STRENGTHS AND LIMITATIONS IS THIS STUDY
Using a descriptive qualitative approach allowed for the delineating of programme benefits and challenges routed in participants’ experiences.
Sample had higher proportion of female participants which was not reflective of the main trial.
Practical constraints limited collected data at all sites; as such, current findings may not be generalisable to remote or rural areas.
Saturation of key factors found, with research triangulation supporting the synthesis of the data.
As our population ages, the healthcare system has been called on to find innovative ways to support healthy ageing and manage rising healthcare costs. Older adults account for 38%–49% of avoidable emergency medical service calls,1 2 with many of these calls related to issues or conditions that could be effectively managed in the community.3 Community Paramedicine (CP) has been used in rural and urban settings to provide services to vulnerable populations, including older adults. Evidence suggests that CP can reduce emergency room (ER) visits, hospital admissions and assist older adults with ageing in place.4 5
The CP@clinic is a rigorously evaluated CP programme that has been used extensively in Ontario, Canada. Targeting older adults living in community-based social housing, community paramedics hold weekly drop-in sessions to complete health assessments related to cardiovascular health and diabetes, as well as provide tailored health education and community referrals. As sessions were drop-in, no appointments were necessary and residents could attend as they wanted. Consultations were one-to-one, and generally, the same community paramedics attended the same buildings. Reports of health risks assessments (eg, high blood pressure, smoking, etc) were sent back to primary care physicians with participant consent so that these factors could be attended to. Social housing buildings in this study were those that were geared to older adults (greater than 60% of residents were aged 55 or over), had at least 50 units, and where rent is subsidised. As residents were low income, they are not representative of older adults in general in Ontario, Canada. Detailed programme description and evaluation findings have been published with Randomized Controlled Trial results showing significantly lower ambulance calls, decrease in systolic and diastolic blood pressure, and improvement in quality adjusted life years in intervention sites compared with control sites.6–8 Early CP@clinic qualitative work found participants viewed paramedics as supportive health advocates with knowledge and skills to support their health.9 While important, the value of such programmes depends on continued participation and perceived value beyond the study period. The present study aimed to examine participant perceptions regarding their experience of CP@clinic as well as potential ongoing programme benefits.
This study used a descriptive qualitative design.10 11 This approach focuses on understanding a phenomenon in its natural state and the ‘who, what, where’ of an experience. Here, we were interested in understanding resident experiences of the CP@clinic programme. The project was conceived by the lead researcher (GA), a PhD-trained, family physician whose programme of research includes CP, chronic disease management and health services research. There was no prior relationship between researchers and participants.
Setting and participants
All 15 intervention sites from the CP@clinic were invited to attend the focus groups, with 4 buildings agreeing to take part: 2 in Hamilton, 1 in Guelph and 1 in York region. Focus groups took place in each building’s common room which was a familiar, accessible location for participants. All groups were scheduled for 1 hour and there were no repeat groups.
Recruitment for groups took place via paper advertisement posted in each building. Convenience sampling was used and any resident who had attended at least one CP@clinic session was eligible to attend the focus group. There were no other eligibility/exclusion criteria as we sought anyone who wanted to share their perspective to be able to attend. Participants did not have any prior relationship with the researchers before the CP@clinic trial and did not know the interviewers or their personal reasons for being part of this research. Each participant received a CAD$20 gift card as a token of appreciation for their time.
Participant and public involvement
A detailed description of how participant and public involvement efforts have been used was described previously8 and will be briefly summarised. The main RCT for CP@clinic started with an initial pilot site where both community paramedics and those living in social housing provided their input regarding design and implementation of the trial. CPs were instrumental in delineating specific processes that could work (eg, how to send information to resident physicians), and residents gave suggestions for how and when sessions could be held.
The focus groups used a semistructured interview guide (see online supplemental appendix A) written in plain language. The interview guide was developed by the research team and based on related work that had been conducted by the research team. All groups were conducted by an experienced moderator (FM), with a research assistant (JP) assisting, who were both skilled focus group facilitators with experience in managing group dynamics. The facilitators were mindful of hearing both positive and negative feedback about CP@clinic and encouraged participants to share what they felt worked and areas for improvement. We aimed for groups between 8 and 12 participants, a standard supported by literature.12 13 Participants completed a written consent form and a brief demographic form at the onset of the group. Groups were audio recorded and professionally transcribed with participants being anonymised. The facilitators took brief notes during the group to capture key points in the discussion. Informal member checking took place throughout the group, with facilitators summarising the discussion and asking for confirmation about the summary. Transcripts were not returned to participants for feedback.
