examine participant perceptions of their experience with CP@clinic as well as potential ongoing programme benefits.

DESIGN

This descriptive qualitative study used focus groups to understand resident experiences of the CP@clinic programme. Groups were facilitated by experienced moderators using a semistructured guide. An inductive coding approach was used with at least two researchers taking part in each step of the analysis process.

SETTING

Community-based social housing buildings in Ontario, Canada.

PARTICIPANTS

Forty-one participants from four CP@clinic sites took part in a focus group. Convenience sampling was used with anyone having taken part in a CP@clinic session being eligible to attend the focus group.

RESULTS

Analysis yielded six themes across two broad areas: timely access to health information and services, support to achieve personal health goals, better understanding of healthcare system (Personal Benefits); and sense of community, comfortable and familiar place to talk about health, facilitated communication between healthcare professionals (Programme Structure). Participants experienced discernible health changes that motivated their participation. CP@clinic was viewed as a programme that created connections within the building and outside of it. Participants were enthusiastic for the continuation of the programme and appreciated the consistent support to meet their health goals.

CONCLUSIONS

CP@clinic was successful in creating a supportive and friendly environment to facilitate health behavioural changes. Ongoing implementation of CP@clinic would allow residents to continue to build their chronic disease management knowledge and skills.

TRIAL REGISTRATION NUMBER

Trial registration number: NCT02152891, Clinicaltrials.gov.

Delivery of public health interventions by the ambulance sector: a scoping review

BACKGROUND

With millions of unscheduled patient contacts every year and increasing call outs clustered around the most deprived communities, it is clear the ambulance sector could have a role to play in improving population health. However, the application and value of a public health approach within the ambulance sector has not been comprehensively explored. A scoping review was undertaken to explore the role of the ambulance sector in the delivery of public health interventions and what impact this has on population health and ambulance sector outcomes.

METHODS

A search strategy was developed on MEDLINE and translated to other major medical and health related bibliographic databases (Embase; CINAHL; HMIC; Science and Social Sciences Citation Index; Cochrane Library) to identify literature published since 2000 in OECD countries. Targeted grey literature, reference list, and citation searching was also carried out. Search results were downloaded to Microsoft Excel and screened by three reviewers according to pre-determined inclusion / exclusion criteria. Data from included studies, such as the type of activity noted within the paper, the population involved and the public health approach that was utilised, was extracted from within the paper using a data extraction form and narratively synthesised.

RESULTS

Fifty-two references were included in the final review (37 database searching; 9 reference list searching; 6 grey literature). Included articles were categorised according to the relevant public health domains and subdomains as articulated by the UK Faculty of Public Health: 1. Health improvement domain: Public health education and advice (Health promotion sub-domain) (n=13) Emergency Services personnel providing vaccines (Disease prevention sub-domain) (n=1) 2. Health care public health domain Paramedicine (Service delivery sub-domain) (n=30) Screening tools and referral pathways used by the ambulance sector (Service delivery sub-domain) (n=28) Health intelligence using ambulance sector data (population health management sub-domain) (n=26) Of note, some domains (e.g. health protection) returned nil results.

DISCUSSION

The scoping review demonstrates the breadth of public health related activities in which the ambulance sector is involved. However, an overemphasis on demand management outcomes precludes definitive conclusions on the impact of ambulance sector-led public health initiatives on public health outcomes. Future evaluations of public health initiatives should incorporate wider health system perspectives beyond the immediately apparent remit of the ambulance sector.

Social Needs in the Prehospital Setting (SNIPS): EMS Attitudes Toward Addressing Patient Social Needs

Introduction

There has been interest in utilizing EMS to address patients' social determinants of health, which are thought to be the cause of many unnecessary transports, particularly for "super-utilizing" patients. However, existing research is limited regarding EMS clinicians' understanding of social determinants of health and attitudes toward potential interventions.

Methods

This cross-sectional study was conducted using an internet-based survey of EMS clinicians across the United States with multiple methods of recruitment. Descriptive statistics and Chi Square Tests analyzed the data.

Results

A total of 1,112 EMTs and paramedics completed the survey with 43.4% reporting familiarity with the term, "social determinants of health," and 87.7% screening positive for burnout. Greater than 60% reported willingness to use proposed interventions to address patient social needs. Those who reported familiarity with the term, "social determinants of health," were more likely to indicate willingness to utilize interventions and to believe they were responsible for addressing their patients' social needs. Burnout had no effect on clinicians' willingness to use resources.

Discussion

Respondents showed substantial interest in using the proposed resources to address patient social needs, suggesting that EMS clinicians may be receptive to expanding their scope of responsibility to include socioeconomic interventions. EMS clinicians familiar with the term "social determinants of health" were more likely to believe they were responsible for addressing patient social needs and more willing to use interventions, suggesting a potential benefit to more education on the topic. Burnout among EMS clinicians may not be a barrier to implementing such interventions.

Conclusion

Our survey suggests that EMS clinicians may be interested in helping to address their patients' social needs. EMS clinicians should be offered education on social determinants of health in their initial training and through continuing education. Partnerships with human services agencies will be important to ensure the effectiveness of prehospital interventions.

Prevalence of dementia, heart disease and stroke in community-dwelling adults in Canada, 2016-2021: opportunities for joint prevention

INTRODUCTION

This aim of this study is to provide updated estimates on the prevalence of dementia, heart disease, and stroke in Canadian communities. Targeting all three conditions together, at the community level, may be key to disease prevention and health aging in the Canadian population.

METHODS

Using nationwide health survey data, we calculated the age-standardized prevalence of self-reported dementia, heart disease and stroke in adults aged 18 years and over residing in Canadian communities from 2016 to 2021. Poisson regression models were used to detect statistically significant changes in the prevalence of all three conditions from 2016 to 2021.

RESULTS

Less than 1% (~ 175,000 individuals) of adults residing in Canadian communities reported dementia, 5% (~ 1.5 million individuals) reported heart disease, and more than 1% (~ 370,000 individuals) reported stroke annually from 2016 to 2021. Overall, the age-standardized prevalence for stroke decreased minimally from 2016 to 2021 (p = 0.0004). Although the age-standardized prevalence of heart disease and dementia decreased from 2016 to 2018, subsequent increases in prevalence from 2018 to 2021 led to a lack of overall statistically significant changes from 2016 to 2021 (p = 0.10 for heart disease and p = 0.37 for dementia).

