Community paramedicine (CP) is an emerging model of care which expands paramedic scopes of practice to collaboratively support primary healthcare delivery in underserviced and disadvantaged communities. CP is a patient-centred holistic approach focussed on improving health outcomes, with success heavily reliant on integrative partnerships. This research aimed to identify key stakeholder perspectives about the value of CP in rural Australia.
A workshop was conducted using a modified soft system methodology (SSM) that asked participants to consider the value of CP from the perspective of five key stakeholder groups. The 50 participants consisted of paramedics and volunteer ambulance officers, paramedic service executives, paramedic educators, Medicare Local representatives and a general practitioner. Participants were randomly allocated to five stakeholder groups: paramedic profession; Minister for Health and Ageing; consumers, chief executive and executive management team of an ambulance service; and healthcare professionals. The application of SSM placed the five groups into three broad categories of stakeholders: customers, actors, and owners.
‘Customers’ in this context are patients, families and carers. ‘Actors’ are paramedics and volunteer ambulance officers, and ambulance service executives. The ‘owners’ are the Office of the Minister and those with the power to facilitate or block initiatives. Participants were allocated 15 minutes to brainstorm the question: “What can a community paramedic do for you to improve rural health provision?” Group views were verbally shared with all workshop participants and video recorded for analysis.
The ‘customers’ asked about CP from patient, family and carer perspectives, and were highly engaged with questions about how, when and where CP could operate. The paramedic and volunteer ambulance officer group of ‘actors’ battled to move beyond their emergency response mindset to articulate a clear CP vision. The executive management team responded from a strategic and risk management perspective focussing on patient safety and corporate image. They identified the need to form stakeholder partnerships. The ‘owners’ representing the Office of the Minister focussed on the holistic and wellness benefits of CP. The health professional group anticipated the CP role could provide collaborative care and support doctors.
The findings suggest many participants had a limited understanding of CP, which creates a barrier for implementation. Key benefits identified included a reduction in financial and physical burdens on the rural healthcare sector and improved outcomes for consumers. Active participation of stakeholders in the process of introducing CP programs, where people are comfortable questioning current practices and encouraged to explore new concepts and innovations, would enable a shared understanding of program aims and expectations. For paramedic services to expand service delivery models in rural Australia community participation and engagement with stakeholders is essential. They and paramedics must be willing to embrace meaningful and collaborative partnerships with patients, broader health networks, social services, politicians and researchers, and be prepared to step away from their traditional ‘command and control’ culture to co-design innovative paramedic models. SSM was a worthwhile approach to stakeholder engagement that has the potential to improve implementation of community paramedic programs through improved inclusion and the valuing of stakeholder perspectives.
Bigham BL, Kennedy SM, Drennan I, Morrison LJ. Expanding paramedic scope of practice in the community: a systematic review of the literature. Prehosp Emerg Care 2013;17:361-72.
Martin AC, O'Meara P. Perspectives from the frontline of two North American community paramedicine programs: an observational, ethnographic study. Rural Remote Health 2019;19.
O'Meara P, Ruest M, Martin A. Integrating a community paramedicine program with local health, aged care and social services: an observational ethnographic study. Australian Journal of Paramedicine 2015;12.
Long D, Clark M, Lim D, Devenish S. What's in a name? The confusion in nomenclature of low-acuity specialist roles in paramedicine. ibid. 2016;13.
Eastwood K, Morgans A, Smith K, et al. A novel approach for managing the growing demand for ambulance services by low-acuity patients. Aust Health Rev 2016;40:378-84.
O'Meara P, Wingrove G, Nolan M. Frontier and remote paramedicine practitioner models. Rural Remote Health 2018;18:4550.
Gainey CE, Brown HA, Gerard WC. Utilization of mobile integrated health providers during a flood disaster in South Carolina (USA). Prehosp Disaster Med 2018;33:432-5.
Kizer K, Shore K, Moulin A. Community paramedicine: a promising model for integrating emergency and primary care. California report 2013;1-24. Available at: https://health.ucdavis.edu/iphi/publications/reports/resources/IPHI_CommunityParamedicineReport_Final%20070913.pdf
O'Meara P, Stirling C, Ruest M, Martin A. Community paramedicine model of care: an observational, ethnographic case study. BMC Health Serv Res 2016;16.
Martin A, O'Meara P, Farmer J. Consumer perspectives of a community paramedicine program in rural Ontario. Aust J Rural Health 2016;24:278-83.
O'Meara PF. Community paramedics: a scoping review of their emergence and potential impact. International Paramedic Practice 2014;4:5-12.
Jensen JL, Travers AH, Marshall EG, et al. Insights into the implementation and operation of a novel paramedic long-term care program. Prehosp Emerg Care 2014;18:86-91.
Jensen JL, Travers AH, Bardua DJ, et al. Transport outcomes and dispatch determinants in a paramedic long-term care program: a pilot study. CJEM 2013;15:206.
