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

Paramedicine in Canada and throughout the developed world is currently undergoing unprecedented transformation to its service delivery model, largely driven by the need to relieve healthcare systems from overcrowding, and ensure its availability for all citizens. These changes are facilitated by the ability of paramedic services to adopt a number of innovative technologies, and their ability to respond by adopting new service delivery models, which may entail the deployment of paramedics in various non-emergency roles or integration with other healthcare services. The purpose of this dissertation is to determine how paramedic services innovate, and how that innovation is influenced by technology in particular. To fulfill this purpose, a two-phase sequential explanatory mixed-methods study is conducted, with a quantitative phase followed by a qualitative phase. In the first phase a multilevel theoretical model consisting of constructs that measure Service Innovation Performance, Dynamic Capabilities, Information Technology (IT) Capabilities and Group-Level Healthcare Informatics Competencies was evaluated with WarpPLS 5.0. A dataset with participation from paramedic leaders of Canadian land-based paramedic services (n=43) and paramedics employed at these services (n=502) was used for this purpose. Findings from this phase indicate that the information technology related knowledge and skills possessed by paramedics have an impact on various organization level dynamic capabilities, as do various IT Capabilities that focus on the relationship between the paramedic service leadership and the IT service provider. In the second phase, a qualitative approach was taken to explore contextual and other factors that facilitate or inhibit the ability of a paramedic service to innovate. Results from this phase suggest that Canadian paramedic services primarily undertake innovative activities with a strong focus on assuring and improving patient care. The use of an electronic patient care record (ePCR) is an important resource, as it enables activities such as the improvement of the clinical skills of paramedics, as well as facilitates the generation of business cases for equipment investment. Further, the informatics competencies of paramedics greatly facilitate the adoption of technology and equipment by individual services, as paramedics with a high amount of these competencies assist other paramedics when adopting technology, communicate innovative ideas within a service, and identify areas in need of change. The results of this dissertation underline the value of technology-related knowledge and skills for paramedics, and the importance of technology in ensuring that paramedic services provide a high and continually improving standard of patient care. / Thesis / Doctor of Philosophy (PhD) / Paramedicine in Canada is currently undergoing unprecedented transformation. These changes are driven by the need to relieve emergency healthcare resources from overcrowding, the increase in number of innovative technologies adopted by paramedic services, deployment of paramedics in various non-emergency roles, and increased integration with other healthcare services. The purpose of this dissertation is to determine how paramedic services innovate, and how innovation is influenced by technology. To this end, a two-phase sequential explanatory mixed-methods study is conducted, producing a few key findings that underline the value of technology in paramedicine. First, paramedics with information technology related skillsets can better identify opportunities for improvement in service delivery, and facilitate the organizational adoption of technology. Second, electronic patient care records are a vital source for a variety of innovative activities in paramedic services, such as organization-wide improvement of clinical skills and identification of areas where patient care can be improved.

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)

<p>Inappropriate ambulance use can be defined broadly as the use of emergency medical services (EMS) transport for non-urgent medical conditions, or when the patient does not use alternate transportation available. It drains health system resources, contributes to low morale among paramedics, and can delay care for patients who may be appropriately treated in alternative settings. An increasing number of studies indicate <em>that</em> inappropriate EMS use occurs, but few studies investigate how perspectives of inappropriate use are constructed. This study explores the construct of appropriateness in the context of ambulance use, and examines the implications of varying perspectives on ambulance billing policies.</p> <p>We present a grounded theory on the construct of appropriate ambulance use from interviews with paramedics in Ontario, national media reports and online reader commentary. Findings show that the role of paramedics varies across regions, and includes various types of care (e.g., emergency response, primary care and preventative care), and transportation (e.g., to the emergency department or urgent care clinics). In turn, constructs of appropriateness vary. In ambiguous cases, paramedics use their perception of the patients’ ability or attempts to cope with the medical situation to evaluate the appropriateness of ambulance use. Unexpectedly, the most frustrating cases of inappropriate ambulance use tend to be initiated by organizations, such as long-term care facilities, rather than members of the general public. These findings raise questions about the potential for ambulance user fees conditional on ‘appropriateness’ to improve either the effectiveness or the efficiency of ambulance services.</p> / Doctor of Philosophy (PhD)

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.