CONCLUSION

Recent increases in the prevalence of dementia, heart disease and stroke in Canadian communities threaten to reverse any gains in vascular disease prevention over the past six years. Findings reveal the urgent need for intensified prevention efforts that are community-based with a focus on joint reduction in the shared risk factors contributing to all three diseases.

Mobile Integrated Health Interventions for Older Adults: A Systematic Review

Background and Objectives

Mobile integrated health (MIH) interventions have not been well described in older adult populations. The objective of this systematic review was to evaluate the characteristics and effectiveness of MIH programs on health-related outcomes among older adults.

Research Design and Methods

We searched Ovid MEDLINE, Ovid EMBASE, CINAHL, AgeLine, Social Work Abstracts, and The Cochrane Library through June 2021 for randomized controlled trials or cohort studies evaluating MIH among adults aged 65 and older in the general community. Studies were screened for eligibility against predefined inclusion/exclusion criteria. Using at least 2 independent reviewers, quality was appraised using the Downs and Black checklist and study characteristics and findings were synthesized and evaluated for potential bias.

Results

Screening of 2,160 records identified 15 studies. The mean age of participants was 67 years. The MIH interventions varied in their focus, community paramedic training, types of assessments and interventions delivered, physician oversight, use of telemedicine, and post-visit follow-up. Studies reported significant reductions in emergency call volume (5 studies) and immediate emergency department (ED) transports (3 studies). The 3 studies examining subsequent ED visits and 4 studies examining readmission rates reported mixed results. Studies reported low adverse event rates (5 studies), high patient and provider satisfaction (5 studies), and costs equivalent to or less than usual paramedic care (3 studies).

Discussion and Implications

There is wide variability in MIH provider training, program coordination, and quality-based metrics, creating heterogeneity that make definitive conclusions challenging. Nonetheless, studies suggest MIH reduces emergency call volume and ED transport rates while improving patient experience and reducing overall health care costs.

Aging in Place in Social Housing: A Scoping Review of Social Housing for Older Adults

Access to affordable housing is a rising concern, and social housing is one approach to support low-income, older renters. A scoping review was undertaken to understand the characteristics of older tenants and social housing services to identify strategies to promote aging in place. Seven peer review databases were searched to identify relevant articles. A total of 146 articles were included. Almost all examined socio-demographic and health characteristics of older tenants, while 72 per cent examined social housing services, including eligibility policies, staffing, and access to on-site services. This review points to a high vulnerability among older tenants and highlights the importance of co-locating services on-site with a tenant-facing support staff to identify vulnerable tenants and link them to services. More research on tenancy issues (e.g., unit condition, rental management) is needed to identify new opportunities for social housing landlords to help older tenants age in place.

Factors Associated With Successful Enrollment in a Community Paramedicine Program for Heart Failure

Introduction Participation in community paramedicine (CP) programs, sometimes referred to as Mobile Integrated Healthcare (MIH), may improve patient-centered outcomes and reduce hospital readmissions. The objective of this study was to correlate patient and system-specific factors with successful enrollment in a CP program for heart failure.  Methods We conducted a retrospective review of patients enrolled in a CP program after hospitalization for a heart failure-related diagnosis. All patients greater than 18 years of age referred to the CP program with a heart-failure-related diagnosis were included. Factors including age, sex, hospital length of stay, enrollment method, concurrent use of transitional care services, care team, and service line referral were collected. The primary outcome was successful enrollment which led to an initial home visit. Chi-square and t-tests were performed to determine if the outcome differed between cohorts.  Results A total of 908 patients met the inclusion criteria, and 677 (74.7%) received home visits. Increased participation was noted in patients enrolled in person (81.1% vs. 66%, p<0.01) and those also receiving transitional care services (78.9% vs. 62.5%, p<0.01).  Conclusion We conclude that efforts should be made to contact patients in person, prior to hospital discharge, who are eligible for CP services.

The development of community paramedicine; a restricted review

Community paramedic roles are expanding internationally, and no review of the literature could be found to guide services in the formation of community paramedicine programmes. For this reason, the aim of this restricted review was to explore and better understand the successes and learnings of community paramedic programmes across five domains being; education requirements, models of delivery, clinical governance and supervision, scope of roles and outcomes. This restricted review was conducted by searching four databases (CENTRAL, ERIC, EMBASE, MEDLINE and Google Scholar) as well as grey literature search from 2001 until 28/12/2021. After screening, 98 articles were included in the narrative synthesis. Most studies were from the USA (n = 37), followed by Canada (n = 29). Most studies reported on outcomes of community paramedicine programmes (n = 50), followed by models of delivery (n = 28). The findings of this review demonstrate a lack of research and understanding in the areas of education and scope of the role for community paramedics. The findings highlight a need to develop common approaches to education and scope of role while maintaining flexibility in addressing community needs. There was an observable lack of standardisation in the implementation of governance and supervision models, which may prevent community paramedicine from realising its full potential. The outcome measures reported show that there is evidence to support the implementation of community paramedicine into healthcare system design. Community paramedicine programmes result in a net reduction in acute healthcare utilisation, appear to be economically viable and result in positive patient outcomes with high patient satisfaction with care. There is a developing pool of evidence to many aspects of community paramedicine programmes. However, at this time, gaps in the literature prevent a definitive recommendation on the impact of community paramedicine programmes on healthcare system functionality.

