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Community paramedicine: Framework for program development

Authored by CSA Group Prepared by: CSA Group 178 Rexdale Boulevard Toronto, ON, Canada, M9W 1R3 Contractor Document Number: Z1630-17 PSPC Contract Number: W7714-166142 Technical Authority: Michel Ruest, Paramedic Portfolio Manager Contractor's date of publication: June 2017

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Z1630-17June 2017

Title: Community paramedicine: Framework for program development

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Z1630-17 Community paramedicine: Framework for program development

June 2017 © 2017 CSA Group 1

ContentsTechnical Committee on Community Paramedicine 3

Preface 6

0 Introduction 70.1 Overview 70.2 Application 7

1 Scope 7

2 Reference publications 9

3 Definitions 9

4 Guiding principles 104.1 General 104.2 Guiding principles 104.2.1 General 104.2.2 Patient- and family-centred 114.2.3 Needs and evidence based 114.2.4 Goal directed and outcome based 114.2.5 Integrated collaborative care 114.2.6 Patient and provider safety 114.2.7 Stakeholder engagement 114.2.8 Governance and Policy 114.2.9 Sustainability 11

5 Competency, education, and training 125.1 General 125.2 Roles and competencies 125.3 Specialized capabilities 125.4 Education and training 13

6 Models of care 136.1 General 136.2 Models 14

7 Program planning 157.1 General 157.2 Commitment, leadership, and governance 167.2.1 General 167.2.2 Partners 167.2.3 Governance/accountabilities/roles and responsibilities 167.3 Community health needs assessment 167.4 Community resource capacity assessment 177.5 Community and stakeholder engagement 177.5.1 General 17



7.5.2 Community engagement plan 177.6 Program development 177.6.1 Program scope, objectives, and targets 177.6.2 Communications 197.6.3 Documentation and clinical information systems 197.7 Implementation committee 20

8 Implementation 208.1 General 208.2 Safety measures 208.2.1 General 208.2.2 Practitioner safety 208.2.3 Patient safety 218.2.4 Carer support 21

9 Evaluation 219.1 General 219.2 Types of program evaluation 229.3 Monitoring and measuring 229.4 Health care system impact 229.5 Management review and continuous improvement 229.5.1 General 229.5.2 Review input 229.5.3 Review output 23

Annex A (informative) — Checklist for the development of a community paramedicine program 24Annex B (informative) — Community paramedicine resources 27



Technical Committee on Community Paramedicine

M. Nolan Renfrew County Paramedic Service, Pembroke, Ontario Category: User Interest

Chair

P.J. Poirier Paramedic Association of Canada, Ottawa, Ontario Category: Service Industry

Vice-Chair

G. Agarwal McMaster University, Hamilton, Ontario Category: General Interest

D. Allen Regional Municipality of Wood Buffalo, Emergency Services, Calgary, Alberta Category: User Interest

R. Bowles Justice Institute of British Columbia, New Westminister, British Columbia Category: Service Industry

D. Deines Paramedic Association of Canada, Richmond, British Columbia Category: Service Industry

S. Ebrahimi BC Emergency Health Services, Vancouver, British Columbia Category: Service Industry

J. Elliott New Brunswick Department of Health, Fredericton, New Brunswick Category: Government and/or Regulatory Authority

S. Gundu Canadian Mental Health Association, Toronto, Ontario Category: General Interest

J. Heathcote Regina Qu’Appelle Health Region, Regina, Saskatchewan Category: User Interest



N. Henningsen Canadian Home Care Association, Mississauga, Ontario Category: User Interest

C. Hood Paramedic Association of Canada, Ottawa, Ontario Category: Government and/or Regulatory Authority

J. Klich Toronto Paramedic Services, Toronto, Ontario Category: User Interest

R. Kozicky Alberta Health Services, Calgary, Alberta Category: Government and/or Regulatory Authority

M. Leyenaar McMaster University, Hamilton, Ontario Category: General Interest

M.R. MacLeod Island EMS and Holland College, Stratford, Prince Edward Island Category: Service Industry

M. Ruest Defence Research Development Canada – Centre for Security Science Program, Ottawa, Ontario Category: Government and/or Regulatory Authority

R. Simpson Emergency Medical Assistants Licensing Board, Victoria, British Columbia Category: Government and/or Regulatory Authority

J.E. Sinclair Regional Paramedic Program for Eastern Ontario, Ottawa, Ontario Category: General Interest

R. Sneath Winnipeg Fire Paramedic Service, Winnipeg, Manitoba Category: User Interest

D. Socha Hastings-Quinte Paramedic Services, Belleville, Ontario Category: User Interest



B. Stewart Saskatchewan Polytechnic, Saskatoon, Saskatchewan Category: Service Industry

D. Weiss Alberta Health Services, Edmonton, Alberta Category: Government and/or Regulatory Authority

M.R. Wilcox Paramedic Foundation, New Prague, Minnesota, USA Category: General Interest

G. Wingrove Mayo Clinic Medical Transport, Rochester, Minnesota, USA Category: General Interest

R. Meyers CSA Group, Toronto, Ontario

Project Manager



Preface This is the first edition of the CSA Z1630, Community Paramedicine: Framework for Program Development. This Standard provides a framework for the planning, implementation and evaluation of a community paramedicine program. The purpose of this Standard is to provide guidance to fully understand the context, key considerations, and essential elements for community paramedicine program development. The Standard provides a framework and a systematic approach for paramedic services and their partners wishing to establish these programs.

