In the United States, EMS-based mobile integrated healthcare (MIH) and community paramedicine is regarded as one of the most significant innovations in EMS in decades. But MIH programs have been in existence for decades in countries like Canada, the United Kingdom and Australia.
United Kingdom
The origins of mobile integrated healthcare in the U.K. began over 10 years ago in the largely rural English counties of Norfolk and Suffolk. At the turn of the century, U.K. ambulance services had to solve a simple rural service conundrum: If you were the first patient who called, you received the solitary ambulance and, if transport was required, you’d be taken on the 30-mile ride to hospital. If you were the second patient, you could face a long and potentially life-threatening wait.
The solution developed by East Anglian Ambulance Service CEO and primary care physician Chris Carney, MD, was a relatively simple one: Place a lone paramedic in rural areas to ensure a clinical presence and, if necessary, perform lifesaving interventions.
Primary care centers were approached to house the so-called “community paramedics” and their services offered for free to the clinics provided they were allowed to respond when the ambulance pager went off. The system worked very well. Over time, confidence in the paramedics grew and primary care physicians soon realized that the paramedics brought with them mobile health delivery capabilities.
The ability to conduct and interpret 12-lead ECGs, deliver phlebotomy services and, importantly, conduct screening house calls on behalf of the doctor, very quickly won hearts and minds of both the residents and the physicians.
Part of the development of this new healthcare provider required an educational process to make a transition from core emergency response skills to those of primary care skills. In the words of the East Anglian Ambulance medical director at the time, John Scott, MD, “If the paramedic sees a patient with his ear hanging off, he will know exactly what to do; if the same medic saw the same patient with a rash in the ear, he will not know what to do.”
To meet his need, a course was developed to enhance the primary care skills of the community paramedics. Those who successfully completed the training and credentialing process were dubbed emergency care practitioners (ECPs).
One primary care practice in the Norfolk market town of North Walsham, under the medical direction of Paul Everden, MD, developed the Appropriate Care at the Point of Need (ACAPON) system that was launched in a small community in April 2002.1
Everden’s Birchwood Medical Centre introduced a community paramedic (on loan from the East Anglian Ambulance Service) to its healthcare team comprised of a general practitioner, a practice nurse and a healthcare assistant to form a unified multidisciplinary healthcare team. The aim of the project was to provide more appropriate immediate and emergency care within the community through improved access and assessment.
At approximately the same time, in the equally rural areas of southern Yorkshire, similar programs were unfolding. By 2004, the assistant medical director of the East Anglian Ambulance Service, Scott Turner, MD, developed a broader scope ECP program as the spread of community paramedics proliferated.
Today, ECPs are an integral part of the National Health Service (NHS) Ambulance Trusts, providing primary care and patient navigation services throughout the country.
Canada
Toronto: The Toronto EMS community paramedicine program was developed in 1999. It’s a non-emergency, community-based service with a focus on health promotion and injury prevention in urban areas. The mission of this program is to help patients in the community solve some of their medical and care problems before they become real emergencies.
Staffed with paramedics and nurse practitioners, the mobile health bus offers free clinic services throughout the city of Saskatoon, Canada. Photo courtesy Crestline Coach Ltd.
Michael Nolan, president of the EMS Chiefs of Canada, says the aim of community paramedics is to bridge the gap between acute care and primary healthcare, and to help people who aren’t getting help from anyone else in the community and so are relying heavily on emergency services to get the regular care they need. Services offered by this program include heat surveillance, window and balcony safety, vaccinations (influenza, hepatitis A, meningitis C and streptococcal pneumonia), infection prevention and control, and community referrals by EMS (CREMS).2 This program was profiled in a 2007 JEMS article on Canada’s initial offering of mobile integrate healthcare, predicting this was a role that agencies throughout the United States would eventually follow.3
Nova Scotia: In 2001, an innovative practice launched that focuses on increasing access to healthcare professionals in two remote places in Nova Scotia. The initiative is a health service delivery model that introduced a novel collaboration with registered nurse practitioners (NPs).
The first phase of this model was established in an ambulatory base with increased access to paramedic care. Paramedics provided 24/7 ambulatory care to residents. Paramedic services expanded in the second phase to include clinical roles and delivery of non-emergency services.
The third phase marked the addition of the NP and, consequently, led to increased development of non-emergency services by the NP, of complex care by the paramedics, and of prevention and promotion programs by the healthcare team.
Saskatchewan: In 2008, Saskatchewan piloted a “health bus” staffed with a combination of NPs and paramedics that offers free clinic services throughout the city of Saskatoon. The pilot program, conducted in a makeshift motor home, was so successful that the province has made it permanent, with a brand-new bus customized for this use put into service in 2012.5
The concept was born in the spring of 2007 when MD Ambulance sent two representatives to a U.K. trade mission as part of a Canadian delegation. One of the programs running successfully in the U.K. was “mobile community medicine,” which involved NPs and paramedics working side-by-side delivering patient care in communities. MD Ambulance paramedics brought this idea back to Saskatchewan and shared it with the Saskatoon Health Region.
After several months of research and fact finding, the program was ready to be shared with the Saskatchewan Ministry of Health.
In this model, community health, primary healthcare and EMS came together to create a world-class project based on best practices and strong partnerships. The health bus provides blood pressure screening, blood glucose checks, general health checks, chronic disease management, health education, wound care and flu shots.6
Australia & New Zealand
One third of Australia’s population lives outside its major cities. Of this non-metropolitan population, almost 20% is dispersed across more than 1,500 rural and remote communities with fewer than 5,000 residents.7
Often these isolated rural and remote communities are too small to support traditional models of health delivery locally, so residents must access care from larger urban centers. In order to address these access and service problems, specific measures targeting rural health were featured in annual national government budgets from the early 1990s.