Potential for Paramedic roles in Irish General Practice: A qualitative study of stakeholder's perspectives

Background: Irish health policy emphasises the role of Primary Care and General Practice however, there is a growing shortage of General Practitioners (GPs) in Ireland. Paramedics have traditionally focused on emergency care in the community. More recently Paramedics have taken on roles in General Practice in international jurisdictions, but not yet in Ireland. This study aimed to explore key stakeholder perceptions of 'the potential for Paramedic roles in Irish General Practice'. Methods: We conducted an exploratory, qualitative stakeholder consultation study incorporating in-depth semi structured telephone interviews followed by thematic analysis. Interviews were conducted with a total of eighteen participants that included six senior Paramedics (Advanced Paramedics), seven General Practitioners (GPs), three Practice Nurses and two Practice Managers. Results: Participants in this study expressed polarised views on the potential for Paramedic roles in Irish General Practice. Paramedics were enthusiastic, highlighting opportunity for professional development and favourable working conditions. GPs, Practice Nurses and Managers were more circumspect and had concerns that Paramedic scope and skillset was not currently aligned to General Practice care. GPs, Practice Nurses and Managers emphasised a greater role for expanded General Practice Nursing. There were varied perceptions on what the potential role of a Paramedic in General Practice might entail, but consensus that Government support would be required to facilitate any potential developments. Conclusions: The findings of this research can inform future development of novel roles in Irish General Practice and suggests that there is appetite from within the Paramedic profession to pursue such roles. A pilot demonstration project, grounded in an action research framework could address data gaps and potential concerns. Any future developments should occur in tandem with and with due consideration for the expansion of General Practice Nursing in Ireland.

Housing and health in vulnerable social groups: an overview and bibliometric analysis

Previous studies have confirmed that poor living conditions can lead to a wide range of health problems. However, in the context of the COVID-19 pandemic, vulnerable groups in unstable housing are more susceptible to disease. This study aims to systematically examine the housing and health problems of vulnerable groups using a bibliometric approach to explore how housing causes health problems, types of health illnesses, and coping strategies. It is found that the poor housing mechanism, persistent inequalities, and poor housing environments have a significant impact on the health of vulnerable groups. Therefore, the government must make concerted efforts across all sectors to ensure that the housing and health care needs of vulnerable groups are improved, and that housing security standards and related policies are improved; targeted safety plans are formulated with community as the carrier, taking into account the characteristics of vulnerable groups; and new information technology is widely used to provide medical convenience for vulnerable groups. It is hoped that the research in this paper can arouse social attention to the health of vulnerable groups and improve their health from the perspective of housing, so as to point out the direction for solving the housing health problems of vulnerable groups in the future.

Evaluation of an EMS-based community paramedic pilot program to reduce frequency of 9-1-1 calls among high utilizers

Background - Many community paramedic interventions aim to reduce unnecessary emergency department visits among high utilizers of acute care, but fewer focus specifically on reducing summons for emergency medical services (EMS). We implemented an EMS-based pilot program that identified high utilizers of 9-1-1 and facilitated community paramedic outreach encounters to understand and address potentially unnecessary 9-1-1 calls. This study compares the pre- and post-intervention incidence rate of 9-1-1 calls among program participants.Methods - This retrospective evaluation was conducted using pilot data from a single U.S. EMS agency that responds to approximately 100,000 9-1-1 calls annually. High utilizers, defined as individuals with ≥3 9-1-1 calls in 90 days, were identified for recruitment between February 1, 2019 and December 31, 2019. community paramedics recruited participants via phone and then conducted home visits to assist them with navigation away from unnecessary 9-1-1 use. Dispatch data from September 1, 2018 to December 31, 2019 were used to compute the incidence rate of 9-1-1 calls per 30 person-days of observation before and after the initial home visits.Results - Data from 108 program participants were analyzed. The majority were over the age of 50 (79%), and 33% completed more than one visit. Median person-days of observation before and after the initial home visit were 354 days and 132 days, respectively. Participants called 9-1-1 an average of 0.68 times per 30 person-days prior to the community paramedic intervention, and 0.51 times per 30 person-days after the intervention, which represents an overall mean decrease in 9-1-1 utilization of 25% (p < 0.001). Although a decrease in 9-1-1 utilization was observed in the majority of participants, the 9-1-1 call rate increased in 29% of participants. No statistically significant changes in 9-1-1 use were observed in participants who received more than one home visit or who were in the highest quartile of 9-1-1 use prior to the intervention.Conclusion - This pilot work demonstrates the feasibility of an EMS-based, community paramedic-only intervention to reduce unnecessary 9-1-1 calls and suggests that some modest reductions in EMS use may be achievable by dispatching community paramedics to conduct home visits with frequent users of 9-1-1.

Health knowledge and self-efficacy to make health behaviour changes: a survey of older adults living in Ontario social housing

BACKGROUND

Older adults living in social housing are a vulnerable population facing unique challenges with health literacy and chronic disease self-management. We investigated this population's knowledge of cardiovascular disease and diabetes mellitus, and self-efficacy to make health behaviour changes (for example, physical activity). This study characterized the relationship between knowledge of health risk factors and self-efficacy to improve health behaviours, in order to determine the potential for future interventions to improve these traits.

METHODS

A cross-sectional study (health behaviour survey) with adults ages 55+ (n = 599) from 16 social housing buildings across five Ontario communities. Descriptive analyses conducted for demographics, cardiovascular disease and diabetes knowledge, and self-efficacy. Subgroup analyses for high-risk groups were performed. Multivariate logistic regressions models were used to evaluate associations of self-efficacy outcomes with multiple factors.

RESULTS

Majority were female (75.6%), white (89.4%), and completed high school or less (68.7%). Some chronic disease subgroups had higher knowledge for those conditions. Significant (p < 0.05) associations were observed between self-efficacy to increase physical activity and knowledge, intent to change, and being currently active; self-efficacy to increase fruit/vegetable intake and younger age, knowledge, and intent to change; self-efficacy to reduce alcohol and older age; self-efficacy to reduce smoking and intent to change, ability to handle crises, lower average number of cigarettes smoked daily, and less frequent problems with usual activities; self-efficacy to reduce stress and ability to handle crises.

CONCLUSIONS

Those with chronic diseases had greater knowledge about chronic disease. Those with greater ability to handle personal crises and intention to make change had greater self-efficacy to change health behaviours. Development of stress management skills may improve self-efficacy, and proactive health education may foster knowledge before chronic disease develops.