This Standard includes the following elements of a program development framework:a) guiding principles;b) competency, education and training;c) models of care;d) planning, including

i) identifying partners;ii) community and stakeholder engagement;iii) community needs and service gap assessment; andiv) communications;

e) implementation; andf) evaluation and continuous improvement.

This Standard was prepared by the Technical Committee on Community Paramedicine, under the jurisdiction of the Strategic Steering Committee on Healthcare Technology, and has been formally approved by the Technical Committee.Notes: 1) Use of the singular does not exclude the plural (and vice versa) when the sense allows.2) Although the intended primary application of this Standard is stated in its Scope, it is important to note that it

remains the responsibility of the users of the Standard to judge its suitability for their particular purpose.3) This Standard was developed by consensus, which is defined by CSA Policy governing standardization — Code

of good practice for standardization as “substantial agreement. Consensus implies much more than a simple majority, but not necessarily unanimity”. It is consistent with this definition that a member may be included in the Technical Committee list and yet not be in full agreement with all clauses of this Standard.

4) To submit a request for interpretation of this Standard, please send the following information to [email protected] and include “Request for interpretation” in the subject line: a) define the problem, making reference to the specific clause, and, where appropriate, include an

illustrative sketch;b) provide an explanation of circumstances surrounding the actual field condition; andc) where possible, phrase the request in such a way that a specific “yes” or “no” answer will address the

issue.Committee interpretations are processed in accordance with the CSA Directives and guidelines governing standardization and are available on the Current Standards Activities page at standardsactivities.csa.ca.

5) This Standard is subject to review within five years from the date of publication. Suggestions for its improvement will be referred to the appropriate committee. To submit a proposal for change, please send the following information to [email protected] and include “Proposal for change” in the subject line: a) Standard designation (number);b) relevant clause, table, and/or figure number;c) wording of the proposed change; andd) rationale for the change.



Z1630-17Community paramedicine: Framework for program development

0 Introduction

0.1 OverviewThe health care system is facing unprecedented challenges. There is increased financial pressure in the health care system, a shortage and misdistribution of health care professionals in some regions, and increased demand on paramedic services. At the same time, many jurisdictions are increasingly committed to transforming the health care system to be more patient and community-based.

Community paramedicine programs have emerged throughout Canada and internationally in an effort to maximize efficiencies in patient care and resources. These programs provide an innovative model of care that helps to improve access to additional support services for seniors and patients with chronic health and social issues. The development and expansion of these programs allows paramedics to apply their education and skills beyond the traditional role of emergency medical responders. These programs help to support high users of paramedic services to avoid emergency room visits and hospitalizations and can potentially delay entry to long-term care. The aim of these programs is to improve patient outcomes and decrease costs in a way that supplements, but does not replace, services delivered by other health care providers. These programs can help to provide a more sustainable, integrated, patient-centred system.

While many paramedic services and jurisdictions are developing and expanding these programs there are no nationally or internationally accepted guidelines for the development of community paramedicine programs. This Standard addresses the elements that experience has shown to be the most critical in developing an effective community paramedicine program.

0.2 ApplicationThe extent of the application will depend on the circumstances particular to the paramedic service, the nature and location of its operations, the conditions in which it functions and the local gaps in healthcare. The intent of this Standard is not to promote uniformity in the structure of community paramedicine programs, but to encourage organizations to implement programs appropriate to community needs and available resources.

1 Scope

1.1 This Standard provides a framework for the planning, implementation and evaluation of a community paramedicine program, hereinafter referred to as “the program”. The purpose of this Standard is to provide guidance to fully understand the context, key considerations and essential elements for community paramedicine program development. The Standard provides a systematic approach for policy makers, paramedic services and their partners intending to establish a community paramedicine

COMMUNITY PARAMEDICINE

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Develop program

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1.4 This Standard does not provide detailed scope of practice or protocols for the full range of services provided by programs. It is recognized that the regulation of services and personnel cross a number of regulatory authorities including federal, provincial/territorial, regional, and local boundaries. All services and personnel should ensure that they meet the requirements of the various regulatory bodies and authorities having jurisdiction.

1.5 In this Standard, “shall” is used to express a requirement, i.e., a provision that the user is obliged to satisfy in order to comply with the standard; “should” is used to express a recommendation or that which is advised but not required; and “may” is used to express an option or that which is permissible within the limits of the Standard.

Notes accompanying clauses do not include requirements or alternative requirements; the purpose of a note accompanying a clause is to separate from the text explanatory or informative material.

Notes to tables and figures are considered part of the table or figure and may be written as requirements.

Annexes are designated normative (mandatory) or informative (non-mandatory) to define their application.

2 Reference publicationsThis Standard refers to the following publications, and where such reference is made, it shall be to the edition listed below:

IHI (Institute for Healthcare Improvement)IHI Triple Aim Initiative http://www.ihi.org/Engage/Initiatives/TripleAim/Pages/default.aspx

Paramedic Association of Canada2016 Canadian Paramedic Profile

3 DefinitionsThe following definitions shall apply in this Standard:

Case finding — the act or process of identifying or locating at-risk individuals.

Carer — a person who takes on an unpaid caring role for someone who needs help because of a physical or cognitive condition, an injury, or a chronic life-limiting illness. Note: Also referred to as a “caregiver” or “family caregiver”.

Collaborative care — an inter-professional process for communication and decision-making that enables the separate and shared knowledge skills of care providers to synergistically influence the client/patient care provided. Note: Collaborative care implies a shared responsibility for patient care.

http://www.ihi.org/Engage/Initiatives/TripleAim/Pages/default.aspx



Community health needs assessment — a systematic method for reviewing the health issues facing a population, leading to agreed priorities and resource allocation that will improve health and reduce inequities.

