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Community Paramedicine: A New Approach to Health in Rural Communities

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Health &
Wellness
extension.usu.edu/HEART/

January 2021

Community Paramedicine: A New Approach to

Health in Rural Communities
Kira Swensen, BS; Tim Keady, MS; Ashley Yaugher, PhD; Kandice Atismé, MPH; Emma Parkhurst; MS;
Hailey Judd, MPH; Maren Wright Voss, ScD

What Is Community Paramedicine? Other programs focus on improving post-hospitalization

The community paramedicine (CP) concept is becoming outcomes and use CP practitioners to provide scheduled,
widely used in rural communities to assist in maintaining post-discharge follow-ups with patients (Patterson et al.,
and improving health across economic and geographic 2016).
disparities. This model utilizes highly trained emergency
medical service (EMS) professionals under the Many people, especially older adults, find that aftercare
supervision of a physician or other advanced practice is difficult after receiving care at the hospital or an
practitioner (i.e., physician assistants and advanced emergency department (ED) (Shah et al., 2018). CP is
practice registered nurses; Patterson et al., 2016) to equipped to provide around-the-clock care that is always
provide a variety of needed health services tailored to accessible as part of the community's existing
community needs. CP has been shown to be effective in emergency services. Further, CP builds a bond of trust
many communities and, given these positive results, when paramedicine providers offer health coaching
should be considered in rural communities where
(Nejtek et al., 2017). CP paramedics help with the
geographic barriers limit access to healthcare (Martin &
follow-up care that is personalized and includes a
O'Meara, 2019). This fact sheet will review the positive
impacts that CP can have in a community, the policy medical education component, which improves patient
required to start CP, and how individuals can advocate satisfaction and health (Cameron & Carter, 2019; Nolan
for CP in their community. et al., 2018; Shah et al., 2018). In types of medical issues

How Community Paramedicine Can Help

CP with EMS providers can serve many issues and
provide preventative care or aftercare as well as testing
for health conditions (Patterson et al., 2016). While the
broad concept is the same in using the skills of
accessible EMS professionals, each community uses CP
in a different way to meet the health needs of the area
(Figure 1). Some programs assist with the maintenance
of chronic diseases and offer in-home primary care
services utilizing CP practitioners (Nolan et al., 2018).
that carry stigma (e.g., infectious disease, substance use, • Increasing revenue by billing patients or third-
mental health issues, etc.), having a trusted CP offering party payers for services provided, when
in-home services can lead to early intervention and appropriate" (Rural Health Information Hub,
better care. n.d.).
• Reducing paramedic service utilization and
hospital attendance and improving health
outcomes.
• Significantly increasing health care cost savings
(Martin & O'Meara, 2019).