Potential for Paramedic roles in Irish General Practice: A qualitative study of stakeholder's perspectives

Background: Irish health policy emphasises the role of Primary Care and General Practice however, there is a growing shortage of General Practitioners (GPs) in Ireland. Paramedics have traditionally focused on emergency care in the community. More recently Paramedics have taken on roles in General Practice in international jurisdictions, but not yet in Ireland. This study aimed to explore key stakeholder perceptions of 'the potential for Paramedic roles in Irish General Practice'. Methods: We conducted an exploratory, qualitative stakeholder consultation study incorporating in-depth semi structured telephone interviews followed by thematic analysis. Interviews were conducted with a total of eighteen participants that included six senior Paramedics (Advanced Paramedics), seven General Practitioners (GPs), three Practice Nurses and two Practice Managers. Results: Participants in this study expressed polarised views on the potential for Paramedic roles in Irish General Practice. Paramedics were enthusiastic, highlighting opportunity for professional development and favourable working conditions. GP's, Practice Nurses and Managers were more circumspect and had concerns that Paramedic scope and skillset was not currently aligned to General Practice care. GP's, Practice Nurses and Managers emphasised a greater role for expanded General Practice Nursing. There were varied perceptions on what the potential role of a Paramedic in General Practice might entail, but consensus that Government support would be required to facilitate any potential developments. Conclusions: The findings of this research can inform future development of novel roles in Irish General Practice and suggests that there is appetite from within the Paramedic profession to pursue such roles. A pilot demonstration project, grounded in an action research framework could address data gaps and potential concerns. Any future developments should occur in tandem with and with due consideration for the expansion of General Practice Nursing in Ireland.

Designing and Governing Responsive Local Care Systems - Insights from a Scoping Review of Paramedics in Integrated Models of Care

Introduction

Programs that fill gaps in fractured health and social services in response to local needs can provide insight on enacting integrated care. Grassroots programs and the changing roles of paramedics within them were analyzed to explore how the health workforce, organizations and governance could support integrated care.

Methods

A study was conducted following Arksey and O'Malley's method for scoping reviews, using Valentijn's Rainbow Model of Integrated Care as an organizing framework. Qualitative content analysis was done on clinical, professional, organizational, system, functional and normative aspects of integration. Common patterns, challenges and gaps were documented.

Results

After literature search and screening, 137 documents with 108 unique programs were analysed. Paramedics bridge reactive and preventative care for a spectrum of population needs through partnerships with hospitals, social services, primary care and public health. Programs encountered challenges with role delineation, segregated organizations, regulation and tensions in professional norms.

Discussion

Five concepts were identified for fostering integrated care in local systems: single point-of-entry care pathways; flexible and mobile workforce; geographically-based cross-cutting organizations; permissive regulation; and assessing system-level value.

Conclusion

Integrated care may be supported by a generalist health workforce, through cross-cutting organizations that work across silos, and legislation that balances standardization with flexibility.

Integrating community paramedicine with primary health care: a qualitative study of community paramedic views

BACKGROUND

Community paramedicine (CP) is an emerging model of care that addresses local health needs through programs led by community paramedics; however, CP remains poorly defined and appears to lack systematic integration with the broader health system, specifically primary care, within which it is seated. The purpose of the study was to elucidate the views of community paramedics and their stakeholders in Ontario, Canada, on the topic of integrating CP with the broader health system.

METHODS

This was a retrospective qualitative analysis of a public recording of a CP provincial forum held in Ontario, Canada, in 2017. Forum attendees (paramedics and stakeholders) were invited by email if they had attended a similar provincial forum in the past (no exclusion criteria for attendance). In small- and large-group discussions, attendees discussed their views on how CP could fit into primary care and what medical oversight and acceptance for the profession could involve. A recording of the large-group discussion, which is publicly available, was transcribed and thematically analyzed.

RESULTS

The 89 participants varied in professional affiliation (66% from a paramedic service, n = 59). Among those from paramedic services, 33% were community paramedics (n = 14). Five major themes emerged: defining the role of community paramedics, how CP may integrate with other services, how to garner support for CP, where standardization is needed and possible oversight structures.

INTERPRETATION

Community paramedics and their stakeholders have insights into barriers and facilitators for integration with the health system. These study findings could help inform the integration of health and social services in Ontario with a consideration for the unique position and potential of community paramedics.

"We could be good partners if we work together": the perspectives of health and social service providers on the barriers to forming collaborative partnerships with social housing providers for older adults

BACKGROUND

Many older adults are aging-at-home in social housing. However, the lack of integration between housing and health services makes it difficult for older tenants to access needed supports. We examined barriers and facilitators health and social service providers face providing on-site services to older tenants.

METHODS

We conducted semi-structured qualitative interviews and focus groups with health and social service professionals (n = 58) in Toronto, Canada who provide community programs in support of older tenants who live in non-profit, rent-geared-to-income social housing. Interviews examined the barriers they faced in providing on-site services to older tenants.

FINDINGS

Service providers strongly believed that collaboration with on-site housing staff led to better health and housing outcomes for older tenants. Despite the recognized benefits of partnering with housing staff, service providers felt that their ability to work effectively in the building was dependent on the staff (particularly the superintendent) assigned to that building. They also identified other barriers that made it difficult to work collaboratively with the housing provider, including staffing challenges such as high staff turnover and confusion about staff roles, a lack of understanding among housing staff about the link between housing and health, challenges sharing confidential information across sectors, and complex and inefficient partnership processes.

CONCLUSION

Older adult tenants are increasingly vulnerable and in need of supports but the housing provider has a long history of ineffective partnerships with service providers driven by complex and inefficient staffing models, and an organizational culture that questions the role of and need for partnerships. Findings highlight the need for more effective integration of housing and health services. Simplified processes for establishing partnerships with service agencies and more opportunities for communication and collaboration with housing staff would ensure that services are reaching the most vulnerable tenants.

"They're very passionate about making sure that women stay healthy": a qualitative examination of women's experiences participating in a community paramedicine program

BACKGROUND

Community paramedicine programs (i.e., physician-directed preventive care by emergency medical services personnel embedded in communities) offer a novel approach to community-based health care. Project Swaddle, a community paramedicine program for mothers and their infants, seeks to address (directly or through referrals) the physical, mental, social, and economic needs of its participants. The objective of this process evaluation was to describe women's experiences in Project Swaddle. By understanding their experiences, our work begins to build the foundation for similar programs and future examinations of the efficacy and effectiveness of these approaches.

METHODS

We completed 21 interviews with women living in Indiana (July 2019-February 2020) who were currently participating in or had graduated from Project Swaddle. Interviews were audio-recorded, transcribed, and analyzed using a six-phase approach to thematic analysis.