Community paramedicine program — a program that uses paramedics to provide immediate or scheduled primary, urgent, and/or specialized healthcare to vulnerable patient populations by focusing on improving equity in healthcare access across the continuum of care.

Community paramedic — a paramedic who has completed a formal and recognized educational program and has demonstrated competence in the provision of health education, clinical assessment and monitoring, point of care diagnostics, and treatment modalities within or beyond the role of traditional emergency care and transport.

Community resource capacity assessment — the combined influence of a community’s commitment, resources, and skills that can be deployed to build on community strengths and address community problems and opportunities.

Differentiated practice — the use of paramedics in a non-emergency setting or acute non-life threatening situations according to their expertise and qualifications.

Evidence-based practice — the integration of best research evidence with clinical expertise and patient values to facilitate clinical decision making.

Sustainable health and health care — the appropriate balance between the cultural, social, and economic environments designed to meet the health and health care needs of individuals and the population (from health promotion and disease prevention to restoring health and supporting end of life) and that leads to optimal health and health care outcomes without compromising the outcomes and ability of future generations to meet their own health and health care needs.

4 Guiding principles

4.1 GeneralThe overall goal of any program should be to promote the patient's access to the right care, delivered by the right provider, at the right time, resulting in the best outcomes and the most effective and efficient use of resources. The foundation of any program will be dependent on stable and sustainable partnerships among numerous community-based agencies, teams and organizations.

While each program will be unique, based on the specific needs and resources of the community, common principles shall guide the program and guide the program’s evaluation and continuing improvement, from the outset.

4.2 Guiding principles

4.2.1 GeneralThe following eight principles underlie the structure and aims of an effective community paramedicine program. They are as follows:a) patient- and family-centred;b) needs and evidence based care;c) goal directed and outcomes based;



d) integrated collaborative care;e) patient and provider safety;f) stakeholder engagement;g) governance and policy; andh) sustainability.

4.2.2 Patient- and family-centredPatient- and family-centred care recognizes and incorporates the carer’s needs, the patient’s personal circumstances, their overall health history, the social and cultural context, as well as factors associated with the location and environment of patient encounter. Patients and their carers are integral parts of the care team who collaborate with the health care professional in making clinical decisions.

4.2.3 Needs and evidence basedEach program shall assess community needs and identify the gaps between the services and resources available. It shall then define its service model with system-specific health status benchmarks and performance indicators. The model of care shall integrate and balance best research evidence with paramedics’ clinical expertise and the patient’s and family’s values and needs.

4.2.4 Goal directed and outcome basedCommunity paramedic programs shall undergo ongoing and rigorous evaluation and improvement of their service and community paramedic roles related to pre-determined outcome-based goals.

4.2.5 Integrated collaborative carePrograms should build on existing and established community linkages and partnerships and should supplement provision by other providers. Programs should provide seamless care pathways along and within each patient’s continuum of care and assist patients with navigation of the health care system. This involves the understanding that it shall be the responsibility of all partners to ensure that optimum patient care is provided and that there is a shared responsibility and accountability of patient care.

4.2.6 Patient and provider safetyThe safety of the patient and the community paramedic shall be keystones of community paramedicine programs. Engagement in voluntary and mandatory patient and practitioner safety reporting systems are key characteristics of a community paramedicine program.

4.2.7 Stakeholder engagementEngagement of stakeholders is key to program success and should be reinforced during the planning stages and implementation of the program. Communications should be open and transparent to increase community/public awareness and establish strong partnerships.

4.2.8 Governance and PolicyEffective programs benefit from strong governance and leadership. Programs shall have policies, protocols, and assessment tools in place and have senior management commitment. These programs shall be aligned with the organization’s mission and vision, values, strategic plan, and the management system and organizational practices. As well, jurisdictional and regulatory requirements shall be aligned.

4.2.9 SustainabilityCommunity paramedicine contributes to the sustainability of an integrated health system by increasing efficiencies and delivering cost effective care. Programs should be evaluated based on a uniform and



validated set of measures leading to optimum sustainability and utilization of patient- and family- centred services.

5 Competency, education, and training

5.1 GeneralThe Program should establish and maintain a procedure toa) define the ideal and minimal competencies required of community paramedics; andb) ensure that paramedics are competent to carry out all aspects of their unique role and

responsibilities, including standard operating procedures.

5.2 Roles and competenciesWhile some consider that community paramedicine is an expanded role for paramedics, in reality it is not a new practice, but has evolved as a professional specialty. This model of care has the potential to transform the overall role of paramedicine. For successful programs, the roles, scopes of practice and competencies should be clarified and formalized.

The Paramedic Association of Canada 2016 Canadian Paramedic Profile will provide the foundation for the roles and competencies specific to community paramedicine. These overarching roles includea) clinician;b) professional;c) educator;d) advocate;e) team member; andf) reflective practitioner.

5.3 Specialized capabilitiesThe community paramedic is a patient advocate who displays strong communication, time management, and clinical decision-making skills while interacting with a diverse, multidisciplinary workforce often situated within complex organizational structures. The community paramedic shall ensure safe, proficient, and appropriate patient care through paramedic protocols, medical consultation, recognized best practices of care, and clinical referral requests. As a professional, the community paramedic shall demonstrate ongoing working knowledge of paramedic and allied partners: protocols, policies and procedures, local service and business unit standards, and governance documents.