In 1994, the Australian Health Ministers’ Conference endorsed the first National Rural Health Strategy, paving the way for community paramedics to help serve in a primary care substitution model.
Ambulance staff, trained in additional clinical skills, are sent to patients with conditions considered amenable to treatment in their own homes or local communities. In the Sydney West-Nepean catchment area, the ECP program commenced operations in December 2007 and the South Australian Ambulance Service introduced an ECP program in the metropolitan area in December 2008.8
Facing a similar challenge to delivering healthcare to rural citizens, compounded by a shortage of general practitioners and rising ED admission rates, New Zealand’s Wellington Free Ambulance (WFA) service initiated an ECP model of care in May 2009 called Urgent Community Care for the Kapiti Coast, a rural district with approximately 50,000 residents and a high proportion of over-65-year-olds.9 WFA expanded the concept to Porirua in July 2014 in an effort to reduce that area’s high ED admission rate for children under 9 and older people aged 55—64.10
In rural areas of New Zealand, Urgent Community Care paramedics have the ability to treat non-acute illness and injury and provide patient navigation services so as to avoid transport and unnecessary ED admission. Photo courtesy Wellington Free Ambulance.
9-1-1 Nurse Triage
One of the interventions that may comprise an MIH program is a nurse triage system that uses specially trained nurses, paired with computerized decision support software systems such as the Priority Solutions LowCode software.
The early roots of modern 9-1-1 nurse triage systems can be traced to the U.K. NHS. NHS Direct, the 24-hour telephone advice line staffed by nurses, was introduced in three pilot sites in 1998 and extended to 22 sites, covering the whole of England, during 2001. This early concept was accessed through the use of a designated alternate number to 9-9-9, the U.K. emergency access number. Nurse advisors used computerized decision support software to triage callers to self-care, to contact their general practitioner immediately or later, or to attend accident and emergency departments urgently, or as an emergency via ambulance.
The East Anglian Ambulance Service NHS Trust, off the back of their introduction of community paramedics, also introduced one of the first versions of the Priority Solutions Integrated Access Management programs that allowed diversion of 9-9-9 low-acuity patient cases to the nurse call taker to offer “hear and treat” services.
This delivery model wasn’t integrated into the NHS ambulance component until 2006, when a study evaluated a small pilot of the NHS Direct concept into the NHS ambulance 9-9-9 control center and concluded that transferring non-urgent 9-9-9 calls for further advice and assessment provides a safe and cost-effective service for some of these calls. Today, the nurse triage system is fully integrated with the 9-9-9 service for specific response determinants through its emergency medical dispatch system.11
The concept of 9-1-1 nurse triage was first brought to the U.S. in Richmond, Va., by the Richmond Ambulance Authority in 2004. The Richmond system, despite its pioneering intentions, struggled due to a lack of care pathways in which to appropriately refer patients. Quite simply, the program was ahead of its time and not ready for implementation, and it was reluctantly suspended until conditions are created to properly implement the service. Today, 9-1-1 nurse triage systems are used in locations such as Louisville, Ky.; Fort Worth, Texas; and Reno, Nev.
Conclusion
Although many EMS systems, medical directors, state health administrators and legislators feel that EMS-based MIH and the work performed by the involved EMTs and paramedics extends beyond state or regional protocols, the reality is that they do not. As the international programs profiled in this article illustrate, MIH initiatives are a key part of illness and injury prevention, which the U.S. federal government and most state EMS agencies have adopted as one of the critical components of an EMS system.
References
- Everden P, Eardley M, Lorgelly P, et al. Emergency care. Change of pace. Health Serv J. 2003;113(5865):28—30.
- Wang H. Summary of community paramedicine evidence. (January 2011.) International Roundtable on Community Paramedicine. Retrieved May 4, 2015, from www.ircp.info/Downloads/Research.
- Garza M. Beyond EMS. Community paramedics make house calls. JEMS. 2007;32(9):62—68.
- Long and Brier Island community paramedicine project. (March 6, 2013.) Accreditation Canada. Retrieved May 4, 2015, from www.accreditation.ca/long-and-brier-island-community-paramedicine-project.
- Lunau K. (Nov. 16, 2011.) Where the clinic hits the road. Maclean’s. Retrieved May 4, 2015, from www.macleans.ca/society/health/where-the-clinic-hits-the-road/.
- Health bus. (2009.) MD Ambulance. Retrieved May 4, 2015, from www.mdambulance.com/healthbus.aspx.
- Tham R, Humphreys J, Asaid A, et al. “˜Making a difference’–The impact of sustainable primary health care on rural health [conference paper]. 10th National Rural Health Conference: Cairnes, Australia, 2009.
- Finn JC, Fatovich DM, Arendts G, et al. Evidence-based paramedic models of care to reduce unnecessary emergency department attendance–feasibility and safety. BMC Emerg Med. 2013;13:13.
- Swain AH, Hoyle SR, Long AW. The changing face of prehospital care in New Zealand: The role of extended care paramedics. N Z Med J. 2010;123(1309):11—14.
- Community-led trial to improve Porirua health and social outcomes. (Dec. 5, 2013.) New Zealand Ministry of Health. Retrieved May 4, 2015, from www.health.govt.nz/news-media/news-items/community-led-trial-improve-porirua-health-and-social-outcomes.
- Turner J, Snooks H, Youren A, et al. (April 2006.) The costs and benefits of managing some low priority 999 ambulance calls by NHS Direct nurse advisers. University of Sheffield. Retrieved May 4, 2015, from www.sheffield.ac.uk/polopoly_fs/1.43653!/file/The-costs-and-effectiveness-of-managing-low-priority-999-ambulance-calls-by-NHS-Direct-nurse-advisors.pdf.
