Report on the Status of Community Paramedicine in Ontario

Report on the Status of Community Paramedicine in Ontario November 2019 This publication may be reproduced in whole or in-part for noncommercial purposes only and on the condition that the original content of the publication or portion of the publication not be altered in any way without the express written permission of authors. To seek permission, please contact: [email protected] ISBN: 978-1-4868-4034-2 ISN: 2563-0156 Recommended Citation: Matthew S. Leyenaar, Ryan Strum, Mashiat Haque, Michael Nolan, and Samir K. Sinha on behalf of the Ontario Community Paramedicine Steering Committee. “2019 Report on the Status Of Community Paramedicine In Ontario” Toronto: The Ontario Community Paramedicine Secretariat; 2019. Available at: www.ontariocpsecretariat.ca TABLE OF CONTENTS 4Executive Summary 8Background and Context 10 The Work of Ontario Community Paramedicine Secretariat (OCPS) 12 2019 Report on the Status of Community Paramedicine in Ontario 13 Community Paramedicine Characteristics 16 Case Study: County of Simcoe 17 LHIN Reported Data on Community Paramedicine in 2018-2019 18 Emerging and Innovative Community Paramedicine Models and Initiatives 22 Case Study: Niagara 24 Case Study: Champlain 25 Community Paramedicine Program Patient/Client Identification and Referral Sources 26 Community Paramedicine Health System Partnerships 27 Case Study: WaterlooWellington 28 Identified Community Paramedicine Program Implementation Challenges and Opportunities 32 Demonstrating Success Through Ontario-Based Research in Community Medicine 33 Looking Towards a Future for Community Paramedicine in Ontario 36 Conclusion 37 Appendix A 39 Appendix B 40 Appendix C 42 Appendix D 44 Appendix E 45 Appendix F EXECUTIVE SUMMARY The Ontario Community Paramedicine Secretariat was established in 2018 with the support of the Ontario Ministry of Health (MOH) and its 14 Local Health Integration Networks (LHINs). The role of the Secretariat is to support the ongoing growth and development of community paramedicine programs across Ontario, continuing the work that began in 2014 when the MOH began investing $6M annually towards supporting this developing area of care. To better appreciate how the field and practice of community paramedicine is rapidly evolving in Ontario, the OCPS launched its inaugural 2019 Report on the Status of Community Paramedicine in Ontario. This review has involved contacting all 52 municipal paramedic services and all 14 LHINs across Ontario to determine the current state of their LHIN and non-LHIN funded community paramedicine programming. Identified paramedic service representatives were asked a series of structured questions pertaining to their respective program’s goals, characteristics of the individuals and patients they were serving, health system partnerships, successes and challenges, and plans for the future. The following summarizes what was found: Virtually every part of Ontario is now being served by at least one community paramedicine program. Across Ontario’s 52 municipal paramedic services, 48 (92%) are now operating a total of 143 unique community paramedicine programs – representing an average of 3 programs per service that served an estimated record 56,640 individuals and patients in 2018-19. 7(13%) municipal paramedic services were providing a single program, while 4 (8%) were not providing a program at all. Excluding these services, the remaining 41 (78%) were operationalizing an average of 3.4 programs per service. This indicates that the majority of municipal paramedic services across Ontario are now including some additional novel dimension or model of care beyond the three early predominant types of community paramedicine models of care (Assessment and Referral Programs, Community Paramedic-Led Clinics and Home Visit Programs) that were described in the MOH’s 2017 Community Paramedicine Framework for Planning, Implementation, and Evaluation. New models of care that have emerged and spread amongst municipal paramedic services in more recent years include: Remote Patient Monitoring Programs, Community Paramedic-Specialist Response Programs, Hospital Discharge Programs, and Influenza Surge Programs. The rapidly evolving and growing multi-dimensionality of community paramedicine programs being offered appears to represent a growing intentional strategy by Ontario’s municipal paramedic services to provide individuals and patients with greater access to other community-based care providers and services that can help lessen a patient’s reliance on the province’s 9-1-1 safety net and reduce emergency department visits and hospitalizations. 4 Assessment and Referral Programs are the most common type of community paramedicine programming across Ontario The majority of Ontario’s Paramedic Services are operating a variety of community paramedicine programs In 2018-19, 39 (75%) Ontario’s municipal paramedic services were delivering more than one community paramedicine model of care. 35 (90%) were offering Home Visit Programs that served an estimated 3,790 patients, 23 (59%) were offering Community Paramedic-Led Clinics that served an estimated 17,680 patients, 23 (59%) were offering Remote Patient Monitoring programs that served an estimated 2,300 patients, 10 (26%) were offering Community Paramedic-Specialist Response Programs that served an estimated 7,840 patients, and 6 (15%) were offering additional programs that served another 1,990 patients. There is a growing trend of paramedic services operating multi-component or multi-dimensional community paramedicine programs that represents a rapidly maturing community paramedicine landscape across Ontario ever since the MOH’s 2014-2017 demonstration project period. With the growing role that multi-component or multi-dimensional community paramedicine programs are now playing, 24 municipal paramedic services that are offering community paramedicine services stated that they have a complement of between one and three full-time equivalent community paramedics staffing their initiative, while 8 noted that they have at least four or more fulltime equivalent community paramedics employed to deliver their programs. Most municipal paramedic services across Ontario have aligned their community paramedicine programs with their traditional emergency response activities by having all of their frontline paramedics routinely identify individuals and patients who may benefit from a community paramedicine intervention when or if they do call 9-1-1. Currently, community referral programs, through which frontline paramedics connect individuals calling paramedic services with other care providers, is the most common community paramedicine program model in place across Ontario. In 2018-19, 45 (87%) of 52 Ontario municipal paramedic services actively referred 23,040 patients to other services such as LHIN home and community care services through these programs. 