The capabilities most commonly identified as important to the role of a community paramedic includea) breadth and depth of clinical knowledge;b) knowledge of the healthcare system and how it works;c) working in the community and working in uncontrolled environments;d) knowledge of the local community, particularly other health care providers and opportunities for

collaboration;e) communication and relationship-building skills;f) comprehensive assessment and examination skills, including the capacity to see the complexities of

a persons situation and issues broadly;g) understanding of the social determinants of health;h) advanced clinical reasoning and decision-making skills that are not soley reliant on protocols but

can operate within guidelines; and



i) being particularly skilled at working within complex systems of care practiced in the context of progressively more challenging problems, projects, and standards of performance.

5.4 Education and trainingThe community paramedicine program should ensure that community paramedics receive specialized education and continuing professional development appropriate to the program’s model of care. The educational requirements should provide foundational knowledge based on a recognized or approved curriculum.

Training chosen should fit the needs of the community and the learners, based on the health care gaps identified through the community assessment. If an educational program from a post-secondary educational institution is not available locally, the program may develop an in-house program or work collaboratively with a local educational institution to develop a customized training program.

6 Models of care

6.1 General

6.1.1 A model of care provides details regarding community paramedicine program delivery. This can entail acting in expanded roles and/or with an extended scope of practice in applying paramedic competencies in non–traditional community environments through collaborative or differentiated practice. For example, some community paramedicine programs may aim to reduce the number of patients transported to emergency departments either by re-directing them to service providers not located at a hospital or by providing the necessary care in place.

6.1.2 Historically, program models evolved out of the need to address issues of access to health care in under-serviced, often rural and remote areas. However, community paramedicine programs have also been introduced or expanded to address a wider range of health care and social issues, particularly in response to the needs of the elderly and those with chronic diseases, including in all geographic settings.

The terminology used to classify models of care can vary as can the outcomes of interest. Regardless, each program shall define a model of care that describesa) the population group, cohort, or patient group intended to be served;b) the services or interventions that will be provided;c) the rationale for these services or interventions;d) the pertinent timeframes necessary for program delivery; ande) the settings under which the program will be delivered.

6.1.3 A conceptual framework that provides some examples of models of care is shown in Figure 2. Key health issues in the community served shall be identified, objectives developed for the program, and the appropriate interventions and timeframes selected. Models can be classified into one or more of the following three domains:a) coordination;b) care; and

RESPONSE

COO

RD

INA

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CARE• Diagnostics• Dialysis support• Immunization• Intravenous therapy• Medication administration• Point of care testing• Remote monitoring• Treatment• Wound care

• Care coordination• Early detection and intervention• Fall prevention• Health promotion• Health surveillance• Social inclusion• System navigation• Tele/video assessment

• Case finding and referral• Early discharge• Emergency diversion• Medication management• Palliative care• Re-integration to home• Surge capacity

• Population needs• Illnesses and injuries

• Resources available• Stakeholders

• What we do• Who we reach

• What are the results• How and when do we measure

Assessment Inputs Outputs Evaluation



7.2 Commitment, leadership, and governance

7.2.1 GeneralCommitment, leadership, governance, and effective collaboration are crucial to the successful implementation of the program. The program shall have senior management level commitment and support and the program manager should report directly to senior management. The organization shall provide the primary commitment to the program and should engage health care partners to develop leadership for the implementation of the program. Leadership should be cultivated within and amongst the participant organizations.

7.2.2 PartnersPotential partners and organizations may includea) geriatricians;b) family physicians;c) hospitals;d) community health nurses;e) community mental health;f) emergency physicians;g) primary care clinics;h) walk in and urgent care centres;i) home care agencies;j) social service agencies;k) volunteer organizations;l) regional health management organizations (e.g., Ontario - Local Health Integration Network);m) allied public safety services (e.g., police, fire);n) housing agencies/organizations (a key player when it comes to stabilizing vulnerable clients); ando) paramedic regulators.

Partner organizations should establish effective partnering agreements and information exchange agreements [i.e., memorandum of understanding (MOU’s)].

7.2.3 Governance/accountabilities/roles and responsibilitiesThe community paramedicine program should clearly identify organizational executive level commitment for the human, financial, capital, and equipment necessary to develop, implement, and manage the community paramedicine program both clinically and administratively. It is important to ensure policies and procedures are developed that outline the community paramedic role related to autonomy, authority, and accountability.

7.3 Community health needs assessmentA community health needs assessment should lead to the development of a program strategic plan which will define how best to incorporate existing community resources, services, and personnel into a program. Successful programs rely on collaboration among health care organizations. The focus of the assessment should be to identify gaps and should be done using a multi-disciplinary process.

A successful program will use new partnerships with community stakeholders (e.g., patients, funding agencies, health care facilities, public health agencies, emergency services, civic leaders, and organizations). The strategic plan for the program should include ongoing evaluation based on defined performance measures with quantifiable clinical significance and feedback from stakeholders.



Resources and tools exist to help organizations conduct community health needs assessments. Some of these are specific to community paramedicine and others are for general community health programs.Note: Refer to Annex B for a listing of community paramedic resources.

7.4 Community resource capacity assessmentThe program should be designed to address concrete and specific community health care needs and respond to local circumstances and conditions. To identify these needs the program should complete a comprehensive inventory that identifies the availability and distribution of current capabilities and resources from many partners and organizations.

Community resource capacity refers to the combined influence of a community’s commitment, resources, and skills that can be developed to build on community strengths and to address community problems and opportunities.

A community resource capacity assessment can be complex and it might be difficult to achieve a complete assessment. As part of the planning phase, preliminary input from other health care providers and stakeholders could help to identify key population groups or conditions that would potentially be targets for the program and to focus the data collection.

