Community paramedicine (CP) is a locally designed, community-based, collaborative model of care that leverages the skills of paramedics and emergency medical services (EMS) systems to take advantage of collaborations between EMS and other health care and social service providers. Community paramedics receive specialized training in addition to general paramedicine training and work within a designated program under local medical control as part of a community-based team of health and social services providers.
Buddy was born with a disability that caused mild cognitive impairment and widespread pain in his bones and joints. His parents cared for him, but as they grew older, they became unable to provide for his needs or to cope with his disruptive behavior. By the time Buddy (not his real name) reached his 45th birthday, he was homeless and living in a San Diego freeway underpass.
Struggling with chronic back and limb pain, Buddy got around with the help of a walker — and by self-medicating with alcohol. Buddy often could be found sprawled out on the sidewalk in front of a liquor store. Each day at least one passerby was disturbed enough by the sight of this intoxicated man with a disability to call 911 to get him help. Fire and Emergency Medical Services (EMS) became the community's method of providing care for Buddy. Fire engines and ambulances responded up to four times a day, usually finding Buddy unable to sit up and always covered in diarrhea. The crew would transport him to the emergency department (ED), whose staff would stabilize him, clean him up, and then discharge him. Buddy would go back to the liquor store and begin drinking again. Four to six hours later, an ambulance would again be called. This cycle continued for months, generating more than 200 trips to EDs in one year.
Many people ask, "How is it that a disabled man can be left to fend for himself on the streets?" It's easy to see how they would conclude that Buddy was falling through the gaps in the system. To serve people trapped in these proverbial gaps, the City of San Diego built a Community Paramedic Pilot Project. The California Health Care Foundation is funding independent evaluation of this and 11 other community paramedicine pilot projects across the state, as well as pilot project management for the California Emergency Medical Services Authority (EMSA).
What causes people to end up like Buddy? Are they being ignored, or is their situation caused by a lack of services? Sometimes both are true, but as community paramedics, what we most often observe is a disconnect between entire systems of care. Interestingly, the birth of community paramedicine is reminiscent of the birth of emergency medical services just a few decades ago. Each was established to address gaps between systems of care.
Buddy is one of thousands of people living with the burdens of a complicated story. For decades, as paramedics saw patients like Buddy die on the streets, we were only authorized to transport people to emergency rooms. Under this pilot project, San Diego community paramedics are able to provide care and referrals to needed services like behavioral health, transportation, and housing for individuals like Buddy without taking them to hospitals. This approach has not only proved to be lifesaving, it has enhanced the quality of life for many.
From a systems perspective, all community services are divided into components that theoretically collaborate to help community members achieve a good quality of life. For example, health care and public safety are two services that must work together. In the 1970s when they weren't well coordinated, EMS was established to integrate health care, public health, and public safety. The skill set of the nation's paramedic corps reflects this. EMS is a bridging discipline that can, for example, help a citizen injured in a public safety emergency, like a traffic accident, and connect him to the health care system.
For Buddy and hundreds of other frequent 911 callers, the traditional EMS service is not equipped to address their complex social situations. But because 911 is the easiest, most accessible service for these people, they continue to call 911 as a coping mechanism. Paramedics have become unique witnesses to social vulnerabilities, engaging the community in uncommon places at uncommon times. With their versatile nature and intimate knowledge of the city, its people, and its health care institutions, San Diego's 911 paramedics evolved quite naturally into community paramedics.
This is not to say that community paramedicine is simple. When we brought Buddy to an alcohol treatment center, they told us they couldn't accept him because of his diarrhea. To them it was a sign of medical instability, and before moving forward with alcohol treatment, they needed to understand his underlying medical condition. Obtaining a diagnosis for the cause of the diarrhea was difficult because he was never sober enough for a legitimate primary care assessment. We couldn't help him sober up without housing, and housing couldn't accept him because of his diarrhea. How do you overcome such a predicament?
For weeks, our community paramedicine team looked for a solution, trying to interrupt Buddy's cycle of behavior. As we bounced from one service to the next, we began making allies. We found individual providers willing to go above and beyond routine care because they knew that in the grand scheme it would make a difference. The solution to Buddy's predicament was navigating his access to multidisciplinary care, but it couldn't have happened without eyes on the streets and someone to act as that bridge.
After just a few extra medical tests, Buddy was medically cleared, and he was able to detox. After detox, the medical community formalized his underlying disability, and he became eligible to transition into a skilled nursing facility for care. After he stabilized, it was as if he had become a new person.
Buddy is a kind man. He is the type of person who asks how you and "the team" are doing, and he mentions the community paramedics by name. In his new facility, he tells jokes to other residents and laments about how they "never get it." He is happy and has achieved a better quality of life.
San Diego's Community Paramedic Pilot Project is one of 12 now operating in California. The projects are testing six different models of community paramedicine. On September 22, community paramedics from all over California will gather in San Diego to discuss best practices and lessons learned under the California EMSA Pilot Project. The EMSA website hosts an introduction to the project, fact sheet (PDF), and community paramedicine report (PDF). Read a case study of the Community Paramedicine Pilot Project currently underway in Stanislaus County.
Watch this video to learn more about community paramedicine.