5 Towards their goal of better integrating care, municipal paramedic services across Ontario have listed numerous health system partners from home and community care, primary care, long-term care, palliative care, mental health service providers, and public health units who are actively working to deliver more integrated care with them. A number of municipal paramedic services pointed to having team huddles and/or establishing connectivity tables as key characteristics of their programs’ successes. Their successful teamwork approach can be summarized by the following statement: By consistently partnering with other health system partners, community paramedicine programs have ensured that individuals and patients and other health care providers can better navigate the health system, thereby reducing their need to call 9-1-1 and be transported to a local emergency department. Community paramedicine programs continue to also note that their ability to intervene before a patient’s condition worsens is a key marker of their unique impact. Increasingly, community paramedicine programs are demonstrating their considerable capability to redirect 9-1-1 calls, reduce emergency department visits, decrease hospitalizations and avoid revisitations. Furthermore, outcomes data continues to show that for frail individuals and patients enrolled in community paramedicine Home Visit Programs, almost no increased utilization of 9-1-1 services has been observed compared to the previous year, when their utilization would typically be expected to increase with their expected advancing frailty and age. Our willingness to adapt, be flexible, easily reachable, and mobile as Community Paramedics have made us a key method by which other local service providers are utilizing us to overcome their own barriers and challenges in delivering services to their patients. – Guelph Wellington Paramedic Service The most commonly identified goals across all Ontario community paramedicine programs are to connect individuals and patients to other health care services, improve the integration of care, and to reduce repeated utilization of paramedic services. 6 There is a growing broader interest in the development of community paramedicine across Ontario and beyond. The Ontario Community Paramedicine Secretariat has collected 28 media articles, where local, regional and national media outlets have written or reported about the impacts that Ontario community paramedicine programs are having over the past year. The growing publication of research study findings over the last year related to community paramedicine activities in Ontario in peer-reviewed academic journals demonstrates that Ontario’s growing investment in community paramedicine programs is indeed achieving increasingly evidence-informed patient and system level benefits that are well-understood and reproducible. Ontario community paramedicine research is helping to lead a growing global interest in the development of community paramedicine models and research around them. With the current move towards the creation of Ontario Health Teams (OHTs), the establishment and growth of community paramedicine programs will become one clear opportunity to advance the mission and activities of this integrated team-based approach to the delivery of more patient-centred care. If OHT development parallels the development of the Accountable Care Organization (ACO) movement in the United States, then community paramedicine will likely take on an even great role in the future of the delivery of care across Ontario Overall, in 2019 community paramedicine programs appear to be evolving to better meet their local needs and becoming increasingly well-positioned to support the province’s current goal to end hallway healthcare by improving access to more proactive care and other community-based health care providers and in helping to support patients to stay safely in their homes and communities for as long as possible. 7 The umbrella term ‘community paramedicine’, describes a growing field of paramedicine practice that emphasizes a more proactive and preventive approach to care that utilizes paramedics in expanded roles.1 Community paramedicine leverages paramedics to provide immediate or scheduled primary, urgent, and/or specialized healthcare to vulnerable patient populations by focusing on improving the health system access, care, and experiences across the continuum of care.2 It represents an evolution of embedding emergency management principals3 into a paramedic’s scope of practice to help patients stay healthy and independent in their communities, prevent future unplanned health events and decline, support recovery after an acute medical event, and optimize the provision of future care.4 In 2014, the Ontario Ministry of Health (MOH) began investing $6 million annually to support the development of 30 Community Paramedicine Demonstration Projects across the province. This funding was allocated on the recommendation that the MOH invest in the development of community paramedicine as part of the 2012 Living Longer, Living Well Report5 by Dr. Samir Sinha that informed the development of the Government of Ontario’s subsequent Seniors Strategies. 1 Lezzoni LI, Dorner SC, Ajayi T. Community Paramedicine—Addressing Questions as Programs Expand. N Engl J Med. 2016;374(12):1107–9. 2 CSA Group. Community Paramedicine: Framework for program development. Toronto, ON: CSA Group; 2017. 3 CANADA. An Emergency Management Framework for Canada [Internet]. 3rd ed. Ottawa: Emergency Management Policy and Outreach Directorate; 2017. Available from: www.PublicSafety.gc.ca 4 Nolan MJ, Nolan KE, Sinha SK. Community paramedicine is growing in impact and potential. CMAJ. 2018;190(21):636–7. 5 Sinha SK. Living longer, Living well: Recommendations to Inform a Seniors Strategy for Ontario. Gov Ontario [Internet]. 2012;234. Available from: http://www. longwoods.com/blog/wp-content/uploads/2013/01/seniors_strategy.pdf BACKGROUND AND CONTEXT 8 In 2017, at the conclusion of a successful three-year demonstration period, the MOH decided to provide Ontario’s 14 Local Health Integration Networks (LHINs) with $6 million in on-going base funding to continue the development of community paramedicine programs across every region of Ontario and transferred to each LHIN the responsibility of overseeing these ongoing activities. In 2018, upon the recommendation of Ontario’s LHIN CEOs, an Ontario Community Paramedicine Secretariat (OCPS) was established under the oversight of a volunteer provincial OCPS Steering Committee (membership and staff listed in Appendix A). The Secretariat Staff supports the Steering Committee in further advancing the field of community paramedicine in Ontario and in advising the LHINs and the MOH on the current and future policy and practice directions for community paramedicine in Ontario. The overall goal of the Secretariat is to support the strengthening of collaborations and partnerships, particularly with primary, home and community care providers, that can reduce hallway healthcare, prevent hospitalizations, and improve patient-centred care and experiences as they transition from acute care settings back to the community. The Secretariat also specifically supports a larger provincial community paramedicine network, enabling and facilitating work on the creation and dissemination of standardized care processes, performance reporting and measurement activities, and other aspects of knowledge translation and exchange. 