RESULTS

Program enrollment was influenced by the community paramedics' experience and connections, as well as information received in the community from related clinics or organizations. Participants viewed the community paramedic as a trusted provider who supplied necessary health information and support and served as their advocate. In their role as physician extenders, the community paramedics enhanced patient care through monitoring critical situations, facilitating communication with other providers, and supporting routine healthcare. Women noted how community paramedics connected them to outside resources (i.e., other experts, tangible goods), which aimed to support their holistic health and wellbeing.

CONCLUSIONS

Results demonstrate Project Swaddle helped women connect with other healthcare providers, including increased access to mental health services. The community paramedics were able to help women establish care with primary care providers and pediatricians, then facilitate communication with these providers. Women were supported through their early motherhood experience, received education on parenting and taking control of their health, and gained access to resources that met their diverse needs.

Health-Promoting Behaviors of Low-Income Adults in a Community Health Center

Health-promoting behaviors improve health, prevent disease, and decrease healthcare costs. This study describes the health-promotion behaviors and identifies influencing factors of health-promoting behaviors in low-income patients at a community health center. This cross-sectional study used participants from a center serving a low-income population. Spiritual growth and interpersonal relations were the two most practiced health-promoting behaviors. Age and education influenced participation in health-promoting behaviors. Promoting spiritual growth and interpersonal relations is a critical part of supporting health-promoting behaviors. Findings provide guidance for nurses to contribute to increasing healthy behaviors and develop interventions to improve participation in health-promoting behaviors.

Community nurse-paramedics' sphere of practice in primary care; an ethnographic study

Background

Primary care, the principal function of the health care system, requires effort from all local primary health care teams. Community Paramedicine (CP) has managed to reduce the use of Emergency Medical Services (EMS) for non-emergency calls, but for the paramedic to move from traditional emergency calls to non-emergency care will mean new demands. There is a paucity of research exploring nurse-paramedics’ experiences and perceptions of their novel roles as community paramedics in Finland. This study aims to explore the community nurse-paramedics’ (CNP) experiences in their new sphere of practice.

Methods

A descriptive ethnographic study was conducted, to collect data through participant observation (317 h total) and semi-structured interviews (N = 22) in three hospital districts (HD) where the CNPs have worked for at least 1 year. Both data sets were combined, organised, and analysed using inductive content analysis.

Results

Five main categories were developed by applying inductive content analysis: the new way of thinking, the broad group of patients, the way to provide care, the diversity of multidisciplinary collaboration, and tailored support from the organisation. The CNP was identified as needing an appropriate attitude towards care and a broader way of thinking compared to the traditional practice of taking care of the patient and the family members. The diversity of multidisciplinary collaboration teams can be a sensitive but worthwhile topic for offering new possibilities. Tailored support from the organisation includes tools for future CP models.

Conclusions

Our results indicate the CNPs’ deep involvement in patients’ and families’ care needs and challenges with their skills and competencies. Their professional attitudes and eagerness to develop and maintain multidisciplinary collaboration can offer preventive and long-term caring solutions from which citizens, allied health, safety, and social care providers benefit locally and globally.

Improving Primary Health Care for Residents Living in Assisted Living: Evidence for Practice and Policy

The fact that there is a large and growing number of older Canadians has generated a sense of urgency in improving seniors' access to health and long-term care services. Many provincial health care systems have engaged in a range of reforms to help older adults remain healthy and independent. Although many transformational changes have taken place across Canada to improve primary care, variations exist across provinces and territories in terms of older adults' access to primary health care. Opportunities exist for provinces to learn from successful reforms implemented in other Canadian jurisdictions. Residents of assisted living (AL) facilities are an ideal group to whom to target primary health care reforms, given the important role these facilities play in the care continuum and the complex needs of their residents. Allowing practitioners to practice to their full scope and assume greater responsibility within the health care system is a strategy adopted in some jurisdictions with success. This article reports on reforms that have been made to expand the scopes of practice of nurse practitioners and paramedics in some provinces, but also have the potential to improve access to primary health care for those living in AL across the entire country, including those living in smaller provinces such as New Brunswick.

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.

The impact of health-related supports in senior housing on ambulance transfers and visits to emergency departments: The Right Care, Right Place, Right Time Project

OBJECTIVE

To test the impact of placing a wellness team (nurse and social worker) in senior housing on ambulance transfers and visits to emergency departments over 18 months.

DATA SOURCES/STUDY SETTING

Intervention sites included seven Boston-area buildings, with five buildings at comparable settings acting as controls. Data derive from building-level ambulance data from emergency responders; building-level Medicare claims data on emergency department utilization; and individual-level baseline assessment data from participants in the intervention (n = 353) and control (n = 208) sites.

STUDY DESIGN

We used a pre/postdifference in difference quasi-experimental design applying several analytic methods. The preintervention period was January 2016-March 2017, while the intervention period was July 2017-December 2018.

DATA COLLECTION/EXTRACTION METHODS

Emergency responders provided aggregate transfer data on a daily basis for intervention and control buildings; the Quality Improvement Organization provided quarterly aggregate data on emergency department visit rates; and assessment data came from a modified Vitalize 360 assessment and coaching tool.

PRINCIPAL FINDINGS

The study found an 18.2% statistically significant decline in ambulance transfers in intervention buildings, with greater declines in buildings that had fewer services available at baseline, compared to other intervention sites. Analysis of Medicare claims data, adjusted for the proportion of residents over 75 per building, found fewer visits to emergency departments in intervention buildings.

CONCLUSIONS

Health-related supports in senior housing sites can be effective in reducing emergency transfers and visits to emergency departments.

Paramedics Have Untapped Potential to Address Social Determinants of Health in Canada

The role of paramedics, including select paramedics providing primary and preventive care in homes and community settings, is evolving in health systems around the world. These developments are associated with improvements in health outcomes, improved access to services and reduced emergency department use. Building on these existing trends in paramedicine, and because social conditions contribute to illness and are strong predictors of future health service use, addressing patients' social needs should be integrated into core paramedic practice in Canada. We discuss how paramedic education, culture and governance could better enable paramedics to address the social determinants of health.

