A practical result of the research conducted through completion of thesis was the interRAI Community Paramedicine Home Visit Assessment instrument. / This thesis presents a systematic framework for developing and evaluating a multi-dimensional patient assessment system for community paramedicine home visit programs. Underlying all of this work was a hypothesis that multi-dimensional patient assessment systems hold clinical utility to inform care planning activities, which in turn can direct appropriate patient care. I outline considerations for using assessment instruments to assist in the assessment process including strengths and weaknesses of using single-dimension or multi-dimensional assessment instruments when attempting to complete a consistently organized, multi-domain, and comprehensive assessment. The thesis includes a framework that outlines the major stages in developing and evaluating a new multi-dimensional patient assessment system. The framework uses community paramedicine home visit programs as an example of its application and subsequent chapters present and discuss key research questions related to each stage of the development and evaluation process; establishing a comprehensive set of clinical observations to be assessed and the related application of assessment findings to care planning activities. Two chapters explore existing assessment practices in community paramedicine home visit programs with findings that informed creation of a prototype assessment system that was pilot-tested. The fifth chapter describes results of the pilot-test and the sixth chapter investigates the clinical utility of the prototype assessment system to care planning of community paramedics. The development approach is informed by next-generation assessment practices and my work evaluating community paramedicine home visit programs provides a basis for appraisal of evidence in an emerging practice setting that does not have broadly established clinical practice guidelines. The accumulation of the evidence established in my thesis has led to the creation of a multi-dimensional patient assessment system for community paramedicine home visit programs. My research methods and findings can assist clinicians, decision makers or other researchers where a multi-dimensional assessment system is being developed or implemented. / Thesis / Candidate in Philosophy

ABSTRACT Introduction: An increase in the population of older adults is a growing public health concern. Health promotion and prevention programs provide a myriad of physical, social and psychological benefits for older adults, and recent health care trends has seen the emergence of Emergency Medical Services (EMS) in providing these programs. However, to date little is known about these programs, commonly titled, “community paramedicine”. Methodology: This study utilized a mixed methods, interpretivist qualitative approach to understand older adults experiences with a novel community paramedicine program, the Cardiovascular Health Awareness Program by EMS (CHAP-EMS), operating in a subsidized housing building in Hamilton. Participant observation and semi-structured interviews were conducted with participants of the program in addition to surveys of non-participating building residents. Data was analyzed using thematic analysis. Results: Six themes arose from the participant data including: filling the health care gap; motivators to attend; relationships between the paramedics and participants; social connectedness; the added value of EMS skills; and changes due to the program. Conclusion: Community paramedicine programs may provide older adults with access to social support, opportunities for social engagement and a reliable environment to discuss their health. However, barriers such as conflict between residents, conflicting beliefs of the program, and language barriers may impede participation in this initiative if left unaddressed. / Thesis / Master of Arts (MA)

Paramedic services are developing a new model of service delivery known as community paramedicine (CP). This service delivery model seeks to build on existing paramedic skills, establish collaboration with non-traditional health care partners, and create alternative pathways for accessing care. Frequent users of paramedic services represent patients that are of particular interest to CP programs. Chapters 2 and 3 of this thesis address questions of effective delivery of these programs. The second chapter is a spatial-temporal analysis of frequent users in Hamilton, ON. Drawing on concepts of time-geography and dynamic ambulance deployment, this analysis identifies space-time patterns in paramedic service utilization by frequent users. Data were aggregated to represent daily demand in terms of space and time. Analysis employed generalized linear mixed models that included a random slope effect for time intervals for each geographic unit. Fixed effects included distance to emergency department, proportion of residential addresses, and proportion of older adult population. Locations and times that had greater or less than expected daily demand from frequent users were identified. The findings can be used to tailor deployment of community paramedics in dual-capacity roles to address the system demand of frequent users. The third chapter analyzes the geographic influence of CP service delivery in Renfrew County, ON. This research draws on concepts of spatial accessibility and geographic profiling to estimate spatially defined probabilities of paramedic service use by frequent users. Due to ongoing CP programs within the county, the resultant community health profiles serve as an evaluation of the benefit of these programs. The community health profiles can also be used to assess community level probabilities of patient needs for future interventions. This analysis can serve as a new way to assess spatial accessibility to health care services and identify locations with increased risk of frequent use of paramedic services. / Thesis / Master of Arts (MA)