9 LHINs: Central and North Simcoe Muskoka (NSM) Paramedic Service: County of Simcoe Paramedic Service (COSPS) Community Paramedicine Programs Objective: Reducing 9-1-1 call volumes, improving primary care capacity, and supporting acute care cost avoidance in Simcoe County. Community Paramedicine Program Impact: The County of Simcoe Paramedic Service reported that their Assessment and Referral program has demonstrated that 60% of their referrals to local home care and community services providers result in the achievement of new or increased services for their patients. In 2018, through their Home Visit Program, community paramedics provided 104 unscheduled visits to the 100 rostered chronic disease patients. 79 of these clinics stayed at home following a visit from their community paramedic, 75% of unscheduled visits avoided a 9-1-1 call and 76% of the time these patients were able to remain at home, avoiding an emergency department visit. There were 22 less primary care visits by patients in the home care program during their first 6 months, compared against their last 6 months before entering the program. COSPS partnered with the Orillia Family Health Organization to obtain direct referrals for home visit from their 33 physicians. An analysis by NSM LHIN estimated that the combined cost avoidance resulting from COSPS community paramedicine programs to be $175,280 in 2018 alone. CASE STUDY: How the County of Simcoe Paramedic Service is Using Community Paramedicine to Respond to Its Locally Identified Needs GEORGIAN TRIANGLE SOUTH SIMCOE BARRIE & AREA NORTH SIMCOE ORILLIA & AREA 16 LHIN REPORTED DATA ON COMMUNITY PARAMEDICINE IN 2018-2019 LHINs have been collecting data on their funded community paramedicine activities using a standardized reporting template that was created by the MOH in 2017. The OCPS has aggregated available data to produce a provincial overview (See Table 3). It is important to note that a number of the data elements being collected by the LHINs reflect process measures of community paramedicine programs requested by the MOH rather than specifically enrolment and outcomes measures. Due to variations in use and uptake of the reporting framework across LHINs and paramedic services, the data provided likely underestimates the actual number of individuals and patients benefiting from LHIN funded community paramedicine activities over a given year. Table 3: A Provincial Overview of LHIN Funded Community Paramedicine Activities during FY 2018-19 Community Paramedicine Category Data Element Provincial Estimate, n (rounded to nearest 10) Community Assessment and Referral Programs Number of calls resulting in an individual being referred to local services/programs 23,040 Home Visit Programs Number of patients enrolled in a community paramedicine Home Visits Programs 3,790 Number of patients ≥ 75 2,260 Number of patients with 3 or more ambulatory care sensitive chronic health issues 2,060 Number of home visits 12,420 Number of referrals 1,560 Community Paramedic-Led Clinics Number of patients who attended oneto-one community paramedicine Clinic education sessions 13,340 Number of patients who attended group community paramedicine Clinic education sessions 4,340 Number of patients ≥ 75 4,030 Number of patients with 3 or more ambulatory care sensitive chronic health issues 3,450 17 39 municipal paramedic services across Ontario are now operating multi-dimensional Community Paramedicine Programs, with deliberate strategies intended to provide individuals and patients in their catchment area with better access to other care providers who may not be readily accessible through the 9-1-1 system and local Emergency Departments. This represents a growing concerted effort that is being made across Ontario to proactively help vulnerable patient or population groups so they don’t have to rely on the 9-1-1 safety net to access the care and supports they need. The 2019 Report noted that 28 municipal paramedic services described community paramedicine programs that did not fit the three previously identified classifications of community paramedicine models of care (Assessment and Referrals Program, Community Paramedic-Led Clinic, or Home Visit Programs) initially described in the 2017 MOH Community Paramedicine Framework for Planning, Implementation, and Evaluation. These other models being described included Remote Patient Monitoring Programs, Community Paramedic-Specialist Response Programs, and others that included Hospital Discharge Programs, and Influenza Surge Programs. This section describes these other newer emerging models. EMERGING AND INNOVATIVE COMMUNITY PARAMEDICINE MODELS AND INITIATIVES 18 Remote Patient Monitoring In April 2015, the Community Paramedicine Remote Patient Monitoring (CPRPM) Program was launched as a 3-year demonstration project through a $2.1M grant from Canada Health Infoway and the South Central Community Development Corporation with in-kind support from municipal paramedic services across Ontario.6 Future Health Services, a subsidiary of the South Central Community Development Corporation took on the management of the program with the goal of creating a sustainable and scalable business model to support remote patient monitoring in Ontario. The CPRPM Program was built on the same components as the jointly funded Canada Health Infoway and Ontario Telemedicine Network (OTN) Telehomecare Program, except that in the CPRPM Model a home visiting community paramedic was employed rather than a remotely available nurse. The CPRPM Program was also strategically initially deployed in the five LHINs that were not providing the OTN Telehomecare Program. Developed as a distributed model to make program expansion possible, the CPRPM initiative quickly expanded from three paramedic services in 2015 to 19 paramedic services by 2018 across 11 of 14 Ontario LHINs, the exceptions being Toronto Central, Central, and Central East LHINs. Future Health Services worked closely with OTN to identify the best patients for each of their respective programs to avoid potential duplications of service. The OTN Telehomecare Program was developed as a coaching model where a patient’s data would be sent to a centralized call centre where nurses would monitor the data and call a patient and provide coaching if there is a concern. This model was developed specifically to support patients with mild to moderate conditions who were willing and able to be coached around their condition using home monitoring equipment and the telephone. The CPRPM Program was specifically designed with the highest health system users in mind. While the OTN Telehomecare Program was designed as a more time-limited coaching, education and self-management program for individuals living with chronic conditions like Chronic Obstructive Pulmonary Disease (COPD), Congestive Heart Failure (CHF) or Diabetes with the goals of supporting their greater ability to self-manage their disease, the CPRPM Program focused more on providing on-going support for frail individuals who would benefit from continuous monitoring couples with the provision of more proactive support. Patients were enrolled into a CPRPM program directly by paramedics through referrals from local primary care providers or LHIN Care Coordinators. The CPRPM program was designed to integrate remotely monitored patient vital signs directly into the work flow of local community paramedics and took advantage of their existing distributed resources across the community (paramedic infrastructure that is already in place) because paramedics would also be the ones that would ultimately respond to the same patient in an emergency or a severe acute exacerbation. When patients were enrolled in a CPRPM program, a community paramedic would visit the patient in their home, set up their home monitoring devices, and train the patient on the use of the remote monitoring equipment. Patients were required to take daily readings which could be viewed in real time by a community paramedic. If a reading was outside of a threshold set by the patient’s physician, a community paramedic was notified to follow up with the patient. Coaching sessions could be completed by a community paramedic to let patients know about their condition, inquire about their current status, and provide comfort that they were being monitored. 6 CPRPM was designed to extend the capacity of community paramedicine (CP) programs, first funded as demonstration projects by MOHLTC and later funded by Local Health Integration Networks (LHINs).. 19 The particular strength of the CPRPM Program was that while community paramedics might contact the patient by phone, they were also able to visit the patient at their home if required. This appeared to provide patients with greater comfort that they could remain in their home and interact with the community paramedic rather than call 9-1-1 and go to their local emergency department. In many LHINs, OTN Telehomecare programs began working in tandem with available CPRPM Programs to further complement each other. For example, if there was an event that required a patient visit, an OTN Telehomecare nurse may call their local community paramedic to visit the patient and address their concerns. The CPRPM Program was evaluated by researchers at Queen’s University7 and showed that it particularly benefited patients with moderate to severe chronic illnesses that would likely not be able to be managed with coaching alone. The program’s overall results showed that for patients enrolled in the program there a 26% reduction in 9-1-1 calls, a 26% reduction in emergency department visits, a 32% reduction in hospital admissions, and a 41% reduction in hospital readmissions was achieved. Combined, this represented a combined cost avoidance of over $29M in downstream health system costs achieved amongst the 2,333 patients that participated in this program during the evaluation period. The overall reductions found in health system utilization generated an estimated $7,279 in cost avoidance for the healthcare system per patient per year, with the cost of community paramedic and equipment of $1,455 per patient per year, a net return on investment (cost avoidance - cost of providing service) $5,842 per patient per year. That the program deferred 3,511 emergency department visits alone demonstrates that it could further represent a practical opportunity to address the province’s goal to reduce hallway healthcare. 7 Brohman M, Green M, Dixon J, Whittaker R, Fallon L. Community Paramedicine Remote Patient Monitoring (CPRPM): Benefits Evaluation & Lessons Learned. Toronto, ON; 2018. 20 Community Paramedic-Specialist Response Programs Maximizing the mobile aspect of paramedic services is a growing concept where municipal paramedic services are increasingly working to provide either an enhanced real-time response to their enrolled community paramedicine patients or a means for health system partners to respond to their patients as soon as the paramedics are notified of a request for assistance. In some emerging models, community paramedics who are not part of the emergency response plan are being engaged proactively to assign themselves to emergency calls when they hear them in progress. This emerging method of providing either scheduled or unscheduled visits through what are being called Community Paramedic Response Units, Mobile Integrated Healthcare, or Paramedic-Specialist Teams has resulted in a growing use of community paramedics in more flexible ways to better meet the needs of individuals using 9-1-1 services. Mental Health and Addictions Support Programs Some municipal paramedic services described developing new partnerships with police, public health, or social services partners in community paramedicine programs designed to support community access to care for patients needing help with behavioural, mental health, and/or addictions conditions. Descriptions of these community paramedicine programs include actively participating in Mental Health Crisis Response Teams, providing care in homeless shelter programs, and assisting in medical oversight at a consumption & treatment site.These approaches to community paramedicine are similar to the rationale that underlies the Community Paramedic-Led Clinic Model that uses a specific location to deliver a community paramedicine program. However, the aims of the program are to address behavioural, mental health or addictions issues rather than a focus on chronic disease management. 21 CASE STUDY: Niagara Emergency Medical Services Mental Health and Addictions Response Team (MHART) LHIN: Hamilton Niagara Haldimand Brant (HNHB) Paramedic Service: Niagara Emergency Medical Services (NEMS) Community Paramedicine Programs Objective: NEMS aims to leverage community paramedicine as an innovative way to improve response and integrate patient care. Community Paramedicine Program Impact: The NEMS Mental Health and Addictions Response Team (MHART) is a community paramedic and mental health nurse that use a non-ambulance response vehicle when low acuity mental health 9-1-1 calls are identified. They improve patient and provider safety through scheduled or unscheduled visits to follow up after 9-1-1 calls for overdoses where a patient refuses transport after treatment. Through the MHART program NEMS has seen a 5% reduction overall of mental health transports to local emergency departments despite experiencing a 7% increase in mental health calls in 2018. HALDIMAND NORFOLK BRANT HAMILTON BURLINGTON NIAGARA 22 Palliative Care Support Programs Most municipal paramedic services across Ontario are actively evaluating their emergency response services for patients receiving palliative care and some are considering how these patients may be better cared for through community paramedicine programs. Challenges around sharing information between care providers, however, have been central to