Abroad variety of community paramedic (CP) projects and pilot programmes have been implemented in the US and internationally over more than 25 years with the goal of increasing access to healthcare services for underserved populations, particularly those in remote and rural settings, as well as underserved populations in urban settings. The trend has included programmes that have expanded the clinical scope of practice of the paramedic and emergency medical technician (EMT) (Alaska Community Health Aide Program (ACHAP), 2011; Bigham et al, 2013; Goodwin, 2012a; 2012b; Tan, 2013), and other programmes that have focused on expanding the roles of the paramedic and EMT (Tan, 2013), with only limited, or minimal, changes in the scope of practice, if any. Those programmes that have focused on expanding the roles, rather than the clinical practices of the CP, include expanding the CP roles to pathway care coordinators, mobile healthcare clinic staff (for wellness checks, routine non-acute visits, routine physical examinations, routine blood pressure and blood glucose checks, etc.).
With the implementation of The Patient Protection and Affordable Health Care Act (ACA) (US Public Law 111–148; AE 2.110: 111–140) in the US, new and substantially different rules and regulations are currently taking effect that will significantly impact health care delivery in the US and are projected to have an impact on healthcare economics in the US. Many of the new rules and regulations apply to personal wellness, prevention, decreasing readmissions to hospitals, and management of chronic diseases (Joint Committee on Rural Emergency Care (JCREC) and National Association of State EMS Officials (NASEMSO), 2010; Haebler, 2012). Other issues addressed in the ACA are the shortages of physicians and nurses in many areas of the US and the disparity of healthcare services that exist between rural and urban areas and wealthy and poor populations (Conrad, 1991; JCREC and NASEMSO, 2010; Haebler, 2012). In order to fill some of the gaps in healthcare services, pilot programmes are being funded to seek new safe, effective and efficient health service delivery models (JCREC and NASEMSO, 2010; NASEMSO et al, 2010; Haebler 2012). A standardised CP curriculum was developed by a collaborative group of physicians, nurses, paramedics and public health officials and rural health officers, with representation from Canada, Australia, and, in the US, Minnesota, Nebraska and Colorado. The parent organisation of the curriculum development group was the North Central Emergency Medical Services Institute (NCEMSI). The CP curriculum development group was formed under the auspices of the NCEMSI by the Community Healthcare and Emergency Cooperative (CHEC) (see Box 1 for CHEC member organisations).
To develop the CP curriculum, the CHEC developmental group reviewed and collectively culled, by consensus, the best practices of the Alaskan Native Health Aid/Practitioner programme (CHAM/CHAPS) and the Navajo Health Aid/Practitioner programme (JCREC and NASEMSO, 2010; US Department of Health and Human Services (USDHHS) et al, 2004; ACHAP, 2011), the Taos County Community Health Practitioner Project (1995–2000), the US Navy Corpsman Training Manual (NAVEDTRA 14319), US Army patient care specialist's (STP 8-68W13-SM-TG), the US Air Force, independent duty medical technician's (AFTM 44–158), as well as the Health Practitioner programme of Australia, and the rural health practitioner programmes of England, Canada and several other countries (Emergency Medical Services Chiefs of Canada (EMSCC), 2006; Mulholland et al, 2009; JCREC and NASEMSO, 2010; ACHAP, 2011). The Health Aid/Practitioner programmes of Alaska and the Navajo reservations have been in existence since the 1950s and are the longest documented and institutionalised programmes of this type (O'Hara-Devereaux and Reeves, 1980; USDHHS et al, 2004; ACHAP, 2011).
Following the delivery and evaluation of initial pilot courses in Minnesota and Colorado, the curriculum was revised to reflect student, instructor and stakeholder feedback. This was accomplished in 2011 with the convening of a group of subject matter experts and educators (Minnesota Emergency Medical Services, 2013). The goals were to standardise the curriculum, create a more robust educational format and, ultimately, improve sustainability for quality programmes in the future. In addition, a standing curriculum review team was formed to continuously monitor the curriculum development, review and approval process for all future changes to the curriculum.
All of the currently offered and planned CP programmes have a similar goal, which is to fill gaps in community health services that are due to shortages of clinical facilities and professional practitioners, such as physicians, dentists, nurses, various therapists, and health aides. These programmes have successfully demonstrated the safety, competency, and cost effectiveness of this approach to filling gaps in healthcare services in underserved populations by providing supplemental training to paramedics and then utilising those specially trained paramedics (Conrad, 1991; JCREC and NASEMSO et al, 2010). It has also been shown that those specially trained paramedics can safely and effectively provide chronic, palliative, and therapeutic community health services in the US (JCREC and NASEMSO, 2010; NASEMSO et al, 2010; Patterson and Skillman, 2013) and in other countries (EMSCC, 2006; Mulholland et al, 2009; JCREC and NASEMSO, 2010; ACHAP 2011).