Although the recent annual growth rate in the US paramedic field has been 4%, Latino and African American men have been significantly underrepresented in the field compared to their proportion in the US population at large. This problem threatens both the quality and quantity of available emergency health care. The purpose of this study was to describe how men of color (MOC) in community college paramedical programs experienced their awareness, interest, and proactive choice of paramedicine as a course of study. Using a qualitative phenomenological approach and social cognitive career theory as a theoretical framework, I interviewed 23 MOC enrolled during one semester across three community college paramedical programs in the southwestern US: 9 Latino and 14 African American, aged 18-29 with mean age 22 years. The focus of the interviews was the participants' lived experiences at various career points, as well as the enablers and disablers they had encountered. I identified three primary themes for possible use in enhancing recruitment of MOC to the paramedic field: strategic use of new digital media, promotion of the vocation's quasi-familial characteristics, and augmentation of neighborhood-based outreach. Identified areas for further research included recruitment dynamics of female paramedics, MOC persistence issues, and MOC job satisfaction assessments.

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.

Title: Clinical Decision Making in Paramedicine Author(s) & affiliation(s): Michael Eby – McMaster University, Hamilton, ON, Canada Sandra Monteiro – McMaster University, Hamilton, ON, Canada Geoffrey Norman – McMaster University, Hamilton, ON, Canada Walter Tavares – McMaster University, Hamilton, ON, Canada Background: Paramedics are frequently required to make rapid decisions in an uncontrolled, dynamic environment, often with limited diagnostic information. In Ontario, paramedic practice is based on a set of provincial medical directives that provide diagnostic and treatment criteria. Unsupervised deviation from these directives is classified as a form of error and highly discouraged. To date, there is little known about how years of clinical experience or level of certification affect the way these medical directives are used. The purpose of this study was to examine the relationship between paramedic experience, training and accuracy of treatment decisions when faced with patients who meet and fall outside of the existing medical directives. Methods: Thirty-one participants (16 experienced / 15 novice) were recruited from two paramedic services in Ontario. “Experienced” was defined as in-practice for 5 years or more. Participants were presented with 9 scenarios; in 6 scenarios, the patient presentation fit within the existing directives, while in 3 scenarios, the patient presentation fell outside the medical directives. Multiple-choice responses were used to capture participants’ decisions to treat or not treat the patients. Responses were scored and submitted to a mixed-factorial ANOVA to evaluate differences in accuracy between case types, years of experience and level of training. Results: There was a significant effect of case type (p < 0.004). Accuracy was lower when the patient presentation did not meet the criteria of the medical directive (76.34% (CI = 67.15% to 85.53%) vs. 98.35% (CI = 96.55% to 100%) when they did. There was no effect of years of clinical practice or level of certification. Conclusion: The results suggest both novice and experienced paramedics are able to accurately apply medical directives, however, there is a significant decrease in accuracy when the patient presentation does not fit one. This variation in practice may have a significant impact on patient safety, and further research is required to determine what factors may be causing this decreased accuracy. / Thesis / Master of Science (MSc) / Paramedics work in a fast-paced, dynamic environment. The types of patients, and the situations paramedics encounter are different every day. Paramedic practice is based on a series of provincial medical directives that outline the different proceedures, medications and types of patients that can be treated. While these directives cover many of the cases paramedics encounter, there will always be cases that don’t “fit”. The purose of this study is to see if paramedics approach those types of cases in a different way, and if their years of experience or level of training change how good they are at idenfiying what patients require treatment. As there is very little paramedic specific research on this topic, this study will serve as a starting point for future research and hopefully stimulate discussion about paramedic practice, and how to support paramedics getting better at their jobs.