7.5 Community and stakeholder engagement

7.5.1 GeneralCommunity engagement refers to the methods by which the program interacts, shares, and gathers information from and with their stakeholders. The purpose of community engagement is to inform, educate, consult, involve, and empower stakeholders in both program planning, decision making processes, and evaluation of programs. Effective community engagement helps toa) assess the level of community support;b) provide clarity about how the program will interact with existing healthcare delivery system;c) build advocates;d) identify resources; ande) identify barriers.

7.5.2 Community engagement planCommunity stakeholders are individuals, community groups, political leaders, or other organizations who have a vested interest in the outcomes of the program. Anyone whose interests could be positively or negatively impacted by the program, or anyone who can exert influence over the program or its results is considered a program stakeholder. All stakeholders should be identified and involved appropriately.

7.6 Program development

7.6.1 Program scope, objectives, and targets

7.6.1.1 Community paramedic programs should meet the needs of populations by providing community- focused support using innovative means. Program objectives should consider utilizing the Institute for Healthcare Improvement (IHI) Triple Aim* approach to optimizing health system performance.

The IHI Triple Aim

Define “quality” from theperspective of an individualmember of a defined population

Populationhealth

Experienceof care

Per capita cost

System-levelmetrics

Health care

Public healthSocial services

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families

Definition ofprimary care

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Preventionand healthpromotion

http://www.ihi.org/Engage/Initiatives/TripleAim/Pages/default.aspx



7.6.1.3 Effective programs use the Triple Aim and implementation concepts as a framework in their planning, program launch, and evaluation. Other locally derived benchmarks should also be identified according to the gaps in service delivery in the planning stage (identifying the local gaps the program intends to fill), and should also be used during implementation and evaluation.

Monitoring of program objectives and targets should bea) developed by the multi-stakeholder implementation committee;b) measurable;c) consistent with the strategic plan and policies of the paramedic organization;d) compliant with legal requirements and other requirements;e) based on past performance measures, priority health care gaps based on community assessments;f) aligned with the organization’s operational and business requirements and other requirements or

opportunities; andg) reviewed and monitored according to changing information and conditions, as appropriate.

7.6.1.4 Triple to quadruple aimOrganizations now are also considering a fourth aim — improving the work life of those who deliver care. Program objectives should consider the impact on practitioner health and well-being and address issues such as stress, burnout, and turnover. Improving the practitioner experience should be an important goal.

Best practice tip: Once the program scope, objectives, and targets have been identified, it is a good idea to create a one page description of the program to distribute to partners and stakeholders to help build awareness and encourage community support.

7.6.2 CommunicationsA key role for a community paramedic is educator/communicator. This applies to program communications, but more importantly to communications with patients, family, carers, patient advocates, and other health providers. Accurate and timely communication should be a priority to promote continuity of care and help to prevent adverse events. Miscommunication can impact patient safety.

At the program level, the team should establish and maintain policies and procedures for communication and public education to promote health and prevent injuries. Communications shall include both internal and external communications. While much of the communication will be done during the planning and set-up phase, communication about the role of the program should be ongoing both within and outside the organization to help ensure the sustainability of the program.

Best practice tip: Tell the story and tell it often. Translate the complexities of the program into language that everyone will understand.

7.6.3 Documentation and clinical information systemsThe program should create and maintain the documents and records required for the program services. Documentation should be written clearly and be easily understood. While the program may utilize the information systems and documentation of the paramedic organization, there might be a need to develop specialized clinical information systems, records, and tools, recognizing the importance of integrated care and bi-directional information exchange. These may be customized database systems or publicly available patient assessment tools.



Program documentation should includea) program policies and performance measures;b) assignment of duties and responsibilities;c) procedures for program implementation;d) supporting documentation for effective operation of the program (e.g., training records, patient

clinical records, checklists, etc.); ande) other documents or records required (legal requirements for compliance with legislation).

7.7 Implementation committeeA program implementation committee should be established. The success of a program depends not only on leadership, but also on high-level coordination. The implementation committee provides an ongoing forum to foster a participatory approach and a broad understanding of the program and innovative practices. The committee can providea) strategic guidance and oversight for design and implementation of the program;b) effective and ongoing communication;c) information sharing of innovative and best practices; andd) exchange of ideas to ensure an understanding of, and input into, the design of the program.

8 Implementation

8.1 GeneralThe organization shall determine, provide, and maintain the infrastructure and resources needed to implement the program.

8.2 Safety measures

8.2.1 GeneralSafeguards should be adopted and additional efforts should be introduced to assure that the program operates safely and provides the highest quality health services in an environment that is safe for both the client and service provided. Procedures should ensure that decisions remain focused on the safety and welfare of the patient. The program shall also include policies and procedures to ensure the health and safety of the paramedics and other personnel involved with the program. In the care setting, family carers provide a significant amount of patient care for chronic and complex situations. The program should also consider carer safety and support.

8.2.2 Practitioner safetyThe program should ensure that practitioners required to work in the community setting have access to appropriate resources including training, hazard assessments, hazard controls, and response processes to mitigate the risks and ensure safety and wellbeing in the workplace.

The program should ensure that safety plans are developed, implemented, and maintained by the program to provide guidance and to make all practitioners aware of the workplace hazards as well as the controls in place to eliminate or reduce risk. Plans should includea) communication procedures and emergency contact lists that incorporate readily available

assistance in the event of an injury, illness, or emergency;b) communication devices, e.g., radio or phone;c) clearly defined roles and responsibilities, e.g., supervisor and practitioner;



d) training on the hazards, controls, and safety plans of their respective departments;e) emergency response plans in the event that a practitioner does not respond to communication,

and/or has been involved in an incident; andf) a reporting process.