The implementation of community paramedic programmes have, in certain settings, led to role conflicts and inter-professional tension, as the term paramedic in the US has been deeply enculturated and codified in legislation over the past 30 years, after the passing of the US EMS Act of 1973. While in the US, the paramedic primarily provides emergency response care (911), along with interfacility transportation, the roles of the paramedic working in mobile units do not extend to continuous care, chronic care (e.g. routinely scheduled home visits), wellness checks (e.g. routine physical examinations and counseling), and general public health roles (e.g. health care access and pathways coordination). While these roles for the paramedic are generally limited to these roles in the US, many other nations of the world utilise the terms ‘paramedic’ and ‘paramedical’ to refer to a broader and more general clinician who not only provides emergency response and interfacility transfer health care, but also wellness visits, chronic care, and routine healthcare services, according to the International Dictionary of Medicine and Biology (Landau, 1986; Ruest et al, 2012). As medical and nursing organisations, such as the National Association of EMS Physicians (NAEMSP) and American Nurses Association (ANA) have engaged in the discussion about the CP roles and scope of practice, recommendations have been made to modify the nomenclature to that of mobile integrated healthcare practice (MIHP) (Hunt, 2014; NAEMT, 2014). The North Central EMS Institute Community Healthcare and Emergency Cooperative (NCEMSI-CHEC), the International Roundtable of Community Paramedicine and other organisations have, however, viewed MIHP to be a misleading term, as the CP practice has been located in the home and clinics, and does not imply patient transport. In addition, MIHP is a conceptual framework where CP is an actual provider of care.
As paramedics are trained to perform advanced invasive procedures, e.g. endotracheal intubation, intravenous access and continuous medication administration, medication injections, and electrotherapy, as well as many other advanced invasive procedures (National Highway Traffic Safety Administration Emergency Medical Services, 2009), they require only targeted special training to expand their practice to new palliative, chronic, and wellness care roles (JCREC and NASEMSO, 2010; NASEMSO et al, 2010; Patterson and Skillman, 2013). The CP curriculum developed by CHEC recommends, for experienced practising US paramedics, approximately 100–120 hours of didactic instruction and approximately 120–160 hours clinical rotations, primarily working in family practice and public health settings. Additional time and clinical training settings may be required for newly trained paramedics or those from non-EMS backgrounds, such as social services workers, nurses’ aides, dental technicians, etc., and less time may be required for other practitioners who already have a professional background in providing community health services, e.g. registered nurses and midwives (JCREC and NASEMSO, 2010).
The community paramedic roles go well beyond the American-centric traditional paramedic role of serving as an extension of the physician. The community paramedic practice is oriented toward non-emergent medical care and the management and monitoring of chronic disease states and chronic health issues (JCREC and NASEMSO, 2010; NASEMSO et al, 2010). It is noteworthy that the roles of the community paramedic appear to be an appropriate fit with the US Affordable Health Care Act, and its emphasis on preventative health and the economic savings associated with decreasing the number of emergency department visits to acute care hospitals, decreasing unnecessary hospital readmissions, and more efficient utilisation of all healthcare providers and resources globally (JCREC and NASEMSO, 2010; Patterson and Skillman, 2013).
Methods
This research survey was developed and delivered by a multi-agency and multi-disciplinary health care research team, comprised of four paramedics, three registered nurses and one family medicine physician, located in three states and five agencies in the US. We sent the survey to 223 individuals throughout the world who had requested a copy of the CP curriculum. Of the 223 total surveys sent out, 195 were sent to US recipients, 17 were sent to Canadian recipients, 10 were sent to Australian recipients, and one was sent to a recipient in Ireland. The respondents included administrative and educator representatives of accredited post-secondary educational institutions and Government officials, all of whom had previously requested a copy of the curriculum. As such, this was a population survey, and not a sample.
We utilised SurveyMonkey® to develop and distribute the survey, rather than a specific university-based system, to neutralise a potential perception that only one educational institution was conducting the survey. The survey consisted of 19 questions. ‘Skip logic’ was utilised, which permitted respondents to bypass questions that were not applicable to their agencies. The Creighton University Institutional Review Board approved the project as exempt status. Participation in the survey was voluntary and anonymity of the subjects was guaranteed. The survey was initiated 14 October 2013, with a distribution to 223 subjects. A reminder was sent out to non-respondents after two weeks and the survey was closed 19 December 2013.