How Community Paramedicine Works

The Joint Committee on Rural Emergency Care
(JCREC) defines a CP paramedic as someone who:
• Holds a state-license as an EMS professional.
• Completes an appropriate education program.
• Demonstrates competence in the provision of
health education, monitoring, and services.
• Monitors chronic disease and educates patients.
(Rural Health Information Hub, n.d., para. 4)
The general paramedicine curriculum from the National
Association of Emergency Medical Technicians (n.d.)
Figure 1. Uses of Community Paramedicine Programs operates under the supervision of a physician or
advanced practice provider and is conducted by a
CP is promising for reducing healthcare costs as well as paramedic or EMS care provider that has extensive
improving access to services (Patterson et al., 2016). training. It includes the following EMS training and
Specifically, by addressing the education of patients on skills:
various topics (e.g., managing chronic conditions, • Assessing patients.
mental health, aftercare, etc.), improving access to health • Initiating life-sustaining stabilization.
monitoring, and improving supports for vulnerable • Treating acute or chronic illness and/or injuries.
populations, CP can fill a gap in health services (Martin • Transporting to an ED.
& O'Meara, 2019). The use of CP for mobile integrated
• Releasing to a higher level of care.
health services can improve quality of life, reduce pain,
• Performing all trained skills, including:
and improve mobility (Gregg et al., 2019; Nejtek et al.,
o Advanced airway management (such as
2017). Additionally, this model improves patient
endotracheal intubation).
satisfaction with their health care needs (Gregg et al.,
o Electrocardiographs (ECGs).
2019).
o Inserting intravenous (IV) lines.
o Administering numerous emergency
There are many barriers in rural areas that lead to lack of
medications.
services, and one way to help with this is increased
o Assessing ECG tracings.
public health services along with training professionals
o Defibrillation.
to implement more comprehensive services (Johansson
et al., 2019). CP is essential for many rural communities
Beyond the skills listed above, the additional clinical
that do not have access to critical healthcare resources
and is expanding with more home care partnerships and educational requirements under the CP model include
wellness clinics (Cameron & Carter, 2019). CP can training in preparing and following an existing
benefit rural communities and EMS agencies by: collaborative medical care plan for a patient's health care
• "Reducing 9-1-1 requests for non-urgent, non- services outside of the hospital.
transport services that are not reimbursable.
• Decreasing the 'downtime' between calls,
exercising medical skills, and improving access
to providers to meet the community's primary
care needs.
Goals of Community Paramedicine assessments, wound care, and more (Pearson &
Shaler, 2017).
Goals of the CP Model
Prevent hospitals readmission. 3. California – HOME Team. In California, the
Identify and support frequent EMS and ED users. Homeless Outreach and Medical Emergency
Manage multiple chronic conditions (such as congestive (HOME) Team CP program was developed to find
heart failure (CHF), chronic obstructive pulmonary frequent emergency service users, connect them to
disease (COPD), asthma, and diabetes. community-based care, and advocate for long-term
Evaluate and manage chronic disease. care when appropriate. The HOME Team provided
Assess and stabilize patients with a behavioral health care to 59 individuals who had used emergency
diagnosis. services four or more times per month during the last
Determine alternative destinations (including clinics and 15 months. Approximately one-third were homeless,
doctors’ offices, with appropriate regional EMS scope of and the majority of individuals cared for had a
practice permission). substance use disorder at the time of contact and had
Improve the patient's quality of life. a history of psychiatric disorder. The clinical
Decrease overall healthcare costs. planning resulted in new, long-term care placement
options for patients with both mental health and
CP activities must be allowable/supportable within EMS substance use disorders (Kizer et al., 2013; Rasku et
regulations, licensure, certification, and scope of practice al., 2019).
for the regions and providers utilizing the model. The
use of CP is intended to expand providers’ reach in 4. Pennsylvania, Minnesota, and Colorado.
primary care and the public health service. The specific Organizations like Geisinger in Danville,
rules and services are determined by community health Pennsylvania and North Memorial Health Care in
needs and in collaboration with public health and Robbinsdale, Minnesota are using specially trained
medical direction. paramedics to assess and stabilize at-risk patients,
thus avoiding unnecessary ED visits and
Successful Examples of Community hospitalizations. Colorado CP programs were used
Paramedicine to address the gap between EMS and health care as a
way to cut down on lengthy home health needs and
1. California – Commonwealth Care Alliance. In for home-based primary care ordered by doctors for
recent years, the practice of CP has become chronic disease monitoring and educational services
increasingly utilized with significant successes. (Martin & O'Meara, 2019). In total, 48 states report
Hegwer (2019) showed that Commonwealth Care supporting the CP model of care (National
Alliance, a healthcare company in California, Association of State EMS Officials, 2020). With
reduced unnecessary ED visits and hospitalizations savings of up to $8,500 per patient reported in a
by using CP and specially trained paramedics in study of reduced inpatient ED usage (Ahlers et al.,
targeted California communities. By assessing and 2018), CP is a value in health care that cannot be
stabilizing at-risk patients at home under a ignored.
physician's supervision instead of the hospital, CP
prevented unnecessary transports, ED visits, and 5. Canada. In a rural community in Canada, where
hospitalizations. This change generated savings of community paramedicine has become more
approximately $1,900 per case, with a total cost prevalent, a qualitative study showed a significant
savings of approximately $6 million over one year desire to increase education to provide these
(Hegwer, 2019). essential services (e.g., chronic disease management,
crisis intervention, care for aging populations, and
2. Maine. Maine's population is older than many states, health education) as integral components of
with 18% of the state aged 65 years or older. Maine's implementing this model (O'Meara et al., 2014).
population is also considered rural, with higher
poverty rates and lower incomes. CP was used in
Maine to address these issues by providing episodes Payment Paradigms and Policy
of patient evaluation, advice, and treatment to Considerations
prevent or improve medical conditions within their
The use of EMS providers outside of the traditional
scope of practice, under the direction of a doctor. CP
prehospital care emergency response "load and go"
providers performed blood draws, medication
format is not a new paradigm. Communities have been
reconciliation, diabetes care, in-home fall prevention
relying on licensed/certified paramedics and EMTs for requirements for CP. A community gap assessment has
many years to provide hospital emergency coverage in not been completed for the state, making it difficult to
the event of staffing shortages and catastrophic determine if CP programs will benefit Utah
emergencies. The progression in using EMS providers communities.
outside of their original scope of practice and into CP
and other nontraditional fields occurred in areas with Some challenges of implementing CP include (Flex
fewer traditional medical providers (e.g., MDs, DOs, Monitoring Team, 2014):
NPs, PAs, etc.), noncompliant patients, and high costs • Potential overlap with other healthcare and
(Rural Health Information Hub, n.d.). While EMS is home healthcare professionals.
used in these circumstances, the difficulty has been in • Issues of recruitment, retention, and medical
qualifying for reimbursement and payment for these direction.
nontraditional services. • Geographic barriers.
• Inadequate opportunities along with limited
The ability of states to be reimbursed for care by financial resources for training.
Medicaid is an essential part of the CP equation. In • Issues of licensure, scope of practice,
2013, the Centers for Medicare and Medicaid Services integration, and reimbursement.
(CMS) changed the rule about who could be reimbursed
through Medicaid for delivering preventive services. For Utah to have a successful and sustainable CP
This change allows services by a CP provider to be program, it needs to complete a gap assessment and
covered as long as a physician or other licensed establish important parameters to determine spread
practitioner recommends those services (CMS, 2013).
within the scope of practice and training requirements.
Some states have passed legislation to allow for
reimbursement from Medicaid (Bennett et al., 2018), and
some private insurance companies have agreed to
reimburse for programs (Rural Health Information Hub,
n.d.).