8.2.3 Patient safetyPatient safety can be addressed through the following methods:a) selection of qualified personnel to receive community paramedic training and be utilized in this

role;b) thorough training to ensure adequate knowledge and competencies of all program personnel;c) through the establishment of appropriate clinical practice guidelines and program policies;d) frequent and consistent review and reporting of program data and timely investigation of all

clinical patient care concerns/complaints; ande) conducting patient and environment assessments, where appropriate (i.e., home safety inspection

to assess the safety of the home environment).

8.2.4 Carer supportFamily carers are critical partners in the care of patients, particularly for those with chronic illnesses. As the population ages and health care needs become more complex, community paramedicine programs can play an important role in helping family carers protect their own health and safety, and become more confident and competent. The health and safety hazards are both physical and psychological.

Programs should consider how toa) identify, assess, and reduce health and safety risks for carers;b) provide carer support to strengthen carer competency; andc) educate carers on skills that will enhance patient safety.

9 Evaluation

Note: Annex B includes a list of some program evaluation resources and tools.

9.1 GeneralThe organization, in collaboration with the implementation committee, shall develop or adapt an evaluation framework for the program. While each program might be unique in terms of its specific aims and objectives, the guiding principles for effective community paramedicine programs are common (see Clause 4).

The implementation committee should develop a community paramedicine program evaluation plan. Each program should define its system-specific health status benchmarks and performance indicators. These performance indicators should reflect the structure, process, and clinical outcomes of the program.

Developing an evaluation plan during the planning process is critical. It helps to ensure that data can be collected in a systematic way that can be analyzed to assess the program outcomes and impacts. Plus, evaluation is important to help secure financial support (“return on investment”) to maintain or expand the program.



9.2 Types of program evaluationThe main types of evaluation includea) monitoring and measurement of quality improvement metrics (based on guiding principles,

program integrity requirements, and specific objectives and targets identified in the strategic plan);b) academic evaluation (i.e., peer reviewed studies and research); andc) consumer and provider feedback (i.e., qualitative evaluations from patients, family, professionals,

volunteers, and other health organizations).

9.3 Monitoring and measuringThe organization should establish and maintain a set of measures to monitor, measure, and record the performance and effectiveness of the program on a regular basis. This monitoring and measurement shoulda) determine the extent to which the program policies, objectives, and targets are being met;b) provide feedback on program effectiveness and impact;c) identify areas for corrective action and quality improvements;d) meet requirements for patient safety reporting and action;e) provide the basis for decisions around budget, staffing, resources, training, and service gaps;f) help identify required changes to clinical guidelines and protocols;g) provide information to help improve the planning process and input to management review;h) provide information to be shared with program partners, stakeholders, and the public; andi) contribute to benchmarking and program comparisons.

9.4 Health care system impactWhile each program will have a set of specific measures, it is important that each evaluation helps to show the value of community paramedicine as part of an integrated health care system. Some of the key questions that should be included in any evaluation of the impact of a program are as follows:a) Has the program impacted paramedic service utilization?b) Has the program resulted in a decrease in emergency department use?c) Has the program decreased the waiting times for alternate level of care patients?d) Has the program decreased the demand on long term care?e) Has the program decreased repeat paramedic service users?

9.5 Management review and continuous improvement

9.5.1 GeneralSenior management, in collaboration with the implementation committee, should review the program at planned intervals to ensure its continuing suitability, adequacy, sustainability, and effectiveness. This review should include an assessment of the need for changes to the program, including the overall strategies, policies, and objectives. The review should include an assessment of opportunities for continual improvement.

9.5.2 Review inputThe input to the management review should include the following information:a) results of monitoring and measurement;b) feedback received from stakeholders and members of the community;c) research on updated clinical procedures and best practice;d) new regulatory requirements and trends;e) how well targets have been met;



f) status of any corrective actions;g) changing circumstances (e.g., population demographics, funding opportunities); andh) recommendations for improvement.

9.5.3 Review outputThe organization should develop actions plans from the management review. The organization should have a process for recording and communicating the findings, conclusions, and action plans to program personnel, the implementation committee, and other interested stakeholders.



Annex A (informative)Checklist for the development of a community paramedicine programNote: This Annex is not a mandatory part of this Standard.

A.1 This checklist is intended to assist paramedic services and their partners in considering key factors required when developing or implementing a community paramedicine program. This checklist is meant to be used a guide, and factors should be considered according to community needs, resources and appropriateness.

Overarching principles:

The overall goal of any program should be to promote the patient's access to the right care, delivered by the right provider, at the right time, resulting in the best outcomes and the most effective and efficient use of resources.

While each program will be unique, based on the specific needs and resources of the community, common principles should guide the program and guide the program’s evaluation and continuing improvement, from the outset. Organizations can utilize this checklist at each stage of the development and implementation of a community paramedicine program. There are three stages, each of which is outlined below.

Stage I: Guiding principles — For use at the conceptual stage□ Each one of the following eight principles that underlie the structure and aims of an effective community paramedicine program have been considered:1) Patient and family centred

– The patient and carers’ needs, the patient’s personal circumstances, their overall health history, the social and cultural context, and factors associated with the location and environment of patient encounter will be considered.

2) Needs and evidence based – Community needs and gaps between the services and resources available can be identified.

3) Goal directed and outcome based – Ongoing and rigorous evaluation and improvement can be implemented.

4) Integrated collaborative care – The program will build on existing and established community linkages and partnerships and supplement healthcare provision by other providers.

5) Patient and provider safety – Patient and community paramedics will be considered.