comprehensively addressing this opportunity. In some cases, municipal paramedic services are approaching this area of service delivery with the direct integration of frontline paramedics. In other instances, patients receiving palliative care are being registered to a community paramedicine program roster first to permit notification to responding paramedics of their overall status. Either approach is requiring paramedic services to determine ways to improve their service delivery model to align with the palliative and end-of-life care preferences of those receiving community-based palliative care. Influenza Prevention and Surge Management Support Programs In multiple LHINs, community paramedicine influenza surge programs have been initiated to increase vaccination of at-risk populations with the influenza vaccine and to promote a more appropriate response to individuals with influenza-like presentations. In these models, municipal paramedic services are leveraging their mobile service delivery capabilities to assist in public health surveillance activities, provide vaccinations for individuals in community settings, and provide integrated care and support to individuals with influenza-like presentations in retirement, nursing and other residential environments for older adults. In these programs, community paramedics can complete point of care tests to screen patients for influenza and are further able to assist in symptom treatment and in the provision of anti-viral medications which can further support care in-place and pre-empt the need to transfer patients to a local emergency departments. Transitional Care Support Programs A number of community paramedicine programs have started partner with discharge planning teams in hospitals to better aid their health system partners in meeting the guidelines established for care transitions by Health Quality Ontario8 to help avoid hospital readmissions. In some situations, patients are being identified on discharge from an Emergency Department for follow-up by a community paramedic to ensure that the patient and the other providers involved in their care are aware of any changes that have been recommended by the emergency physician such as new or discontinued prescriptions. 8 Quality Standards: Transitions From Hospital to Home [Internet]. 2019 [cited 2019 Aug 9]. Available from: https://www.hqontario.ca/Portals/0/documents/ evidence/quality-standards/qs-transitions-in-care-draft-quality-standard-en.pdf 23 LHIN: Champlain Paramedic Services: Cornwall SDG Paramedic Services, Country of Renfrew Paramedic Service, Lanark County Paramedic Service, Leeds-Grenville Paramedic Service, Ottawa Paramedic Service, and Prescott-Russell Paramedic Services Community Paramedicine Program Objective: Provide preventative and proactive program to address seasonal increase in 9-1-1 demand and emergency department visits for patients from targeted community residences who experience influenza-like illness. Community Paramedicine Program Impact: Across the Champlain LHIN, over 3400 patients received the influenza vaccination from community paramedics. Some patients were followed by community paramedics with a resulting emergency department diversion of over 2400 patients. By providing both influenza immunization and special medical directives to treat patients with influenza-like illness in retirement homes or long-term care residences, community paramedicine programs helped to address seasonal surges in 9-1-1 calls and subsequent transports to emergency departments attributed to influenza. CASE STUDY: Champlain LHIN Influenza Prevention and Surge Management Support Programs RENFREW COUNTY NORTH LANARAK OTTAWA STORMONT RENFREW COUNTY NORTH LANARAK OTTAWA PRESCOTT/ RUSSELL STORMONT / DUNDAS/ GLENGARRY 24 All of the municipal paramedic service operating at least one community paramedicine program were asked how they identified patients/clients for enrollment in their respective programs. 75% (n=36/48) of the services indicated that they used multiple referral sources to support the identification of patients/clients for enrollment into their programs. In total the 48 municipal paramedic services identified 172 unique referral sources amongst them in relation to their particular programs and these are presented in Figure 3. Individuals and patients were most often identified by the municipal paramedic services themselves via a referral from their own frontline emergency paramedics (n= 34) or through am internal process that identified repeated users of 9-1-1 services (n=18), or by referral from another local health system partner such as a hospitals (n=25) home care provider (n=24), primary care providers (n=23), and specialists (n=14). Community Paramedic-Led Clinics were unique in that individuals and patients attended these on their own accord in response to a notice about the clinic’s location, time and services being rendered (n=20). Respondents listed other means of identifying patients 14 times. Figure 2: Referral Sources of Patients/Clients for Ontario Community Paramedicine Programs. *Paramedic services were invited to indicate how they defined a ‘frequent user of 9-1-1services. While definitions varied, frequency seemed to indicate a minimum of 3 calls in a specific time period that could vary between 30 days and one year. Identified as a “Frequent User” or Repeated 9-1-1 Caller* 19.8% 14.5% 14% 11.6% 13.4% 10.5% 8.1% 8.1% Referral by Frontline Paramedics Referral by Primary Care Providers Referral by Home & Community Care Providers Referral by Hospital (ED or Inpatient) Referral by Medical Specialist Patient Selfidentified/ Presented (ie. Community ParamedicLed Clinics) Other How are patients identified or referred for enrollment in a community paramedicine program? n=18 n=34 n=23 n=24 n=25 n=14 n=20 n=14 COMMUNITY PARAMEDICINE PROGRAM PATIENT/CLIENT IDENTIFICATION AND REFERRAL SOURCES 25 DEMONSTRATING SUCCESS THROUGH ONTARIO-BASED RESEARCH IN COMMUNITY PARAMEDICINE Findings from Toronto published over the past year have shown that Assessment and Referral Programs improved access to home care services by 24%, led to an average increase of 17.4 hours in total home care services per person, while reducing 9-1-1 calls by 10% and ambulance transports to emergency departments by 7% over the study period.10 The Ontario based CP@Clinic model also demonstrated through a randomized control trial that the establishment of Wellness Clinics in subsidized housing buildings can reduce 9-11 calls by 28% while also improving patient wellbeing and quality of life.11 A Home Visit program in Renfrew County has demonstrated its ability to achieve reductions in 9-1-1 utilization by 24%, ED visits by 20%, and hospital admissions by 55%.12 The Ontario Community Paramedicine Remote Patient Monitoring (CPRPM) Program demonstrated its ability to provide a 542% return on investment for helping older patients with chronic conditions to live in their homes and reduced their need to call 9-1-1 by 26%, visit the ED by 26%, or be admitted to hospital by 32% while further improving the efficiency of Home Visit Programs by allowing community paramedics to manage greater caseload.13 Finally, a community paramedicine enabled hospital discharge program from Sudbury resulted in a 50% reduction in total health care costs per patient and estimated cost avoidance to be $10,000 per patient enrolled.14 Multiple other examples of reports or news stories reflecting the demonstrated success of community paramedicine initiatives across Ontario have been catalogued in Appendix F. 10 Verma A, Klich J, Thurston A, Scantlebury J, Kiss A, Seddon G, Sinha SK. Paramedic-initiated home care referrals and use of home care and emergency medical services. Prehospital Emergency Care. 2018 May 4;22(3):379-84. 