Background: Community paramedicine (CP) is an emerging form of health services delivery with the potential to reduce emergency department (ED) visits and to improve access to care. Rationale: There is growing global interest towards CP. Studies have focused on health outcomes and cost-effectiveness, but there is no comprehensive understanding about the types of CP programs and training; this knowledge may support the development of CP programs, training, and policy. Objectives: To describe CP programs and the skills for each program type, and to inform recommendations for CP programming and growth. Methods: A systematic review of MEDLINE and Embase was completed in duplicate by two independent reviewers. The Mixed Methods Appraisal Tool (MMAT) was used to assess studies’ methodological quality. A full methodology is available on PROSPERO (CRD42017051774). Results: The yield of 47 studies captured 44 unique CP programs. CP programs most often served emergency callers and individuals at risk for ED admission or readmission or hospitalization. The most common services provided were physical assessment; and assessment, referral and/or transport to community services. Training was not described by 43% of CP programs, and the mean MMAT score was three out of four criteria met. Study heterogeneity prevented meta-analysis of health outcomes. Discussion: CP programs have adapted to various populations by providing different services and training. CP training is centred on technical skills and knowledge. Since CP often involves more client interactions and inter-professional collaboration than traditional paramedicine, CP training should also include communication and teamwork skills. Challenges to CP growth include unclear role definition, introducing new healthcare roles, and competing services. Conclusion: Of the 44 unique CP programs, common services provided included physical assessments and assessing clients for community services. CP training was centred on technical skills and knowledge, but there should be more training on communication and teamwork skills. / Thesis / Master of Public Health (MPH) / Community paramedicine (CP) is an emerging form of health services delivery with programs established internationally. Community paramedics take on expanded paramedicine roles, including community-based health promotion and prevention activities. Studies on CP have focused on health outcomes and cost-effectiveness, but there is no comprehensive understanding about the types of CP programs and training. Through a systematic review of the literature, the goals of this thesis are to describe CP programs and the skills required for each program type, and to use findings to inform recommendations for CP program development and growth. No other literature review provides information on the components of CP programs and their training. Communities interested in CP can use the findings of this thesis to inform the development of their CP programs and training. By discussing challenges facing continued CP growth, this thesis also identifies areas for change at the program and policy levels.

Older adults, especially those who are of low socioeconomic status, experience higher rates of mortality and chronic disease. As a result, older adults are frequent users of emergency medical service (EMS), comprising approximately 38-48% of all EMS calls. In response to higher EMS demands, community paramedicine has recently emerged as a non-traditional model whereby paramedics provide care in a community- based setting. CP@clinic is a community paramedicine programme that focuses on disease prevention and health promotion with the goal of reducing EMS demand. Given the knowledge that older adults who live in subsidized housing have poorer health outcomes, CP@clinic has been implemented in several subsidized housing building across Ontario. A program evaluation of CP@clinic is currently underway to make recommendations to paramedic partner stakeholders regarding program delivery. As part of this evaluation, I sought to understand the association of the number of CP@clinic sessions held per month and EMS calls per apartment unit. De-identified EMS call data were collated from 9 paramedic services across Ontario from February 2015 to December 2019. I conducted a three-level multilevel regression analysis, with EMS calls per apartment unit as the outcome. The primary analysis found that a one-session increase in the number of sessions held per month was associated with an average 2.4% higher incident rate of EMS calls, adjusted for building size. A secondary analysis, with the number of sessions per month as a categorical variable, revealed that two CP@clinic sessions per month had the smallest association with EMS calls, adjusted for building size. Based on these results, it is recommended that paramedic services offer two or more CP@clinic sessions per month. Future research should investigate the factors that impact each services’ ability to offer the CP@clinic programme. / Thesis / Master of Science (MSc) / Older adults experience high rates of chronic diseases, especially older adults living in subsidized housing. Community paramedicine has recently emerged as a way of addressing the healthcare needs of older adults living in subsidized housing, while simultaneously decreasing the burden on EMS. CP@clinic is a community paramedicine programme aimed at improving the health of older adults and reducing the demand on EMS. To make recommendations to the paramedic services operating CP@clinic, I sought to understand the association between the frequency of CP@clinic sessions and the number of EMS calls per apartment unit in Ontario. Based on the results, CP@clinic sessions were associated with higher incident rate of EMS calls, after accounting for building size, reflecting the trend of rising EMS calls in Ontario. Overall, paramedic services may see improved EMS call outcomes with two or more CP@clinic sessions per month but should offer the programme according to their organizational capacity.