6) Stakeholder engagement – Engagement of stakeholders will be reinforced during the planning stages and implementation of the program.

7) Governance and policy – Strong governance and leadership, policies, protocols, and assessment tools will be developed.

8) Sustainability – The community paramedicine programs will be evaluated based on uniform and validated measures



Competency, education, and training — For use when defining staff roles□ Ideal and minimal competencies required of community paramedics can be defined.□ Competence to carry out all aspects of the unique role and responsibilities can be ensured.□ Roles, scopes of practice, and competencies can be clarified and formalized. □ Specialized education and continuing professional development can be provided.

Stage II: Program planning — For use at the planning stage□ A comprehensive, collaborative strategic plan for the development of the community paramedicine

program, with executive buy-in and sponsorship has been planned by the organization.□ Specific measurement strategies, implementation milestones, a communication plan that includes

engagement with local and regional stakeholders, and a financial sustainability plan have been developed.

□ The program plan is integrated into, or compatible with, the other management systems in the organization.

Community paramedicine program governance and accountability□ Senior management level commitment and support are provided.□ The program manager reports directly to senior management.□ Health care partners are engaged to develop leadership for the implementation of the program.□ The organizational executive level commitment for the human, financial, capital, and equipment has

been identified that is necessary to develop, implement, and manage the community paramedicine program both clinically and administratively.

Community health needs assessment□ A community health needs assessment has been conducted.□ A program strategic plan defining how best to incorporate existing community resources, services,

and personnel into a program has been developed.□ The assessment has identified gaps and was performed using a multi-disciplinary process. □ Ongoing evaluation based on defined performance measures with quantifiable clinical significance

and feedback from stakeholders has been built in.

Community resource capacity assessment□ A comprehensive inventory that identifies the availability and distribution of current capabilities and

resources from many partners and organizations was completed.□ The program addresses concrete and specific community health care gaps relevant to local

circumstances and conditions.

Community engagement plan□ Community stakeholders (individuals, community groups, political leaders, or other organizations

that have a vested interest in the program’s outcomes) have been identified and involved appropriately.

Program scope, objectives, and targets□ Community paramedic programs should meet the needs of populations by providing community-

focused support using innovative means.□ Utilizing of the Institute of Healthcare Improvement (IHI) “Triple Aim” approach to optimizing health

system performance has been considered.



Communications□ Accurate and timely communication is a priority to promote continuity of care and help to prevent

adverse events.□ Policies and procedures for communication and public education to promote health and prevent

injuries have been established. Communications will include both internal and external communications.

□ There is ongoing communication about the role of the program both within and outside the organization to help ensure the sustainability of the program.

Documentation and clinical information systems□ The program should create and maintain the documents and records required for the program

services. Documentation should be written clearly and be easily understood.

Implementation committee□ A program implementation committee should be established. The success of a program depends not

only on leadership but high-level coordination.

Stage III: Implementation and evaluation — For use at the implementation stage□ The organization should determine, provide, and maintain the infrastructure and resources needed

to implement the program.

Safety measures□ Safeguards have been adopted and efforts made to assure that the program operates safely and

provides the highest quality health services.□ Procedures ensure that decisions remain focused on the safety and welfare of the patient.□ Carer safety and support has been considered.□ Community paramedicine program evaluation tools have been adapted to local context and

jurisdictional requirements.□ System-specific health status benchmarks and performance indicators have been defined.

Monitoring and measuring□ A set of measures have been established to monitor, measure, and record the performance and

effectiveness of the program on a regular basis.

Health care system impact□ Planned evaluation shows the value of community paramedicine as part of an integrated health care

system.

Management review and continual improvement□ Senior management and the implementation committee review the program at planned intervals to

ensure its continuing suitability, adequacy, sustainability, and effectiveness.□ The review includes assessment of opportunities for continual improvement, the need for changes to

the program, including the overall strategies, policies, and objectives.



Annex B (informative)Community paramedicine resourcesNote: This Annex is not a mandatory part of this Standard.

B.1 IntroductionIn developing this Standard, a wide variety of reference material was identified and obtained for review by the CSA Technical Committee, including relevant standards and accreditation documents, policy documents, handbooks and program materials, research studies, reports and articles and competency, curriculum and training documents. Reference material gathered provided an understanding of the issues and challenges surrounding community paramedicine program development. Reference materials originated from Canada, US and other countries such as Australia and United Kingdom. A number of paramedic organizations / stakeholders throughout Canada shared their experiences in developing and delivering community paramedicine program services, as well as sharing their policy and program materials to help facilitate the development of this standard.

Provided below is not a comprehensive bibliography or list of resource material on the subject of community paramedicine, but is a reference to some key resources to help organizations in their development, implementation and evaluation of a community paramedicne program.

B.2 Community paramedicine resourcesProgram assessment and evaluationAlberta Health Services EMS Evaluation Plan. Calgary Zone Community Paramedic Program CCT, Version 4, January 2017.

Alberta Health Services, Calgary Zone, Community Paramedic Occupational Competency Profile, Dec. 2013.

Centers for Disease Control and Prevention. A Framework for Program Evaluation in Public Health https://www.cdc.gov/eval/framework/

Mobile Integrated Healthcare Metrics for Community Health Interventions – Measurement Strategy Overview NAEMT - the National Association of Emergency Medical Technicians. http://www.naemt.org/docs/default-source/community-paramedicine/mih-cp-toolkit/mih-metrics-for- community-health-interventions—final-for-release-11-1-16.pdf

Quality Improvement & Innovation Partnership Advancing Improvement in Primary Healthcare in Ontario, Government of Ontario http://www.hqontario.ca/Portals/0/documents/qi/qi-rg-needs-assessment-0901-en.pdf

U.S. Department of Health and Human Services — Health Resources and Services Administration. 2012. Community Paramedicine Evaluation Tool.