11 Agarwal G, Angeles R, Pirrie M, McLeod B, Marzanek F, Parascandalo J, Thabane L. Evaluation of a community paramedicine health promotion and lifestyle risk assessment program for older adults who live in social housing: a cluster randomized trial. CMAJ. 2018 May 28;190(21):E638-47. 12 Ruest MR, Ashton CW, Millar J. Community Health Evaluations Completed Using Paramedic Service (CHECUPS): Design and Implementation of a New Community Based Health Program. JHHSA. 2017;(Fall). 13 Brohman M, Green M, Dixon J, Whittaker R, Fallon L. Community Paramedicine Remote Patient Monitoring (CPRPM): Benefits Evaluation & Lessons Learned. Toronto, ON; 2018. 14 McNeil D, Blanchard T. Community Paramedicine Program Evaluation [Internet]. Available from: https://agendasonline.greatersudbury.ca/index. cfm?pg=feed&action=file&attachment=16613.pdf 32 LOOKING TOWARDS A FUTURE FOR COMMUNITY PARAMEDICINE IN ONTARIO The Ontario Community Paramedicine Secretariat has become actively engaged with Ontario’s municipal paramedic services and LHINs to understand how community paramedicine has been evolving and identify emerging programs and innovative practices that have demonstrated their ability to deliver improved patient and system outcomes that could also be scaled and spread across Ontario. Within a rapidly transforming healthcare landscape, community paramedicine programs are demonstrating their growing ability to address care gaps and support the current agenda to address hallway healthcare by improving patient care to pre-empt or prevent emergency department visits and hospital admissions. The findings of our report illustrate that multiple municipal paramedic services are already starting to integrate community paramedicine initiatives with their regular emergency response activities either by facilitating the pre-notification of worsening symptoms amongst patients enrolled in Remote Patient Monitoring Programs or by identifying patients who could benefit from a more comprehensive assessment available from a community paramedic amongst those who call 9-1-1. Indeed, if the 9-1-1 system was imagined originally as a safety net designed to catch people when something goes wrong, community paramedicine could represent a safety harness that can prevent patients from falling into or back into the 9-1-1 safety net. 33 During this time of significant health system transformation in Ontario, including enabling new models of care for select 9-1-1 callers, we can draw on findings from other jurisdictions that have undergone some of these aspects of system change. Models of care enabled through an integration of community paramedicine programs and emergency response have further demonstrated their overall ability to achieve reductions in rates emergency department visitation and an increase in referrals to primary care providers.15,16 Allowing alternative models to ambulance dispatch have achieved successful results elsewhere,17 particularly when callers are able to speak with an individual who has experience as a frontline responder.18 The experience and abilities of paramedics as responders provides them with unique insights during a call for help, as has been demonstrated through Ontario’s CPRPM program.19 Other examples of providing ‘on-demand’ community paramedic availability have demonstrated promising results in helping maintain individuals safe in their homes who are waiting to transition to long-term care, even preventing long-term care admissions.20 Integrating community paramedicine programming with ambulance communication centres and spreading the success of similar programs province-wide could potentially have a further significant impact on improving care in the community, reducing emergency department visits, and hospital admissions (and alternate level of care) that contribute to the hallway healthcare problem. The OCPS therefore encourages the Ministry of Health to consider community paramedic staffing models in communications centres. Most municipal paramedic services that are delivering community paramedicine services already have established relationships with physicians in fields other than emergency medicine to support setting and service appropriate medical delegation of controlled acts in the delivery of their community paramedicine programs. Most frequently, community paramedicine programs can enable a direct link to primary care providers and facilitate shared care planning that enables these patients to avoid emergency department visits.21 Similar program designs have been reported in other settings where paramedic scopes of practice have been expanded.22 15 Swain AH, Hoyle SR, Long AW. The changing face of prehospital care in New Zealand: the role of extended care paramedics. J New Zeal Med Assoc NZMJ [Internet]. 2010;19(123):11–4. Available from: http://www.nzma.org.nz/journal/123-1309/3985/ 16 Evans R, McGovern R, Birch J, Newbury-Birch D. Which extended paramedic skills are making an impact in emergency care and can be related to the UK paramedic system? A systematic review of the literature. Emerg Med J [Internet]. 2013 Apr 10;594–603. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23576227 17 Jensen JL, Carter AJE, Rose J, Visintini S, Bourdon E, Brown R, et al. Alternatives to Traditional EMS Dispatch and Transport: A Scoping Review of Reported Outcomes. Can J Emerg Med. 2015;17(5):532–50. 18 Dib JE, Naderi S, Sheridan IA, Alagappan K. Analysis and applicability of the Dutch EMS system into countries developing EMS systems. J Emerg Med. 2006;30(1):111–5. 19 Brohman M, Green M, Dixon J, Whittaker R, Fallon L. Community Paramedicine Remote Patient Monitoring (CPRPM): Benefits Evaluation & Lessons Learned. Toronto, ON; 2018. 20 Ruest M, Stitchman A, Day C. Evaluating the impact on 911 calls by an in-home programme with a multidisciplinary team. Int Paramed Pract. 2012;1(4):125–32. 21 Leyenaar M, Mcleod B, Chan J, Tavares W, Costa A, Agarwal G. A scoping study and qualitative assessment of care planning and case management in community paramedicine. Irish J Paramed. 2018;3(July):1–15. 22 Mason S, Coleman P, Keeffe CO, Ratcliffe J, Nicholl J. The evolution of the emergency care practitioner role in England: experiences and impact. Emerg Med J. 2006;23:435–9. 