Examples of cost savings and community benefit from

CP include (Hegwer, 2019):
• Improving responsiveness to people with mental
illness.
• Reducing 30-day readmission inpatient rates.
• Improving patients' medication and dietary
prescribed treatment adherence.
• Reducing EMS transports for frequent users. Conclusion
• Providing accelerated patient referrals to Social
Services. The evidence from multiple communities suggests a
• Improving compliance in patients with great deal of value in a CP model, which can offer
tuberculosis (TB). follow-up care, chronic disease management, in-home
• Reducing risks to themselves and the services, patient education, and more. Barriers to
community. reimbursement rates and policy considerations can be
• Reducing the incidence of unwanted transport of addressed, but only if the community’s citizens
patients in hospice. recognize the need for a CP model and advocate for
better access to care. In Utah, the benefits of using EMS
Because CP is a new concept, implementing programs services in geographically dispersed areas to offer better
access to healthcare is a massive advantage of CP
can be difficult because of the lack of rules, regulations,
implementation. By using CP and bringing community
and laws defining the programs. According to an
partners and coalitions together, CP can be adapted to
analysis in 2017, all 50 states have laws for governing fill the healthcare needs and overcome the barriers in
emergency medical systems, while 16 states have laws rural communities.
pertaining to CP, and concluded that there was a lack of
guidance and consistency for CP programs and their
scopes of practice (Glenn et al., 2018). Currently, Utah
does not have enabling legislation or education
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