Community Paramedicine Models for Improving Access to Primary Care

Community paramedics play an important role on a patient's care team because they can deliver basic primary care services in the patient's home without requiring them to travel to a clinic. In rural communities where transportation may be difficult to obtain or distance is a barrier, community paramedicine services can ensure prompt care and identify health issues that need to be escalated to another provider. Community paramedics can also facilitate communication between the patient and their primary care provider.

Connecting with Primary Care

In rural communities, limited transportation may be a barrier to accessing primary care, especially for people who are elderly or homebound. Community paramedics help fill that gap by offering these services directly in the patient's home. In addition, if specified as part of the patient's care plan, community paramedics can help connect patients with a new primary care provider or medical home.

Monitoring Vital Signs

Community paramedics can conduct a variety of physical assessments during a home visit, including weight, blood pressure, heart rate, blood glucose, and oxygenation level. Routine monitoring of these data helps providers understand what is “normal” for a given patient and detect changes that indicate a potential problem. For example, weight gain in patients with congestive heart failure often indicates their condition is getting worse.

Vital signs readings can be shared with the patient's primary care provider or other specialists managing their care. Changes may signal to the provider that the patient's medications should be adjusted or other interventions should be explored.

In addition to vital signs checks during a home visit, some rural community paramedicine programs use in-home patient monitoring devices that send data remotely to the paramedic using Bluetooth or Wi-Fi connectivity. Providers can more closely manage their patient's vital signs without requiring a home visit, though one may be triggered if the patient's health status changes unexpectedly.

Other Primary Care Functions

Depending on scope of practice regulations in the state in which the program is operating, community paramedics can complete additional activities that often take place in primary care settings. This is particularly beneficial when patients are unable to obtain transportation to their primary care provider or live in frontier and tribal communities where primary care services are limited.

Specimen collection. During a home visit, community paramedics can draw blood, collect urine, or obtain other materials that are needed for laboratory tests ordered by the patient's provider. These specimens are then transported to a laboratory for analysis. The patient’s provider can discuss the results with the patient by phone, or the community paramedic can share them at a follow-up visit. Alternatively, some community paramedicine programs are exploring point of care testing, which is done by the paramedics while at the patient's home. In consultation with the provider, results of these tests can help the paramedic make decisions about whether a patient needs prompt care at a medical facility.

Vaccination. Working with the local health department, community paramedics can provide routine vaccinations to their patients, including seasonal influenza, childhood vaccines, and hepatitis A. This service can be particularly important for homebound older adults or people living with disabilities who are at increased risk for developing serious flu complications.

Wound care. Chronic wounds or wounds that do not heal properly can be due to poor circulation in the legs and feet, a complication of diabetes, or pressure ulcers resulting from poor mobility. Treatment is beneficial to speed healing and minimize the risk of infection. Depending on the patient's needs and program protocols, community paramedics may make a home visit or use telehealth to examine the wound for concerning changes that indicate an infection and clean and dress the wound as needed.

Examples of Rural Community Paramedicine Programs Improving Access to Primary Care

The Laguna Community Paramedicine Program at the Laguna Fire and Rescue Department in western New Mexico was formed to serve members of the Pueblo of Laguna. Based on previously identified needs in the community, the program focused on chronic wound care for geographically isolated, elderly patients who were unable to travel long distances to Albuquerque for regular treatment. In the first two years of the program, community paramedics made 221 visits and saw improvement in patients' conditions.
The Regional Emergency Medical Services Authority (REMSA) in Washoe County, Nevada, uses remote health monitoring devices to track patients' vital signs. The Bluetooth devices, which were purchased through a USDA grant, monitor blood pressure, blood oxygen, weight, and physical activity. This information is then transmitted back to the patient's medical record, where community paramedics can monitor their health and share data with the patient's primary care provider. REMSA also offers in-home nebulizer treatments, intravenous rehydration, EKG testing, and point-of-care lab tests to provide immediate results to the patient's healthcare provider.
Located in a rural resort community in Colorado, Eagle County Paramedic Services runs one of the longest-standing community paramedicine programs in the U.S. Its comprehensive services include a well-baby program, blood draws, wound checks, immunizations, and intravenous catheter changes. In the first 18 months of the pilot, the program reported a net cost savings of $288,028.

Considerations for Implementation

If the program does not have available resources to increase the certification level for participating staff, one option may be to partner with a community nurse from the public health department who has an additional license and can provide primary care services that are out of the paramedic's or emergency medical technician (EMT)'s scope of practice. This model can increase the range of services provided by the program and help strengthen partnerships with local public health authorities.

One key to success is implementing data systems that share patient information across platforms with emergency medical services (EMS), the local hospital, primary care, and other healthcare providers. This kind of data sharing ensures all members of the patient's care team are aware of changes in health status, hospital admissions, and updated prescriptions. There are several EMS data platforms with built-in capability to interface with major electronic health record providers that capture the work of community paramedics, which are structured differently from traditional incident-based EMS systems. If technical incompatibility makes it challenging to share patient data, case conferencing with providers, EMS, and community organizations can accomplish many of the same goals while coordinating care plans and avoiding duplication.

Some pharmaceutical or medical equipment manufacturers provide patients with free glucose meters. Community paramedics can work with distributors to obtain the glucose meters and provide education to the patient on how to use and care for their new device. Newer glucose meters provide historical data to the patient's primary care provider about how often they are checking their blood sugar and what the readings have been. This information helps the provider understand how well the patient is managing their diabetes at home.

Program Clearinghouse Examples

Resources to Learn More

Community Paramedicine Remote Patient Monitoring (CPRPM): Benefits Evaluation & Lessons Learned, April 2015 – December 2017
Document
Evaluates a Canadian remote patient monitoring program administered by community paramedics in which patients use at-home monitoring devices to transmit readings to providers, allowing for additional follow-up care. Includes lessons learned, the benefits of a patient portal, and the best methods for providing meaningful data. Covers key implementation considerations that could be valuable to U.S.-based programs.
Author(s): Brohman, M.K., Green, M.E., Dixon, J., Whittaker, R., Fallon, L., et al.
Organization(s): Sustainable Execution Research Collaborative, Canada Health Infoway
Date: 5/2018