Results
A total of 223 surveys were sent out and 68 (30.49%) responses were received. Of the 68 responses, 60 were from US recipients, five were from Australian recipients and three were from recipients in Canada. None of the recipients ‘opted out’ from any of the questions (i.e. SurveyMonkey® skip logic function). Three responses indicated that a community paramedic curriculum was received by an alternate source; however, these ‘alternate sources’ were actually the original CHEC curriculum and all received the same version of the curriculum from one member of the CHEC curriculum development group. Forty-seven of the 68 respondents (69.11%) answered the question: ‘When does your educational institution plan on offering the community paramedic course?’ Thirty-five of the 47 respondents (74.46%) stated that their institution had already conducted a course, was currently conducting a course at the time they responded, or was planning on conducting a course within the next five years. (See Figure 1).
Only four respondents answered a question about the median years of experience of students taking a CP course. Three of the responses indicated that the experience level of those taking the CP course was five years, and other experience levels were spread evenly with one each from one year of experience to 20 years of experience. Forty-six respondents answered a question about the range of ages of the majority of their CP students. Of these 46 respondents, the largest age range group was reported by ten respondents (21.74%) to be between 25 and 45 years, and for the ages between 30 and 45 years was reported by six respondents (13.04%) (See Figure 2).
We asked a question about how the respondents anticipated CP programmes in their communities would be funded after the programmes were offered. Fifty-seven of 68 respondents (83.8%) did not answer this question. Eleven (16.17%) responded to this question, with five (45.45%) indicating that the main source of funding was anticipated to be fee-for-service, four (36.36%) indicating non-Governmental agency as the main funding source, two (18.18%), each indicating an even split between federal Government grant and local Government funding, and one (9.09%) indicating a state Government grant as the funding source. No respondents indicated that they anticipated any non-Governmental grants for a funding source for a CP course (See Figure 3). These percentages total more than 100%, i.e. 127.27%, as respondents reasonably anticipate more than one source of funding.
We asked: ‘How did their institution plan on funding their CP course?’ Forty-four (44) respondents answered this question. Of these 44 responses, 36 respondents (81.82%) indicated that student tuition would be the main funding source. Fourteen respondents (31.82%) indicated that they anticipated Government would be funding their programmes. Two respondents (4.55%) indicated that they anticipated receiving non-Government grants to fund their CP courses. Seven respondents indicated that they anticipated non-Governmental support, other than grants, to fund their CP courses.
We asked the respondents to identify the types of agencies that they projected their future CP students who complete their courses would be associated with. Forty-three (43) responded to this question, with 22 (51.16%) indicating that they expected those completing the training would be working for a Fire Department EMS agency and 20 (46.51%) projecting that their students would be working at a for-profit EMS agency. The results indicated that a majority of the students would be practising in a combination of rural, suburban, and urban areas, with 32 of the 47 (68.09%) projecting practice in rural settings, 25 (51.19%) in suburban settings, and 29 (61.70%) were projected to practice in urban areas. (See Figure 4). The results add up to 182.9%, as the respondents projected that students would work in multiple settings, even within the same organisation, at times.
Delimitations and limitations
This survey was sent to all individuals that had requested and received the NCEMSI-CHEC community paramedic curriculum (Version 3.0), and thus, is a total target population study. The survey was conducted solely as an internet-based (SurveyMonkey®) survey, with one initial email distribution and one follow up reminder request to non-respondents. The survey was closed 19 December 2013. A limitation of the study is that all but one of the authors are members of the organisational group (NCEMSI-CHEC) that was responsible for developing and disseminating the survey; thus, a bias in favour of promoting the results may be construed. This potential bias was, however, negated to the extent possible by the inclusion of one disinterested author and due diligence to report all of the data received without any biased interpretations. No responses were excluded.
Another limitation of this survey is that 68 of a total of 223 recipients of the CP Curriculum responded for a response rate of only 30.49%. Although we did send one email follow-up request, we did not send paper surveys or make telephone or other modes of contact, which might have increased the response rate. Thus, a selection bias may exist, where those non-respondents have categorically tended to be doing something that is different than the response group.
Conclusions
The authors concluded that the current NCEMSI-CHEC standard CP curriculum that is being disseminated internationally at no charge to accredited post-secondary educational institutions is contributing to the implementation and standardisation of community paramedic education. The CP curriculum is already being integrated internationally into many of the two-year and four-year undergraduate degree programmes (O'Meara et al, 2014). Based on the expressed trending intent to offer more CP courses over the next three years by additional institutions, the authors concluded that the CP curriculum is beginning to establish a broad base acceptance that can be seen in the United Kingdom, Canada, Australia and the United States. Lastly, the feedback received from the respondents has helped to inform the curriculum development group about possible changes that can be made to improve the curriculum.