34 As such, the OCPS expects that new models of care that are designed to complement and extend existing community paramedicine programs will be successful in enabling paramedics to: •Arrange or provide transportation of patients to destinations other than an emergency department where they can receive further treatment; •Diagnose and treat patients on-site and if necessary, refer them to another health care provider; •Treat and release patients from their care on-site; and •Refer select patients before, during or after a 9-1-1 call to the most appropriate care options in the community. •Provide ‘on-demand’ assistance or consultation, in person or over the phone in coordination with primary care providers or other health system partners. The Ontario Community Paramedicine Secretariat is prepared to assist with the development of evaluation frameworks for the delivery of community paramedicine programs as new models of care are developed by drawing from innovative solutions.23 As community paramedicine is further integrated in delivery of care and treatand-release and alternate destinations become part of the routine delivery of emergency response, community paramedicine will play an active role in ensuring that patients receive the appropriate care. 23 Turner J, Siriwardena AN, Coster J, Jacques R, Irving A, Crum A, et al. Developing new ways of measuring the quality and impact of ambulance service care: the PhOEBE mixed-methods research programme. Program Grants Appl Res. 2019;7(3):1–90 35 26 Mason S, Coleman P, Keeffe CO, Ratcliffe J, Nicholl J. The evolution of the emergency care practitioner role in England: experiences and impact. Emerg Med J. 2006;23:435–9. 27 Turner J, Siriwardena AN, Coster J, Jacques R, Irving A, Crum A, et al. Developing new ways of measuring the quality and impact of ambulance service care: the PhOEBE mixed-methods research programme. Program Grants Appl Res. 2019;7(3):1–90 CONCLUSION The OCPS was recently established during a time of both regulatory changes to the practice of paramedicine and the greatest level of health care system transformation seen in decades. This 2019 Report on the Status of Community Paramedicine in Ontario helps to provide a clear understanding of how the field of community paramedicine is growing and evolving to better meet the needs of Ontarians in need of care and support in ways that can deliver integrated patient-centred care and help to reduce hallway healthcare. With community paramedicine programs now being delivered by 92% of municipal paramedic services across Ontario, the rapidly evolving and growing multi-dimensionality of community paramedicine programs represents a growing intentional strategy by Ontario’s municipal paramedic services to provide individuals and patients with greater access to other community-based care providers and services that can help lessen a patient’s reliance on the province’s 9-1-1 safety net and avoid emergency department visits and hospitalizations. With the current move towards the creation of Ontario Health Teams (OHTs), the establishment and growth of community paramedicine programs will become one clear opportunity to advance the mission and activities of this integrated team-based approach to the delivery of more patient-centred care. If OHT development parallels the development of the Accountable Care Organization (ACO) movement in the United States, then community paramedicine will likely take on an even greater role in the future of the delivery of care across Ontario. In spite of the challenges that have been presented, community paramedicine programs are demonstrating effective and efficient ways to provide short-to-midterm episodic care to underserved patient populations. It is further expected that more multi-dimensional community paramedicine strategies will be developed to help patients overcome barriers or challenges in accessing timely coordinated care. The OCPS is eager to continue to support planning and implementation of community paramedicine programs and future reporting on the impacts of these programs. Overall, in 2019 community paramedicine programs appear to be evolving to better meet their local needs and becoming increasingly well-positioned to support the province’s current goal to end hallway healthcare by improving access to more proactive care and other community-based health care providers and in helping to support patients to stay safely in their homes and communities for as long as possible. 36 APPENDIX A Community Paramedicine Steering Committee Membership Name Title/Position and Organization Representative Role Co-Chairs Dr. Samir Sinha Director of Geriatrics, Sinai Health System, University Health Network Expert Lead – Ontario Seniors Strategy Senior’s Physician Lead – Toronto Central LHIN Geriatrician Representative Michael Nolan Chief of Paramedic Services, County of Renfrew Board Member – Ontario Association of Paramedic Chiefs (OAPC) Chief Paramedic Representative Members Adam Thurston Superintendent, Community Safeguard Services, Toronto Paramedic Services OAPC Toronto Zone Representative Amy Olmstead Director, Home and Community Care Branch, Ministry of Health Ministry of Health Representative Dr. Andrew Costa Assistant Professor, Schlegel Chair in Clinical Epidemiology & Aging | Dept. of Health Research Methods, McMaster University Research & Evaluation Representative Brad Davey Chief Executive Officer, Connex Ontario Community Mental Health Representative Brent McLeod CP Strategic Lead, Hamilton Niagara Haldimand Brant Local Health Integration Network LHIN Representative Chris Spearen Chief and General Manager, York Region Paramedic and Seniors Services Paramedic and Long-Term Care Representative Dan McCormick Chief Administrative Officer, Rainy River DSSAB Northern Ontario Service Deliverers Association (NODSA) Representative Doug Socha Chief, Hastings Quinte EMS OAPC East Zone Representative Dustin Carter Superintendent of Community Paramedicine, Middlesex-London EMS OAPC South West Zone Representative Dr. Gina Agarwal Associate Professor, Academic Family Physician, Primary Care Epidemiologist Primary Care Representative Jean Carriere Director and Chief of EMS, Cochrane District, CDSSAB OAPC North Zone Representative Jeff Gunner Chief, Weeneebayko Area Health Authority Paramedic Service Indigenous Paramedic Service Representative Joe Pedulla Superintendent, Community Paramedicine and Research, Hamilton Paramedic Service OAPC Central Zone Representative Karen Hurlburt Vice President, Strategy and External Relations, Sinai Health System Hospital Representative Kate Krestow Manager, Public Education and Awareness, Ministry of Senior Affairs and Accessibility Ministry of Senior Affairs and Accessibility Representative Leslie Hirst Regional Palliative Care Network Director, Hamilton Niagara Haldimand Brant Local Health Integration Network (LHIN) Palliative Care Representative Lisa Levin Chief Executive Officer, Advantage Ontario Long-Term Care and Services for Seniors Sector Representative Melissa Roney Deputy Chief (Acting) Greater/ Grand Sudbury Emergency Services Frontline Paramedic 37 Name Title/Position and Organization Representative Role Michelle McMillan Community Paramedicine Coordinator, Cornwall