A scoping review of community paramedicine: evidence and implications for interprofessional practice

Community paramedicine (CP) is an evolving method of providing community-based health care in which paramedics function outside of their traditional emergency response roles in order to improve access to primary and preventive health care and to basic social services. Early evidence indicates that CP programs have contributed to reducing health care utilization and improving patient outcomes leading some to call for a transformation of EMS into value-based mobile healthcare fully integrated within an interprofessional care team. The purpose of this scoping review was to understand the evidence base of CP in order to inform the further evolution of this model of care. Following the PRISMA extension for Scoping Reviews, 1,163 titles were screened by our research team. Eligibility criteria were publication in English after January 1, 2000; description of a CP program located in a Western nation; and inclusion of a discussion of outcomes. Twenty-nine publications met the criteria for inclusion. The literature was varied in terms of study design, program purpose, and target audience. The lack of rigorous, longitudinal studies with control groups makes rendering conclusions as to the value and effectiveness of CP programs difficult. Further, the extent to which community paramedics operate within interprofessional teams remains unclear. However, some programs demonstrated improvement in both health services and patient outcomes. As stakeholders continue to explore the potential of CP, results of this review highlight the importance of further investigation of outcomes, the professional identity of the community paramedic, and the role of the community paramedic on interprofessional teams.

Participation in the Cardiovascular Health Awareness Program (CHAP) by older adults residing in social housing in Quebec: Social network analysis

BACKGROUND

The Cardiovascular Health Awareness Program (CHAP) is as a community-based cardiovascular disease prevention program recently adapted to target older adults living in 14 social housing buildings in Ontario (7) and Quebec (7). Social network analysis (SNA) has been used successfully to assess and strengthen participation in health promotion programs. We applied SNA methods to investigate whether interpersonal relationships among residents within buildings influenced their participation in CHAP.

METHODS

Our aim was to examine relational dynamics in two social housing buildings in Quebec with low and high CHAP attendance rates, respectively. We used sociometric questionnaires and network analysis for the quantitative phase of the study, supplemented by a phase of qualitative interviews. All residents of both buildings were eligible for the sociometric questionnaire. Respondents for the qualitative interviews were purposively selected to represent the different attendance situations following the principle of content saturation.

RESULTS

In total, 69 residents participated in the study, 37 through sociometric questionnaires and 32 in qualitative interviews. Of the latter, 10 attended almost all CHAP sessions, 10 attended once, and 12 attended none. Results of the quantitative analysis phase identified well-known and appreciated local leaders. In Building 1, which had a high attendance rate (34.3%), there was a main leader (in-degree or 'named by others' frequency 23.2%) who had attended all CHAP sessions. In Building 2, which had a low attendance rate (23.9%), none of the leaders had attended CHAP sessions. Results of the qualitative analysis phase showed that residents who did not attend CHAP sessions (or other activities in the building) generally preferred to avoid conflicts, vindictiveness, and gossip and did not want to get involved in clans and politics within their building.

CONCLUSION

We identified four potential strategies to increase attendance at CHAP sessions by residents of subsidized housing for older adults: strengthen confidentiality for those attending the sessions; use community peer networks to enhance recruitment; pair attendees to increase the likelihood of participation; and intervene through opinion leaders or bridging individuals.

Reshaping healthcare delivery for elderly patients: the role of community paramedicine; a systematic review

Background

Healthcare systems are overloaded and changing. In response to growing demands on the healthcare systems, new models of healthcare delivery are emerging. Community paramedicine is a novel approach in which paramedics use their knowledge and skills beyond emergency health response to contribute to preventative and rehabilitative health. In our systematic review, we aimed to identify evidence of the community paramedicine role in care delivery for elderly patients, with an additional focus on palliative care, and the possible impact of this role on the wider healthcare system.

Methods

A systematic review of peer-reviewed literature from MEDLINE, Embase, CINAHL, and Web of Sciences was undertaken to identify relevant full-text articles in English published until October 3, 2019. Additional inclusion criteria were studies focussing on extended care paramedics or community paramedics caring for elderly patients. Case studies were excluded. All papers were screened by at least two authors and underwent a quality assessment, using the Joanna Briggs Institute appraisal checklists for cross sectional, qualitative, cohort, and randomised controlled trial studies to assess the methodological quality of the articles. A process of narrative synthesis was used to summarise the data.

Results

Ten studies, across 13 articles, provided clear evidence that Community Paramedic programs had a positive impact on the health of patients and on the wider healthcare system. The role of a Community Paramedic was often a combination of four aspects: assessment, referral, education and communication. Limited evidence was available on the involvement of Community Paramedics in palliative and end-of-life care and in care delivery in residential aged care facilities. Observed challenges were a lack of additional training, and the need for proper integration and understanding of their role in the healthcare system.

Conclusions

The use of community paramedics in care delivery could be beneficial to both patients’ health and the wider healthcare system. They already play a promising role in improving the care of our elderly population. With consistent adherence to the training curriculum and effective integration within the wider healthcare system, community paramedics have the potential to take on specialised roles in residential aged care facilities and palliative and end-of-life care.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-020-06037-0.

Point-of-Care Testing Practices, Failure Modes, and Risk-Mitigation Strategies in Emergency Medical Services Programs in the Canadian Province of Alberta

CONTEXT.—

Emergency medical services (EMS) programs have been using point-of-care testing (POCT) for more than 20 years. However, only a handful of reports have been published in all of that time on POCT practices in field settings.

OBJECTIVE.—

To provide an overview of POCT practices and failure modes in 3 of Alberta's EMS programs, and to propose risk-mitigation strategies for reducing or eliminating these failure modes.

DESIGN.—

Details about POCT practices, failure modes, and risk-mitigation strategies were gathered through (1) conversations with personnel, (2) in-person tours of EMS bases, (3) accompaniment of EMS personnel on missions, (4) internet searches for publicly available information, and (5) a review of laboratory documents.

RESULTS.—

Practices were most standardized and robust in the community paramedicine program (single service provider, full laboratory oversight), and least standardized and robust in the air ambulance program (4 service providers, limited laboratory oversight). Common failure modes across all 3 programs included device inoperability due to cold weather, analytical validation procedures that failed to consider the unique challenges of EMS settings, and a lack of real-time electronic transmission of results into the health care record.