This study used an inductive approach where three researchers (GA, AZ and AP) initially reviewed the first transcript, coding text units into possible codes. The research team then met to discuss and compare each person’s initial codes, and together created a preliminary organisation of codes which were then organised into broad themes and subthemes which formed the first version of the codebook and included descriptions and definitions of each code. This was then used to formally code the first transcript. Following this, the codebook was updated as each subsequent transcript was reviewed to accommodate possible new themes. Continuous discussion took place during coding to ensure that there was consensus on coding decisions and any new themes, monitoring data saturation through this process. After all groups were coded, two researchers (GA, KN) reviewed coding to ensure consistency in approach and that there was saturation of themes with no further data collection needed. No software was used in the analysis. Rigour and attention to trustworthiness were discussed throughout the research process (see online supplemental appendix B for table describing elements of trustworthiness).
Transcripts were also examined to understand how resident perceptions aligned with an emerging framework regarding paramedic roles in the community.9 This framework suggests that paramedics take on multiple roles that include being: a trusted healthcare professional; a patient advocate; and an emergency expert.9 While not an a priori intent of this study, the nature of data collected aligned with the focus of this framework, providing an opportunity to contribute towards this literature base.
There were 41 CP@clinic participants from 4 intervention buildings. Most participants were women (38/41; 93%) and between the ages of 58–91. The mean age was 71.5 years. All participants were English speaking with everyone but one identifying as Caucasian. There were no participants who dropped out of the study.
Analysis yielded six broad-related themes that encapsulated two main areas: Personal Benefits and Programme Structure. Participants voiced feeling that CP@clinic enhanced their knowledge about chronic diseases management, community resources, ability to access healthcare services, as well as ability to better manage their health. Participants described elements related to programme structure and personal benefits that fostered their interest in taking part in CP@clinic and would support their continued interest in being part of the programme. Themes are listed in table 1 and described in more detail below. CP roles were evident across themes providing support for this framework.
Personal benefits derived from program participation
Timely access to health information and services
Residents described CP@clinic as a place that connected its participants to community resources based on their current needs and health goals. Participants were able to skip several navigation steps that were required to access some community resources as community paramedics provided a more direct route to these services. Paramedics also provided individualised resources specific to their needs (ie, related to chronic condition management) and wants (ie, reaching healthy lifestyle goals). Participants were thankful for paramedics’ efforts to help them more easily access resources as well their advocating for an in-building fresh food market and investigating programmes that offered free podiatry, dental and other services.
Residents were routinely referred to their family physician for follow-up if they presented with signs and symptoms of a condition, or to an emergency room if needed. For some, the CP@clinic was a turning point in their lives, as programme paramedics were able to quickly identify potential forthcoming adverse health events. Several participants expressed their relief and gratitude for their doctor or ER referral, as they were then diagnosed with conditions such as pneumonia, atrial fibrillation and hypertension.
Residents were also referred to resources to alleviate pain, improve their health status and help reach their healthy living goals. These included physiotherapy, diabetic foot clinics and resources offering support for patients with Chronic Obstructive Pulmonary Disease and those experiencing mental health issues (ie, depression, anxiety). Referrals to the local Home and Community Care Support Services allowed residents to receive high-quality patient care and services in their home. Residents were also guided to services that they were unaware of before the clinic, such as eye and ear clinics and fall detection services. Participants were thankful that the paramedics often went above and beyond by bringing needed medical equipment directly to them (eg, new walker, asthma chamber).
Support to achieve personal health goals
Many residents remarked on the support they received to initiate and follow through on personal health goals. Participants valued the active engagement of CPs with chronic disease prevention related to exercise, diet modification and smoking cessation. Weekly check-ins helped to keep goals at the forefront for each participant and they noted how the CP would celebrate both large and small steps with them. One resident mentioned that they eventually discontinued their prescription for blood pressure pills, and another reported having lost 25 lbs from eating healthier and weighing in every week. Another resident was proud to share they had reduced their daily cigarette consumption from 15 to only 2 a day. Reminders to eat more fruits and vegetables, reduce salt and sugar intake, and exercise made participants more accountable and motivated to make healthy changes.
Better understanding of healthcare system
One interesting finding was the shifts in understanding of the healthcare system and when and whom to access (eg, 9-1-1 calls). A participant shared how through their connection with the CP they were able to better recognise when an ambulance was needed.
Regular engagement with community paramedics fostered residents’ personal health awareness along with knowledge of the healthcare system. For other residents, having access to information about community resources allowed for greater ownership of their health and what was available to them.
Created sense of community
Participants appreciated how the structure of CP@clinic fostered community and a sense of comradery and togetherness. Although sessions were individual, participants enjoyed seeing other residents as they waited for their appointment time. Participants voiced feeling grateful that they were able to get to know residents who may typically spend their time in their units and not partake in building activities. One participant described a resident who was not attending the clinic because she felt that she did not belong to it. The other residents at the clinic regularly encouraged this person to attend a session and she has been attending the clinic ever since. Social support from other residents was a key contributor to the growth and reach of the programme.
CP@clinic brought together building residents, with similar interests, who were motivated to learn how to manage and improve their health. There was a sense of being connected to something larger as they took steps to improve their health. This feeling of community motivated some residents to organise additional functions and gatherings within the building, such as Trivia nights, colouring groups and potluck meals.
