Designing and Governing Responsive Local Care Systems – Insights from a Scoping Review of Paramedics in Integrated Models of Care

– People at high risk for hospital readmission [50, 51, 52, 53]

– High utilizers of emergency services [54, 55, 56]

– Emergency episodes: mental health [57, 58, 59, 60], heart attacks [61, 62, 63, 64, 65], strokes [66, 67, 68], low-acuity injuries [69, 70, 71, 72, 73]; falls [74, 75, 76, 77]; and hypoglycemia [78, 79, 80]

– People with multiple chronic diseases such as congestive heart failure (CHF) and chronic obstructive pulmonary disease (COPD) [81, 82, 83]

– People with complex needs: palliative care [84], long-term care [85, 86, 87, 88]

– Older adults and seniors living in the community [89, 90, 91, 92, 93]

– Reduce unnecessary use of hospital and emergency services [52, 90, 94, 95]

– Improve patient experience and appropriateness of care [54, 69, 84, 86, 96]

– Respond to cost, staffing and resource pressures [97, 98, 99, 100]

– Improve care access in isolated rural areas with limited staff [101, 102, 103, 104, 105]

– Improve health promotion and prevention [106, 107]

– Improve patient health outcomes, decrease morbidity and mortality [61, 63, 66, 108, 109]

– Improve access to care for hard-to-reach populations such as people who are homeless and undocumented [55]

– Unscheduled, on-demand episodic care accessed via:

• universal emergency phone number such as 911, 999 or 111 [55, 61, 62, 69, 74, 79, 96, 97, 110, 111]

• dedicated non-emergency number for enrolled populations [83, 112, 113, 114]

– Scheduled and drop-in services: in clients’ homes [51, 72, 102, 108, 115, 116], community spaces [90, 111, 117, 118] or mobile pop-up clinics [119]

– Community-based follow-up care: social work [55, 120, 121, 122], home care nursing [56, 121], diabetes clinics [79, 80], falls prevention teams [75, 77] and mental health facilities [57, 59, 123, 124, 125]

– Clients with certain risk profiles rostered to programs by primary care providers [81, 82, 92, 112, 126], hospitals [51, 52, 95, 108, 120, 127], or by paramedic services [55, 56, 128]

– Case management and coordination for clients with multiple needs [52, 54, 129, 130]

– Informal, ad-hoc collaboration and consultation with primary care physicians, community nurses, pharmacists and social workers [50, 55, 69, 83, 90]

– Formal, protocol-based collaboration with specialists: cardiology [62, 64, 109, 131, 132, 133], neurology [66] and psychiatry and mental health [110]

– Mobile teams of paramedics, pharmacists, nurses and social workers [55, 57, 72, 116, 120]

– Critical care teams consisting of paramedics, nurses and physicians providing specialized care [134, 135, 136, 137, 138]

– Paramedics as autonomous practitioners with independent decision-making [96, 97, 125, 139]

– Paramedics as “physician extenders” who implement physician orders [69, 81, 140, 141]

– Role confusion and interprofessional tensions [117, 141, 142, 143]

– Service-delivery partnerships:

• agreement between a paramedic service and a hospital for provision of post-discharge home visits [51, 94, 108, 127]

• agreement between a paramedic service and a primary care team to respond to acute exacerbation of symptoms for their clients [81, 112]

– Formal taskforce, committee or coordinating entity with joint accountability and shared decision-making [62, 91, 105, 114, 144]

– Being geographically dispersed in a catchment area working across traditional jurisdictional boundaries [83, 84, 120, 141]

– Sharing of paramedic staff with other agencies: general practices and urgent care [71, 142], rural emergency departments [118, 145]

– Need to assess value and cost-effectiveness at a system-level, misaligned reimbursement models [95, 98, 100, 146]

– Major policy drivers influence the development of new programs or initiatives: multi-professional working in the UK [72, 114, 147, 148], financial penalties for 30-day readmissions in the USA [52, 120, 149, 150]

– Limitations of medical oversight mechanisms and medicolegal regulations [119, 151, 152]

– Barriers from legal requirements that mandate transport to a hospital [69, 110, 115, 140, 146]

– Benchmarks and measures of success:

• service utilization (e.g., number of patients, interventions performed) [73, 76, 97, 134]

• time-based indicators (e.g., ambulance response time, total care duration, time to treatment) [64, 66, 131, 132, 137, 138]

• measures of safety (e.g., rate of adverse events) [87, 89, 125, 134]

• service avoidance (e.g., number of ED visits mitigated, length of hospital stays, readmissions) [57, 76, 82, 85, 89, 90]

• patient satisfaction surveys [89, 93, 144, 153]

– Databases or patient registries for longitudinal studies [61, 94, 132, 136, 154]

– Mechanisms to regularly re-evaluate, change or adapt the program in response to new insights [62, 67, 141, 155]

– Learnings from critical cases and feedback provided to staff [109, 112, 114, 156]

– Siloed, inadequate data or IT infrastructure as a limitation to evaluation; datasets managed by different organizations and not interoperable [55, 69, 111, 121]

– Information flow between paramedics and other providers: phone call, paper and fax [51, 77, 82, 86, 108, 121]; one-way electronic transmission of referrals [79, 91, 157]

– Real-time shared patient records between paramedics and other providers [83, 112, 114, 128, 158]

– Tensions in norms around pace of care: faster, structured pace of emergency care versus the slower, uncertain pace of primary care [51, 88, 94, 158, 159]

– Reconceptualizing relationship to risk: from risk avoidance to risk tolerance [141], damaging “domino effect” of activating emergency services leading to over-treatment and poor client experience [82, 129]

– Tensions between independent, autonomous paramedic practice and joint accountability in a care team [118, 148]