CONCLUSIONS.—

A provincial framework for POCT in EMS programs is desirable. Such a framework should include appropriate funding models, laboratory oversight of POCT, and relevant expertise on POCT in EMS settings. The framework should also incorporate specific guidance on quality standards that are needed to address the unique challenges of performing POCT in field settings.

Feasibility of implementing a community cardiovascular health promotion program with paramedics and volunteers in a South Asian population

BACKGROUND

The South Asian population in Canada is growing and has elevated risk of cardiovascular disease and diabetes. This study sought to adapt an evidence-based community risk assessment and health promotion program for a South Asian community with a large proportion of recent immigrants. The aims were to assess the feasibility of implementing this program and also to describe the rates of cardiometabolic risk factors observed in this sample population.

METHODS

This was a feasibility study adapting and implementing the Community Paramedicine at Clinic (CP@clinic) program for a South Asian population in an urban Canadian community for 14 months. CP@clinic is a free, drop-in chronic disease prevention and health promotion program implemented by paramedics who provide health assessments, health education, referrals and reports to family doctors. All adults attending the recreation centre and temple where CP@clinic was implemented were eligible. Volunteers provided Hindi, Punjabi and Urdu translation. The primary outcome of feasibility was evaluated using quantitative process measures and a qualitative key informant interview. For the secondary outcome of cardiometabolic risk factor, data were collected through the CP@clinic program risk assessments and descriptively analyzed.

RESULTS

There were 26 CP@clinic sessions held and 71 participants, predominantly male (56.3-84.6%) and South Asian (87.3-92.3%). There was limited participation at the recreation centre (n = 19) but CP@clinic was well-attended when relocated to the local Sikh temple (n = 52). Having the volunteer translators was critical to the paramedics being able to collect the full risk factor data and there were some challenges with ensuring enough volunteers were available to staff each session; as a result, there were missing risk factor data for many participants. In the 26 participants with complete or almost complete risk factor data, 46.5% had elevated BP, 42.3% had moderate/high risk of developing diabetes, and 65.4% had an indicator of cardiometabolic disease.

CONCLUSION

Implementing CP@clinic in places of worship is a feasible approach to adapting the program for the South Asian population, however having a funded translator in addition to the volunteers would improve the program. Also, there is substantial opportunity for addressing cardiometabolic risk factors in this population using CP@clinic.

Cost-effectiveness analysis of a community paramedicine programme for low-income seniors living in subsidised housing: the community paramedicine at clinic programme (CP@clinic)

OBJECTIVES

To evaluate the cost-effectiveness of the Community Paramedicine at Clinic (CP@clinic) programme compared with usual care in seniors residing in subsidised housing.

DESIGN

A cost-utility analysis was conducted within a large pragmatic cluster randomised controlled trial (RCT). Subsidised housing buildings were matched by sociodemographics and location (rural/urban), and allocated to intervention (CP@clinic for 1 year) or control (usual care) via computer-assisted paired randomisation.

SETTING

Thirty-two subsidised seniors' housing buildings in Ontario.

PARTICIPANTS

Building residents 55 years and older.

INTERVENTION

CP@clinic is a weekly community paramedic-led, chronic disease prevention and health promotion programme in the building common areas. CP@clinic is free to residents and includes risk assessments, referrals to resources, and reports back to family physicians.

OUTCOME MEASURES

Quality-adjusted life years (QALYs) gained, measured with EQ-5D-3L. QALYs were estimated using area-under-the curve over the 1-year intervention, controlling for preintervention utility scores and building pairings. Programme cost data were collected before and during implementation. Costs associated with emergency medical services (EMS) use were estimated. An incremental cost effectiveness ratio (ICER) based on incremental costs and health outcomes between groups was calculated. Probabilistic sensitivity analysis using bootstrapping was performed.

RESULTS

The RCT included 1461 residents; 146 and 125 seniors completed the EQ-5D-3L in intervention and control buildings, respectively. There was a significant adjusted mean QALY gain of 0.03 (95% CI 0.01 to 0.05) for the intervention group. Total programme cost for implementing in five communities was $C128 462 and the reduction in EMS calls avoided an estimated $C256 583. The ICER was $C2933/QALY (bootstrapped mean ICER with Fieller's 95% CI was $4850 ($2246 to $12 396)) but could be even more cost effective after accounting for the EMS call reduction.

CONCLUSION

The CP@clinic ICER was well below the commonly used Canadian cost-utility threshold of $C50 000. CP@clinic scale-up across subsidised housing is feasible and could result in better health-related quality-of-life and reduced EMS use in low-income seniors.

TRIAL REGISTRATION NUMBER

Clinicaltrials.gov, NCT02152891.

Type 2 Diabetes Risk in Older Adults Living in Social Housing: A Cross-Sectional Study

OBJECTIVES

This study aimed to describe the risk of developing diabetes and the probable prevalence of diabetes and prediabetes in residents of subsidized or social housing who were 55 years of age or older.

METHODS

We conducted a cross-sectional study using data collected from an ongoing community health program in social housing buildings-the Community Paramedicine at Clinic (CP@clinic) program. Community paramedics staffing the CP@clinic program conducted lifestyle-related modifiable risk factor assessments of participating social housing residents who were 55 years of age or older. The Canadian Diabetes risk assessment (CANRISK) tool was administered to all participants, and those with moderate-to-high risk of developing diabetes were asked to return for a fasting capillary blood glucose (CBG) measurement. Data were collected from program participants who attended the sessions between December 2014 and May 2018.

RESULTS

There were 728 participants. Most were women (80.5%), aged 65 to 84 (68.1%), white (85.4%) and educated to the high school level or less (69.2%). At baseline, 71.3% were identified as having overweight or obesity, and 12.5% were diagnosed with diabetes. Of participants not diagnosed with diabetes (N=632), 66.6% were at high risk of developing diabetes, and 30.1% were categorized as moderate risk. The CBG assessments showed that 37.7% (N=158) of those with high risk and 22.0% (N=42) of those with moderate risk had blood glucose readings indicating impaired fasting glucose or probable diabetes.

CONCLUSIONS

This study shows that 96.7% of low-income older adults in social housing buildings had moderate-to-high risk of developing diabetes and that the probable prevalence of undiagnosed prediabetes and diabetes was 32.0%.

