Community Support Models and Interdisciplinary Healthcare: A Detailed Guide to Community Paramedicine

The Evolution of Community Paramedicine: From Reactive to Proactive Models

• Historically, paramedicine was strictly limited to a reactive model, characterized by responding to $911$ calls with lights, sirens, and immediate emergency transport.
• The community paramedic model represents a transition into a proactive care model. This is an upstream approach to medicine within the community, focusing on preventing crises before they occur rather than simply reacting to them.
• The timeline of community paramedicine development in Ontario includes:
  • Early emergence around $2015$ in areas such as Red Ford County (Renfrew County).
  • Significant expansion throughout the province since $2020$.
  • Initial growth during the COVID-19 pandemic, where paramedics served as a response team for swabbing and vaccinations.
• The primary goals of community paramedicine are to:
  • Leverage community partnerships to fill gaps in the healthcare system.
  • Allow individuals to age safely at home.
  • Mitigate emergency department (ED) presentations for complications that can be managed in the home environment.
  • Serve as a "bridge" for patients who lack a primary care provider or are "unattached" to a family physician.

Clinical Scope of Practice and Mobile Diagnostics

• Community paramedics utilize medical directives to perform clinical interventions that were traditionally reserved for hospital or primary care settings. These directives allow for the treatment of diseases in real time at the patient's bedside.
• Specific medical treatments and diagnostics mentioned include:
  • Urinalysis (UA): Paramedics use portable urinalysis machines to detect leukocytes and nitrates at the bedside.
  • UTI Treatment: If criteria are met, paramedics can treat non-complicated urinary tract infections using medications like Phosphomycin.
  • Cellulitis Management: Paramedics can administer antibiotics such as Subdroxyl (often preferred over Keflex because it requires fewer doses, like one or two per day instead of four, increasing compliance).
• Point of Care (POC) Diagnostics and Tools:
  • Blood Panels: Bedside blood work to monitor levels such as potassium.
  • Point of Care Ultrasound (POCUS): Used to assess bladder volume for catheter reinsertion or to check for consolidations related to pneumonia.
  • Cardiac Assessments: Checking ejection fractions for patients with congestive heart failure (CHF) to determine if Lasix doses should be adjusted.
• The role also involves assessing social and environmental factors, such as falls risk evaluations and medication reconciliation (checking which medications the patient is actually taking versus what was prescribed).

Interdisciplinary Teams and Systems Integration

• Interagency collaboration is defined not just as working alongside others, but as having purposeful communication and learning the specific strengths of each agency to provide "wraparound care."
• Key partnering agencies and organizations include:
  • Ontario Health Teams (OHTs): Specifically Ottawa West Four Rivers and Lanark-Leeds-Grenville.
  • Local Hospitals: Partnering with Kentville District Hospital (KDH) and Brockville General Hospital (BGH) for discharge coordination.
  • Ontario Health at Home: Ensuring community paramedics do not duplicate existing services like home care, but rather add capacity during gaps (e.g., weekends and evenings).
  • Primary Care Providers: Community paramedics act as the "eyes and ears" for physicians and nurse practitioners, providing updates on patient progress in the home.
• The "Tripod" Model: A future-facing or currently piloted interdisciplinary outreach team consisting of:
  • A community paramedic.
  • A nurse practitioner (or RN).
  • A social worker.
• This holistic approach aims to improve the "patient journey" by ensuring no details are lost in translation between hospital discharge and returning home.

Chronic Disease Management: Lower Limb Preservation and Stroke Programs

• Lower Limb Preservation Strategy: Leeds-Grenville has one of the highest amputation rates secondary to diabetic foot infections. To combat this, a one-year working group was established.
  • Screening: Using the Inlow’s diabetic foot screener in the patient's home where they are more comfortable removing their socks compared to a clinic setting.
  • Education: Paramedics underwent a specialized wound care course (NSWOCC - Nurses Specialized in Wound, Ostomy, and Continence Canada).
  • Outcome: In the first six months, $450$ screenings were performed, leading to early detection and treatment of infections, thereby preventing amputations.
• Stroke Programs: Leeds-Grenville was the first in the region (Southeast/Champlain) to implement post-stroke programming.
  • Follow-up Schedule: Paramedics visit post-stroke patients at day $7$, day $30$, and day $90$ following hospital discharge.
  • Prevention: Assessing the $10$ risk factors for stroke and targeting high-risk individuals to prevent recurrence.
• Respiratory Care: Collaborating with Connect Lung Health for COPD exacerbations and utilizing medical directives for treatments like Atrovent.

Outreach and Vulnerable Populations

• Community paramedics engage in outreach to meet "hospital-averse" individuals where they are, such as in encampments.
• Services provided in encampments include:
  • Wound care for untreated injuries.
  • Point of care STI testing and subsequent treatment.
  • Drug testing to identify dangerous batches of substances (e.g., methamphetamine) to alert the community and public health teams.
  • Preventative vaccinations, including Tetanus and Rabies. (Over $200$ rabies vaccinations were administered in the Leeds area last year due to bat exposures).
• Social Determinants of Health: The program addresses health inequities by removing barriers such as lack of transportation or precarious housing situations, embodying the principle of social justice.

Economic Impact and System Capacity

• Cost-Benefit Analysis: The average cost for an individual to walk through an emergency department door in Leeds-Grenville is approximately $\$450$.
• Emergency Department (ED) Diversion: By diverting $1,400$ patients from the ED through community paramedicine interventions, the program provides a Return on Investment (ROI) of:   $1,400 \times 450 = \$630,000$
• These savings free up critical healthcare dollars for other appropriate programs and demonstrate that the model is a "defensible methodology" rather than just "pie in the sky" thinking.
• Capacity Building: Paramedics work non-traditional hours ($365$ days a year, evenings, and weekends), allowing them to support transitions that occur late on Friday afternoons when other services may have reached capacity.

Healthcare Regulation and the Future of Nursing-Paramedic Partnerships

• Regulation Differences:
  • Traditional $911$ Paramedic: Regulated under the Ambulance Act, requiring a base hospital physician.
  • Community Paramedic: Functions as an extension of primary care, often working under the medical directives of a Family Physician or a Nurse Practitioner (NP).
• Integration of Registered Nurse (RN) Prescribing: As nursing programs like Carleton’s begin to embed RN prescribing, there is a growing opportunity for RNs and community paramedics to work together. RNs can focus on complex foot care and prescribing while paramedics provide mobile diagnostic and assessment support.
• Global Models: The UK and Australia are noted for having established Colleges of Paramedicine and Advanced Paramedic Practitioners who carry blood products and have broader prescribing rights.
• Key Professional Pillars:
  • Humility: Recognizing that no single profession knows best and that collaboration is essential.
  • Curiosity: Being inquisitive about systems and not being afraid to challenge the status quo for the sake of better patient care.
  • Advocacy: Using evidence-based practice to influence policy change and improve health outcomes.

Questions & Discussion

• The host reminded students to prepare questions regarding community paramedics, community collaboration, and interdisciplinary work for the in-person session on June 8.
• Discussion emphasized that healthcare is a "small industry" where connections matter, and maintaining professional curiosity and humility will lead to career opportunities and better system-level change management.