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)

O objetivo do presente estudo foi rever na literatura qual a definição de usuários frequentes/hiperutilizadores de serviços de urgência e emergência e conhecer as implicações destes usuários no serviço de urgência e emergência. Trata-se de um estudo realizado através Scoping Review, conforme a proposta do Joanna Briggs Institute (JBI). Resultados: Identificados 37 estudos e através da leitura do título e resumo, selecionados 27 para leitura na íntegra. Porém após a leitura detalhada foram excluídos 11 estudos que não apresentavam resultados e conclusões diretamente ligados à temática. Assim, a amostra final foi composta por 16 estudos. Entre estes, quatro eram brasileiros e escritos pelo mesmo autor. Não houve 18 consenso entre s autores quanto a definição do termo pesquisado, todavia indicaram como usuário frequente/hiperutilizador o paciente que utiliza o serviço de urgência e emergência mais de 3 vezes por ano. Conclusões: Há lacuna na literatura e não consenso sobre a temática. Há necessidade de mais estudos sobre o assunto para o delineamento de ações que possibilitem a melhora deste quadro / The purpose of this study is to review the definition done by the literature of frequent / hyper-users of immediacy and emergency services and to know the involvement of such users in the immediacy and emergency services. This is a study conducted through Scoping Review (Revisão de Alcance) as proposed by Joanna Briggs Institute (JBI). Results: 37 studies were identified and by means of reading the titles and abstracts, 27 were selected as for thorough reading. However after the itemized reading, 11 studies that did not bring forward results and conclusions directly related to the thematic, they were excluded. So the final specimen was consisted of 16 studies. Four amongst these were Brazilian and written by the same author. There was no consensus between the authors regarding definition of the searched word, nevertheless they indicated as frequent / hyper-user the patient who uses the immediacy and emergency services more than thrice a year. Conclusions: There is a vacuity in literature and no agreement on this thematic. There are needs for further studies on the topic for the delineation of actions to make improvements possible for this picture

Objectifs. Les services hospitaliers d’urgence sont souvent engorgés, et les visites pour des raisons de santé mentale (SM) y contribuent particulièrement. Au Québec, les grands utilisateurs de ces services en SM ont contribué en 2014-15 à près de la moitié du volume des visites aux urgences en SM. Or, le recours fréquent aux urgences par les mêmes patients témoigne généralement d'une inadéquation des services offerts à ces derniers. Pour mieux desservir ces patients et améliorer l’efficacité de l’urgence, il est crucial de mieux comprendre les facteurs facilitant ou entravant les services d’urgence dans leur réponse aux besoins des grands utilisateurs de ces services. Cette étude vise ainsi à identifier les facteurs qui facilitent ou entravent l'efficacité des services d'urgence à répondre aux besoins des grands utilisateurs de ces services en SM (3+ visites/année). Méthode. L’étude utilise un devis qualitatif basé sur la méthode d’étude de cas unique; le cas étant une urgence d’un institut universitaire en SM. Les participants provenaient de l’urgence, d’autres services de l’hôpital (ex. : module d’évaluation-liaison) ou étaient des partenaires de l’urgence du territoire (ex. : centres de crise). L'analyse des données a été guidée par un cadre conceptuel composé de quatre catégories de facteurs facilitant ou entravant l’efficacité de l’urgence, reliés au système de santé, à l’organisation des services, aux professionnels de la santé et aux profils des patients. Résultats. Plus d'entraves que de facteurs facilitants ont été relevées, qui étaient principalement liées au système de santé, comme l'indisponibilité des services en SM et la complexité de la gestion des services, ainsi qu'aux profils des patients, comme certains profils cliniques. Les facteurs facilitants étaient surtout liés aux caractéristiques organisationnelles, notamment les innovations implantées à l'urgence ou en partenariat avec l’urgence, bien que globalement peu déployées. Conclusion. En explorant les facteurs pouvant influencer l'efficacité de la réponse aux besoins des patients grands utilisateurs des services d'urgence en SM, cette étude prépare le terrain pour des recherches futures qui examineront et démontreront l'impact de ces facteurs. Cela permettra de mieux comprendre comment optimiser la réponse aux besoins de ces patients. Mots clés : urgence, grands utilisateurs, santé mentale, facteurs facilitants ou entravants, efficacité, réponse aux besoins / Objectives. Hospital emergency departments (ED) are often overcrowded, and mental health (MH) visits contribute particularly to this situation. In Quebec, frequent users of emergency services accounted for nearly half the volume of ED visits for mental health reasons in 2014-15. Frequent recourse to ED by these patients generally reflects the inadequacy of services available to them. To better serve these patients and improve the ED effectiveness, it is crucial to better understand factors that facilitate or hinder ED services in responding to needs of their frequent users. Thus, this study aims to identify facilitators and barriers to ED effectiveness in meeting the needs of high ED users (3+ visits/year) with mental health issues. Method. The study is based on a qualitative investigation, using a single case study method. The case was an emergency at a mental health university institute in a large urban center of Quebec. Participants came from the ED, other hospital departments (e.g., assessment-liaison module), or were partners of the ED in the territory (e.g., crisis centers). Data analyses were guided by a conceptual framework consisting of four categories related to the health care system, organization of services, health care professionals, and patient profiles, with possible facilitating or hindering factors to ED effectiveness subsumed under each category. Results. More barriers than facilitators were identified, most of which were related to the healthcare system (e.g., the unavailability of MH services and the complexity of ED management), but also to patient profiles (e.g., certain clinical characteristics). The facilitators were mainly related to organizational characteristics, notably innovations implemented in, or in partnership with, the ED, although few were deployed overall. Conclusion. By exploring factors that can influence effectiveness in meeting the needs of high ED users, this study sets the scene for future research that would examine and demonstrate the impact of these factors. This will help us to better understand how to optimize the response to these patients' needs. Keywords: emergency department, frequent users, mental health, facilitating or hindering factors, effectiveness, response to needs