Exploring New Models for Cardiovascular Risk Reduction: The Heart Outcomes Prevention and Evaluation 4 (HOPE 4) Canada Pilot Study

Background

There is a gap between evidence and practice in the management of cardiovascular (CV) risk. Previous research indicated benefits from community-based, multi-faceted interventions to screen, diagnose, and manage CV risk in people with hypertension.

Methods

The Heart Outcomes Prevention and Evaluation 4 Canada pilot study (HOPE 4) was a quasi-experimental pre-post interventional study, involving one community each in Hamilton, Ontario and Surrey, British Columbia, Canada. Individuals aged ≥50 years with newly diagnosed or poorly controlled hypertension were included. The intervention was comprised of: (i) simplified diagnostic/treatment algorithms implemented by community health workers (firefighters in British Columbia and community health workers in Ontario) guided by decision support and counselling software; (ii) recommendations for evidence-based CV medications and lifestyle modifications; and (iii) support from family/friends to promote healthy behaviours. The intervention was developed as part of the international Heart Outcomes Prevention and Evaluation 4 Canada pilot study trial and adapted to the Canadian context. The primary outcome was the change in Framingham Risk Score 10-year CV disease risk estimate between baseline and 6 months.

Results

Between 2016 and 2017, a total of 193 participants were screened, with 37 enrolled in Surrey, and 19 in Hamilton. Mean age was 69 years (standard deviation 11), with 54% female, 27% diabetic, and 73% with a history of hypertension. An 82% follow-up level had been obtained at 6 months. Compared to baseline, there were significant improvements in the Framingham Risk Score 10-year risk estimate (30.6% vs 24.7%, P < 0.01), and systolic blood pressure (153.1 vs 136.7 mm Hg, P < 0.01). No significant changes in lipids or healthy behaviours were noted.

Conclusions

A comprehensive approach to health care delivery, using a community-based intervention with community health workers, supported by mobile-health technologies, has the potential to significantly reduce cardiovascular risk, but further evaluation is warranted.

Poverty and food insecurity of older adults living in social housing in Ontario: a cross-sectional study

BACKGROUND

Poverty and food insecurity have been linked to poor health and morbidity, especially in older adults. Housing is recognized as a social determinant of health, and very little is known about subjective poverty and food insecurity in the marginalized population of older adults living in subsidized social housing. We sought to understand poverty and food insecurity, as well as the risk factors associated with both outcomes, in older adults living in social housing in Ontario.

METHODS

This was a cross-sectional study using data collected from the Community Paramedicine at Clinic (CP@clinic) program. A total of 806 adult participants residing in designated seniors' or mixed family-seniors' social housing buildings attended CP@clinic within 14 communities across Ontario, Canada.

RESULTS

The proportion of older adults reporting poverty and food insecurity were 14.9 and 5.1%, respectively. Statistically significant risk factors associated with poverty were being a smoker (AOR = 2.38, 95% CI: 1.23-4.62), self-reporting feeling extremely anxious and/or depressed (AOR = 3.39, 95% CI: 1.34-8.62), and being food insecure (AOR = 23.52, 95% CI: 8.75-63.22). Statistically significant risk factors associated with food insecurity were being underweight (AOR = 19.79, 95% CI: 1.91-204.80) and self-reporting experiencing poverty (AOR = 23.87, 95% CI: 8.78-64.90). In those who self-reported being food secure, the dietary habits reported were consistent with a poor diet.

CONCLUSION

The poverty rate was lower than expected which could be related to the surrounding environment and perceptions around wealth. Food insecurity was approximately twice that of the general population of older adults in Canada, which could be related to inaccessibility and increased barriers to healthy foods. For those who reported being food secure, dietary habits were considered poor. While social housing may function as a financial benefit and reduce perceived poverty, future interventions are needed to improve the quality of diet consumed by this vulnerable population.

Development of a Logic Model to Guide Implementation and Evaluation of a Mobile Integrated Health Transitional Care Program

To provide medical and social services to underserved communities, many health care organizations across the United States have expanded the role of emergency medical services to include mobile integrated health and community paramedicine (MIH-CP). Although MIH-CP programs differ in structure and setting, many share the common goal of improving health through home-based, patient-centered care management models. Ideally, these innovative programs reduce use of health care services, including 911 (US emergency system) calls and emergency department visits. In 2018 a large, urban academic medical center partnered with the city's fire department to establish an MIH-CP program to support patients as they transition in their first 30 days at home after hospitalization. Prior to launch, a multidisciplinary team developed a logic model to guide development, implementation, and evaluation of this complex and innovative program. This paper describes the team's structured process for developing a logic model. It also describes key components of the initial logic model and the Transitional Health Support program structure, as well as subsequent revisions to both.

Video or Telephone? A Natural Experiment on the Added Value of Video Communication in Community Paramedic Responses

STUDY OBJECTIVE

The objective of this study was to determine the effect of video versus telephonic communication between community paramedics and online medical control physicians on odds of patient transport to a hospital emergency department (ED).

METHODS

This was a retrospective analysis of data from a telemedicine-capable community paramedicine program operating within an advanced illness management program that provides home-based primary care to approximately 2,000 housebound patients per year who have advanced medical illness, multiple chronic conditions, activities of daily living dependencies, and past-year hospitalizations. Primary outcome was difference in odds of ED transport between community paramedicine responses with video communication versus those with telephonic communication. Secondary outcomes were physicians' perception of whether video enhanced clinical evaluation and whether perceived enhancement affected ED transport.

RESULTS

Of 1,707 community paramedicine responses between 2015 and 2017, 899 (53%) successfully used video; 808 (47%) used telephonic communication. Overall, 290 patients (17%) were transported to a hospital ED. In the adjusted regression model, video availability was not associated with a significant difference in the odds of ED transport (odds ratio 0.80; 95% confidence interval 0.62 to 1.03). Online medical control physicians reported that video enhanced clinical evaluation 85% of the time, but this perception was not associated with odds of ED transport.

CONCLUSION

We found support that video is considered an enhancement by physicians overseeing a community paramedicine response, but is not associated with a statistically significant difference in transport to the ED compared with telephonic communication in this nonrandom sample. These results have implications for new models of out-of-hospital care that allow patients to be evaluated and treated in the home.