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

Gina Agarwal; Amelia Keenan; Melissa Pirrie; Francine Marzanek-Lefebvre

doi:10.9778/cmajo.20210179

Article Figures & Tables

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Table 1:

Summary of attendee characteristics

Characteristic	No. of attendees
Professional affiliation, n = 89
Paramedic service	59
MOHLTC	9
Electronic medical record stakeholders	7
Research institution	4
Community social support organizations	4
Base hospitals and regulatory bodies	4
Municipality	1
Not disclosed	1
Role within paramedic service, n = 59^*
Community paramedic	15
Leader	27
Manager or coordinator	12
Other paramedic	5
Location of paramedic service participants in Ontario, n = 59^*
Central West	23
Central East	10
South West	10
Eastern	8
North East	6
North West	2

Note: MOHLTC = Ministry of Health and Long-Term Care.
↵* Only among attendees affiliated with a paramedic service.

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Table 2:

Illustrative quotes from large-group discussion, by attendee group

Themes and subthemes	Illustrative quotes
1. Role of community paramedics
(A) Visit or call	[We make] sure that people who want to stay home can stay at home; people in their homes, the whole 9-1-1 trip to the ER. These are things that we currently do now. (Group 1)
(B) Complex needs and diversity of clients	We often say that “CP fills the gap” but, as a matter of fact, you don’t fill a gap as much as you address a challenging situation that doesn’t fit in sort of one particular pot. (Group 2)
(C) Identify social concerns	[During the] medical assessment that [we do], [an important part] is uncovering these social situations that are leading to the medical concerns. (Group 2)
(D) Adapt	We’re all paramedics that are doing the CP work and pretty much we’re all very adaptable people. It’s something that we kind of pride ourselves in — our ability to walk into various locations, various places, and come out having made friends, come out having gained the confidence of the people we need to gain the confidence of. I call it the chameleon effect. (Group 1)
(E) Patient advocacy	Getting things advocated for your patients … making sure that the patient gets what they need in the way of treatments and in the way of attention. (Group 1)
(F) Target long-term disease	Ultimately, we should all strive to get involved in [clinics]. It’s probably a really good thing; it will minimize calls if you can nip that sort of long-term disease process in the bud — or at least control it. Then, it’s not going to become as much of an issue down the road. (Group 1)
2. Integration with other services
(A) Fit with primary care and social service	The fit is really with primary care and the social service system. So I think we can agree that in Ontario, although it’s all maybe under a giant umbrella of primary care, the 2 systems sometimes don’t work so well together. (Group 2)
(B) In patient care pathway	Basically, communications with the physicians … and making sure that the physician is on board with you — number one: interjecting yourself into his client or patient’s relationship with him. (Group 1)
(C) Make contact and operationalize relationships	The biggest problem is finding some sort of system to make contact with the family doctors, and in particular the solo physicians. (Group 1)
3. Support for CP
(A) Support and acceptance from family physicians	One of the things, of course, that we need to do is obtain buy-in. (Group 3)
(B) Communicate benefits of CP	Somebody mentioned getting into the medical schools so that medical students are learning from the get-go that paramedics are out here, we have a very high skill set, and we are more than willing to work with them to help and benefit their clients. (Group 4)
(C) Central promotion	Centralized awareness — coming up with a system where we can make CP more known with the primary care group. (Group 2)
4. Standardization
(A) Guidelines and directives	[It would be good to have] clinical practice guidelines that we could share with [physicians] and they can approve or at least know what we’re doing. (Group 3)
(B) Skills and equipment	As for the actual oversight, it [is] an issue of standardization of practice. There are something like 8 or 10 [individual paramedic services] in [1] base hospital control [but they] all have somewhat different … equipment; they might have slightly different skill sets. (Group 4)
(C) Documentation and reporting	I know what the documentation is here in < name of region >. I don’t know how it’s different in other services. We need to be talking about the documentation so that everybody is doing the same reports. (Group 4)
(D) Build reputation	We need to establish standardization and have some continuity and … best practice — some clinical best practices — so that the physicians know that it is not a fly-by-night practice that we’re doing. (Group 3)
(E) Need to account for context	It struck me that in our group there were several types of CP programs — all different ways of receiving referrals, all different ways of sort of managing the patient load. And so that right there is great and I think that is what has to happen in Ontario because of the diversity in geography and practice patterns in primary care. (Group 2)
(F) Pilot projects within jurisdictions	If you wanted to work with the LHINs and they’re trying to say “well, you have to do something that is established across the whole LHIN boundaries,” and we have services that have more than 1 LHIN, and certainly have multiple Health Links, then maybe you could do demonstration projects, or pilot projects, within certain areas within that LHIN that could address a certain geographical need within that area. (Group 3)
5. Oversight
(A) External medical directives	When we’re on the road, we’re not truly working as [paramedics], we’re working as community paramedics. So, using our skills is sort of outside the realm of what we should be doing [as paramedics]. So using a medical control … would allow for … different skill levels. What that would allow for is us to do basic checking … for antibiotics, blood, urine dip, that sort of thing; taking blood, sending someone to an urgent care centre [instead of] an ER, to keep the ERs clear. And those are just a few of the things that we came up with. (Group 1)
(B) Need to centralize oversight	If base hospitals could take on a family physician, not as a full-time, but as somebody we could turn to so we’re still only responsible to the base hospital … [perhaps a] family physician … could be taken in on contract with the base hospital. Then, it would all still be 1 oversight. (Group 4)
(C) Self-regulation	Places that do have successful CP programs do have self-regulation — you look at Great Britain, where actually the paramedics are consulting with physicians rather than getting delegation from physicians … paramedics are considered as health care providers, not ambulance drivers …. (Group 3)