Ruest M, Stitchman A, Day C. Evaluating the impact on 911 calls by an in-home programme with a multidisciplinary team. International Paramedic Practice 2012;1:125-32.
Nolan M, Hillier T, D'Angelo C. Community paramedicine in Canada - Emergency Medical Services Chiefs of Canada. 2012;57-80. Available at: www.renfrewparamedics.ca/wp-content/uploads/2018/04/Community-Paramedic-Literature.pdf
Martin-Misener R, Downe-Wamboldt B, Cain E, Girouard M. Cost effectiveness and outcomes of a nurse practitioner-paramedic-family physician model of care: the Long and Brier Islands study. Prim Health Care Res Dev 2009;10.
Brydges M, Denton M, Agarwal G. The CHAP-EMS health promotion program: a qualitative study on participants' views of the role of paramedics. BMC Health Serv Res 2016;16.
Drennan IR, Dainty KN, Hoogeveen P, et al. Expanding Paramedicine in the Community (EPIC): study protocol for a randomized controlled trial. Trials 2014;15.
Pang PSL, Liao M, Herron J, et al. Limited data to support improved outcomes after community paramedicine intervention: a systematic review. Am J Emerg Med 2019;37:960-4.
Krumperman K. Community paramedicine: a historical review of policy development. EMS Insider 2010;37:3-6.
Lezzoni LI, Dorner SC, Ajayi T. Community paramedicine: addressing questions and programs expand. N Engl J Med 2016;374:1107-9.
Augustsson H, Churruca K, Braithwaite J. Re-energising the way we manage change in healthcare: the case for soft systems methodology and its application to evidence-based practice. BMC Health Serv Res 2019;19.
Wang W, Wenbin L, Mingers J. A systemic method for organisational stakeholder identification and analysis using soft systems methodology (SSM). Eur J Oper Res 2015;246:562-74.
Checkland PB. Soft systems methodology. Human Systems Management 1989;8:273-89.
Nguyen TT, Scognamillo DG, Comer CE. Revealing community perceptions for ecological restoration using a soft system methodology. Syst Pract Action Res 2019;32:429-42.
Bergvall-Kareborn B, Mirijamdotter A, Basden A. Basic principles of SSM modeling: an examination of CATWOE from a soft perspective. ibid. 2004;17:55-73.
Braithwaite J, Hindle D, Iedema R, Westbrook JI. Introducing soft systems methodology plus (SSM+): why we need it and what it can contribute. Aust Health Rev 2002;25:195-202.
O'Meara PF, Hickson H, Higgins C. Starting the conversation: what are the issues for paramedic student clinical education? Australasian Journal of Paramedicine 2014;11.
Strauss A, Corbin J. Basics of qualitative research: grounded theory procedures and techniques. 2nd edn. Thousand Oaks, CA: Sage; 1998.
Checkland P. Soft systems methodology: a thirty year retrospective. Syst Res Behav Sci 2000;17(S1).
O'Meara P, Walker J, Stirling C, et al. The rural and remote ambulance paramedic: moving beyond emergency response. Report to the Council of Ambulance Authorities Inc. Charles Sturt University, Bathurst; 2006.
Wankhade P, Mackway-Jones K. Ambulance services. Leadership and management perspectives. Switzerland: Springer International Publishing; 2015.
O'Meara P, Kendall D, Kendall L. Working together for a sustainable urgent care system: a case study from south eastern Australia. Rural Remote Health 2004;4.
Reed B, Cowin L, O'Meara P, Wilson I. Professionalism and professionalisation in the discipline of paramedicine. Australasian Journal of Paramedicine 2019;16.
Johnston TM, Acker JJ. Using a sociological approach to answering questions about paramedic professionalism and identity. ibid. 2016;13.
Ivashkevich M, Fitzgerald M. A framework for implementing community paramedic programs in British Columbia. Richmond, BC, Ambulance Paramedics of British Columbia. CUPE 873;2014. Available at: www.apbc.ca/files/3814/0916/4457/APBC_Community_Paramedicine_Framework.pdf
O'Meara P. Would a prehospital practitioner model improve patient care in rural Australia? Emerg Med J 2003;20:199-203.
Bradbury H, Allen W, Apgar JM, et al. Healthcare transformation: action research linking local practices to national scale. In: Cooking with action research: Stories and resources for self and community transformation. Vol 1. Portland, Oregon, USA.: Action Research; 2017;15-38.
Bradbury H, Waddell S, O'Brien K, et al. A call to action research for transformations: the times demand it. Action Res 2019;17:3-10.
Wankhade P, Wankhade P. Staff perceptions and changing role of pre-hospital profession in the UK ambulance services: an exploratory study. Int J Emerg Serv 2016;5:126-44.
Rasku T, Kaunonen M, Thyer E, Paavilainen E, Joronen K. The core components of community paramedicine - integrated care in primary care settings: a scoping review. Scand J Caring Sci 2019;33:508-21.
Kenny A, Hyett N, Sawtell J, et al. Community participation in rural health: a scoping review. BMC Health Serv Res 2013;13:64.