Program policy and researchAlberta Health Services Calgary Zone, Community Paramedicine Program Outcome and Metrics.

Alberta Health Services Emergency Medical Services, Detailed Design Introduce Calgary Zone Community Paramedics through Partnership with ISFL NP Program. Version 2, July 2012.

https://www.cdc.gov/eval/framework/

http://www.naemt.org/docs/default-source/community-paramedicine/mih-cp-toolkit/mih-metrics-for-community-health-interventions---final-for-release-11-1-16.pdf

http://www.naemt.org/docs/default-source/community-paramedicine/mih-cp-toolkit/mih-metrics-for-community-health-interventions---final-for-release-11-1-16.pdf

http://www.hqontario.ca/Portals/0/documents/qi/qi-rg-needs-assessment-0901-en.pdf



Agarwal G., Angeles R., McDonough B., McLeod B., Marzanek F., Pirrie M., and Dolovich L., Development of a community health and wellness pilot in a subsidised seniors' apartment building in Hamilton, Ontario: Community Health Awareness Program delivered by Emergency Medical Services (CHAP-EMS). BMC Research Notes. 2015 Apr 1;8:113.

Agarwal G., Angeles R., McDonough B., McLeod B., Marzanek F., Pirrie M., and Dolovich L., Rationale and methods of a multicentre randomised controlled trial of the effectiveness of a Community Health Assessment Program with Emergency Medical Services (CHAP-EMS) implemented on residents aged 55 years and older in subsidised seniors’ housing buildings in Ontario, Canada. BMJ Open. 2015 June 11;5(6):e008110.

Agarwal, R., Angeles, R.N., Pirrie, M., Marzanek, F., and Parascandalo, J., (2016, June). Development and validation of the Health Awareness and Behaviour Tool (HABiT). Paper presented at the Trillium Research Day Conference, Toronto, ON.

Bigham B., Kennedy S., Drennan I., and Morrison L., Expanding Paramedic Scope of Practice in the Community: A Systematic Review of Literature, Prehospital Emergency Care, 2013.

Brydges M., Denton M., and Agarwal G., Participants' Views of the Role of Paramedics in a Community Health Promotion Program: CHAP-EMS. Submitted to BMC Health Services Research BMC Health Serv Res. 2016 Aug 24;16(1):435. doi: 10.1186/s12913-016-1687-9.

County of Hastings and Renfrew Paramedic Services, Community Paramedicine Clinical Guidelines. Version 1.

County of Renfrew Paramedic Service. 2013. A Survey of Community Paramedic Programs in Ontario.

Emergency Medical Services Chiefs of Canada, Community Paramedicine Submission to Standing Committee on Health, Dec. 2011.

Evashkevich M., Fitzgerald M., A Framework for Implementing Community Paramedic Programs in British Columbia, May 2014, Ambulance Paramedics of British Columbia.

Kizer K., Shore K., and Moulin A., Community Paramedicine: A Promising Model for Integrating Emergency and Primary Care, July 2013.

Middlesex-London EMS, Community Paramedicine Report, March 24, 2015.

Minnesota Department of Health, Community Paramedic Toolkit Ambulance Service Survey and Focus Group Results, Dec. 2015.

Minnesota Department of Health, Community Paramedicine Toolkit – Review of Existing Community Paramedic Toolkits, Dec. 2015.

Mathis S., Merrell M., Blueprint for Community Paramedicine Programs Especially for EMS Agencies, Version 1: The Abbeville Experience. South Carolina Office of Rural Health.

National Association of State EMS Officials, State Perspectives Discussion Paper on Development of Community Paramedicine Programs, Dec. 2010.

National Rural Health Association Policy Brief, Principles for Community Paramedicine Programs. Sept. 2012. (authored by Ryan White and Gary Wingrove).



North West Ambulance Service, Paramedic Pathfinder and Community Care Pathways, Sept. 2014, V. 3, UK.

O’Meara P., Stirling C., Ruest, M., Martin, A., Community paramedicine model of care: an observational, ethnographic case study. BMC Health Services Research, 2016.

Paramedic Association of Canada, National Occupational Competency Profile for Paramedics (NOCP). October 2011.

Public Health Agency of Canada, “Community Capacity Building Tool”, http://www.phac-aspc.gc.ca/canada/regions/ab-nwt-tno/downloads-eng.php

Social Planning and Resource Council of British Columbia (sparc bc). “Community Engagement Toolkit”, July 2013 http://www.sparc.bc.ca/community-development/sprout/community-engagement-toolkit/

Thompson C., Williams K., Morris D., Lago L., Kobel C., Quinsey K., Eckermann S., Andersen P., and Masso M. (2014) HWA Expanded Scopes of Practice Program Evaluation: Expanding the Role of Paramedics Sub-Project Final Report. Centre for Health Service Development, Australian Health Services Research Institute, University of Wollongong.

Toronto Paramedic Services — Community Paramedicine Program, “Community Paramedic Visit Referral Consent Form”.

University of Toronto Department of Medicine. n.d. Expanding paramedicine in the community (EPIC), Wang H, Community Paramedicine, Jan. 2011.

Western Eagle County Health Services District, Community Paramedic Program Handbook, Fall 2011, Version 1.2.

http://www.phac-aspc.gc.ca/canada/regions/ab-nwt-tno/downloads-eng.php

http://www.sparc.bc.ca/community-development/sprout/community-engagement-toolkit/

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