Beyond the ER: Researchers rethink the role of paramedics in the healthcare system

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As a paramedic, University of Toronto alumnus Amir Allana regularly responds to a wide range of calls – from people suffering from a heart attack or stroke to those with mental health and addiction.

“On any given day, I can go from acute trauma to someone who is 70 years old and has just had a fall but is not otherwise injured,” says Allana, who recently defended her master’s thesis in under the Health Services Research Program offered by the Dalla Lana School of Public Health Institute of Health Policy, Management and Evaluation (IHPME).

“The next call could be for someone who is in a residential system and has a number of chronic conditions that have worsened or just needs a place to go. Are you trying to figure out how much of a health issue it is versus a social issue? Is it an addiction problem? You shift gears all the time, and a lot of it is about finding cases, triaging and navigating the healthcare system,”

In fact, Allana says traditional medical emergencies only make up a small fraction of the cases he sees.

“It’s hard for new paramedics who spend their whole schooling thinking about trauma and cardiac arrest, to realize, ‘Oh, that’s only 10% of what I do,'” he says. “There aren’t enough educational or cultural elements in place to tell them, ‘In fact, your role is mainly to diagnose and guide care. Your role is an extension of health services because you are mobile in the community.’ »

Allana and her co-director, Andrew Pinto, associate professor at the Dalla Lana School of Public Health and family physician at St. Michael’s Hospital, recently published an article in Health policywhich explores how paramedics can act more effectively on the social determinants of health.

Care could be improved, they say, by equipping paramedics with tools for better social and environmental assessments. For example, questionnaires could be used to help paramedics assess risks associated with housing, income, and food insecurity. Paramedics might also address social factors related to health by working directly with community agencies such as legal aid, shelters, drug rehabilitation centers, food banks, and employment agencies. Allana says such an approach would require a shift in paramedic education, culture and governance.

His research also focuses on integrated care and how paramedics can extend primary and preventive care in the home and community.

Allana says the pandemic has exposed the vulnerability of the health system and provides an opportunity to think about how to restructure it to leverage local agencies and services to improve outcomes.

“There are approaches to care that can be delivered in the community, but which require rethinking the role of primary care, community nursing and mobile care teams – including paramedic and mental health services – to respond to the needs of people in a way that doesn’t rely solely on doctors and nurses in a hospital,” he says.

In a study published in the International Journal of Integrated Care, Allana reviewed 108 programs around the world that use paramedics in various care pathways in the community. He discovered that paramedics fill gaps in care by working across the silos that exist between hospitals, social services, primary care and public health. For example, paramedics in some jurisdictions work with primary care teams to treat flare-ups of chronic conditions such as heart failure (when the heart is too weak to meet the body’s pumping needs) and the disorder chronic obstructive pulmonary disease (a lung disease that causes problems) by reaching out to the community to respond to needs both reactively and proactively.

“Even something simple like weight monitoring for people with congestive heart failure can detect deterioration early,” Allana says. “Systems can be put in place by family health teams and paramedics to track care plans and adjust medications. There is something between purely scheduled primary care and very acute unscheduled emergency care – there is a big gap in the middle that no one is filling, and a lot of new [paramedicine] programs fulfill this.

Allana says that ultimately, a broader view of the profession is needed, and investing in the ability of paramedics to provide urgent and preventative care will strengthen the healthcare system for all.

“The use of emergency departments and hospital services has exceeded population growth for several decades and this will continue to happen. The reason is that you don’t provide appropriate care options in the community. We don’t have the capacity in the acute care system to treat people well. If you invest in prevention and care coordination, it will pay off in the long run and limit the need for additional emergency coverage over time.

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