SDG Paramedic Services Frontline Paramedic Philip Kilbertus Director, System Planning, North East Local Health Integration Network LHIN Representative Dr. Richard Dionne Director of EMS Fellowship and Associate Professor, EMS Associate Medical Director, University of Ottawa & Regional Paramedic Program of Eastern Ontario Base Hospital Physician Representative Dr. Ron Hoffman Assistant Professor, Nipissing University Community Mental Health Sector Representative Sharon Lee Smith Interim Chief Executive Officer, Mississauga Halton Local Health Integration Network LHIN CEO Representative Slawomir Pulcer Captain, Professional Standards, Essex-Windsor EMS Frontline Paramedic Steve Haddad Director, Emergency Health Services Branch (ESHB), Ministry of Health Ministry of Health Representative Sue VanderBent Chief Executive Officer, Home Care Ontario Home Care Sector Representative Pending Public Health Representative Pending Patient or Caregiver Representative CommunityParamedicineSecretariatStaff Matthew Leyenaar Director, Community Paramedicine Secretariat Ex-officio Ryan Strum Research Analyst, Community Paramedicine Secretariat Ex-officio Mashiat Haque Program Assistant, Community Paramedicine Secretariat Ex-officio 38 APPENDIX B Current Membership of Ontario Community Paramedicine Secretariat Working Groups Capacity Building & Knowledge Exchange Working Group •Joe Pedulla (chair) •Gary Staples •Gordon Perolli •Jordan Kachur •Karen Totzke •Katie Dainty •Kevin McNab •Rebecca Poulin Performance Measurement & Evaluation Working Group •Brent McLeod (chair) •Andrew Costa •Craig Hennessy •Gina Agarwal •Jeff Dodge •Jim Greenaway •Justin Lammers •Kim Wilhelm •Lesley Hirst •Mathieu Grenier •Melanie Dissanayake •Michelle McMillan •Rick Ferron •Shannon Sibbald Policy & Practice Working Group •Dustin Carter (chair) •Chris Spearen •Elizabeth Anderson •Kayella Mackenzie •Kyle Grant •Kyle MacCallum •Merideth Morrison •Michel Ruest •Natalie Kedzierski •Richard Trombley •Walter Tavares 39 APPENDIX C List of Ontario Paramedic Services and their Reported Types of Community Paramedicine Programs Paramedic Service Assessment and Referrals Programs Community ParamedicLed Clinics Home Visit Programs Remote Patient Monitoring Programs Community ParamedicSpecialist Response Programs Other Algoma District Paramedic Services X X X Brant/Brantford Paramedic Services X X X X Bruce County Paramedic Service X Chatham-Kent EMS XXXXX City of Greater Sudbury Paramedic Services X X X X Cochrane District EMS X X X X X Cornwall SDG Paramedic Services X X X County of Renfrew Paramedic Service XXXXX County of Simcoe Paramedic Service X X X X Dufferin County Paramedic Service X X X Elgin EMS Essex Windsor EMS X X X X Frontenac Paramedics X X Grey County Paramedic Services X X X X Guelph Wellington Paramedic Service XXXXX Haldimand County EMS X Haliburton County Paramedic Service X X Halton Region Paramedic Service X X X X Hamilton Paramedic Service X X X X X Hastings Quinte Paramedic Services X X X X Huron County Paramedic Services X X X Kawartha Lakes Paramedic Service X Kenora District Services Board Lambton EMS X X X X Lanark County Paramedic Service X X Leeds Grenville Paramedic Service X X 40 Paramedic Service Assessment and Referrals Programs Community ParamedicLed Clinics Home Visit Programs Remote Patient Monitoring Programs Community ParamedicSpecialist Response Programs Other Algoma District Paramedic Services XXX Brant/Brantford Paramedic Services XXXX Bruce County Paramedic Service X Chatham-Kent EMS XXXXX City of Greater Sudbury Paramedic Services XXXX Cochrane District EMS XXXX X Cornwall SDG Paramedic Services XXX County of Renfrew Paramedic Service XXXXX County of Simcoe Paramedic Service X X X X Dufferin County Paramedic Service X X X Elgin EMS Essex Windsor EMS XXXX Frontenac Paramedics X X Grey County Paramedic Services XXXX Guelph Wellington Paramedic Service XXXXX Haldimand County EMS X Haliburton County Paramedic Service X X Halton Region Paramedic Service XXXX Hamilton Paramedic Service XXXX X Hastings Quinte Paramedic Services XXXX Huron County Paramedic Services X X X Kawartha Lakes Paramedic Service X Kenora District Services Board Lambton EMS X X X X Lanark County Paramedic Service X X Leeds Grenville Paramedic Service X X Paramedic Service Assessment and Referrals Programs Community ParamedicLed Clinics Home Visit Program Remote Patient Monitoring Programs Community ParamedicSpecialist Response Programs Other Lennox and Addington EMS Manitoulin-Sudbury DSB Paramedic Services X X X Middlesex-London Paramedic Service X X X Muskoka Paramedic Services X X Niagara EMS X X X X Nipissing Paramedic Services X X X Norfolk EMS X X X X Northumberland EMS X Oneida EMS Ottawa Paramedic Service X X X X X Oxford County EMS X Parry Sound EMS X X X X Peel Region Paramedic Service X X Perth County Paramedic Service X Peterborough County Paramedics X Prescott-Russell Paramedic Service X X X X Rainy River District Paramedic Services X X X X Rama Paramedic Services X X Region of Durham EMS X X Region of Waterloo Paramedic Services X X X Six Nations EMS X Superior North EMS (Thunder Bay) X X X Timiskaming EMS X Toronto Paramedic Service X X X X Weeneebayko Area Health Authority Paramedic Service X X York Region Paramedic Services XXX 41 CTV News - Windsor September 7, 2018 Vulnerable Patient Navigator program credited with helping Windsor-Essex residents https://windsor.ctvnews.ca/vulnerable-patient-navigator-program-credited-with-helping-windsor-essexresidents-1.4084722 Windsor Star September 6, 2018 Vulnerable patient program helps sick people get help, reduces 911 calls https://windsorstar.com/news/local-news/vulnerable-patient-program-helps-sick-people-get-help-reduces-911calls CTV News Windsor Video Clip Vulnerable patient Navigator https://windsor.ctvnews.ca/video?clipId=835122 Guelph CHC January 8 - May 6, 2018 Supported Recovery Room-Final Evaluation Report https://guelph.ca/2015/05/guelph-wellington-emergency-medical-service-receives-service-award-geriatricexcellence/ CTV News - Kitchener Video Clip 24-hour beds for people struggling with addiction https://kitchener.ctvnews.ca/video?clipId=1305266&binId=1.1147261&playlistPageNum=1%22%20 %5Cl%20%22_gus&_gucid=&_gup=twitter&_gsc=QQ4FQ3b CTV News - Northern Ontario Video Clip Premier extends Paramedicine project https://northernontario.ctvnews.ca/video?clipId=1133705 CBC News - Ottawa April 6, 2018 Renfrew paramedics road-testing portable records system https://www.cbc.ca/news/canada/ottawa/renfrew-paramedics-prehos-digital-health-1.4606568 OrilliaMatters.com August 17, 2018 Paramedicine program success results in funding booster shot https://www.orilliamatters.com/local-news/paramedicine-program-success-results-in-funding-boostershot-1018262 Global News February 22, 2019 New paramedic pilot program gets financial boost from City of Kawartha Lakes https://globalnews.ca/news/4989081/paramedic-pilot-program-city-of-kawartha-lakes/ The Oshawa Express April 2, 2019 Primary care outreach program now permanent http://oshawaexpress.ca/primary-care-outreach-program-now-permanent/ 48