Comfortable and familiar environment to talk about health
Residents appreciated both the physical environment of the clinic as well as the approach of the paramedics. Weekly check-ups and monitoring gave many peace-of-mind and was an opportunity to discuss previously unconsidered health issues. Residents felt encouraged to put their health first and without judgement of any earlier healthcare decisions. Timing of the sessions were raised by some participants, who noted afternoon sessions were easier to attend.
Several programme participants emphasised that they felt very comfortable with the paramedics and the programme setting. The clinic was a positive environment and many enjoyed the pleasantries and conversation that naturally transpired during each session. The paramedics were approachable and attentive, which contributed to the clinic’s welcoming atmosphere. One participant reported feeling less anxious talking about their health at the clinic than at other settings. During their visit, participants felt more relaxed and at ease asking questions, and were more likely to share concerns about their health and other issues. Conversations sometimes sparked additional health questions and solutions that were never considered before, or not originally the focus of that particular session.
Residents liked that they could attend to their health by simply walking downstairs to the CP@clinic programme, rather than at a public clinic or their regular primary healthcare provider. Participants saved time and some mentioned having less anxiety than when they visited their doctor. The clinic complemented the care received from the primary care provider who they only saw every few months, and for others primary care visits were minimised due to improvements in health from weekly monitoring and behaviour change.
Participants appreciated that the same CP staff attended the clinic allowing for a trusting relationship to form. The regularity of a weekly clinic also conveyed a sense that healthcare providers cared about them and their health. Residents valued paramedics’ patience and attentiveness during each session, and felt they were being listened to, as they were always given their undivided attention. Residents also noted how CPs would monitor attendance and connect with those who had not come for a few weeks. This attentiveness displayed a care and concern that encouraged participation.
Facilitated communication between healthcare professionals
Many participants acknowledged the communication between CP@clinic and their primary care provider and recognised the importance of this continuity of care. A few healthcare providers shared positive sentiments about the programme with participants. One resident was able to show their CP@clinic personal record book to their doctor. This displayed normal blood pressure measurements across several weeks, which led to the discontinuation of their blood pressure medication. For another resident, faxing the CP@clinic assessment report to their physician helped to facilitate a timely appointment from the physician’s office versus the resident needing to remember to book an appointment themselves.
Across all six themes there was evidence of various paramedic roles taken on by those providing CP@clinic: a trusted healthcare professional; a patient advocate; and an emergency expert.9 It was clear that paramedics were seen as providers who offered credible and wanted health information and were advocates not only for personal behavioural changes, but also for resident services in the community. These roles were integral to the perceived value and success of CP@clinic. Paramedics as experts in emergency was less prevalent in these data given its focus on chronic disease management, though there were a few instances where it was evident that this knowledge led to residents getting medical care quickly when needed. This study provides support for the various roles possible for community paramedics where their skills as healthcare providers can facilitate chronic disease management and support.9
Continued involvement with CP@clinic
Participants overwhelmingly noted that they would be interested in continued engagement with CP@clinic and expressed disappointment that the programme had ended in their building. The weekly time commitment was manageable and the focus on personalised goals was helpful. Importantly, participants had experienced discernable changes in their health and health behaviours that they felt positive about and continued support would keep their momentum going.
This study sought to examine resident perceptions of the CP@clinic programme and what factors would support their continued involvement. Results suggest that there are two complimentary factors that need attention. First, there were various structural elements that made this programme appealing to residents, such as a familiar environment, creating a sense of community and direct communication with primary care. Second, residents described personal benefits that kept them engaged including, access to new knowledge and services, support for health goals, and better understanding of the healthcare system.
The CP@clinic programme was developed with theoretical underpinnings of Wagner’s Chronic Care Model14 and Social Cognitive Theory.15 As such, the changes described by participants connect well with both of these, and also align with the main quantitative findings from this study which found reductions in blood pressure and lower risk categories for diabetes.7 Community paramedics were seen as connectors and facilitators which has also been found in work with new mothers,16 and other health promotion and prevention initiatives.17
We also sought to understand whether the roles taken on by CPs in this study aligned with those suggested by the CP role framework.9 This study found all three roles present: caring and trustful healthcare provider, patient advocate, and emergency expert, findings which have concordance with other CP literature.16 This work reinforces that the success of CP programmes requires a balance of both technical and interpersonal skills as drivers to support continued CP@clinic programming. The general primary care literature has also found that patient satisfaction is often related to ease of access, relationship with their primary care provider, and continuity of care.18 19 Residents in the CP@clinic programme experienced similar traits with community paramedics reinforcing that there may be core interpersonal and structural issues that facilitate positive healthcare experiences.
The findings from this study also align with the broader CP literature base. Previous publications have found support for community paramedics in providing rural healthcare,20 mobile integrated healthcare for older adults,21 and chronic disease management.22 There is also a burgeoning evidence base for the role that community paramedics play in integrated, community care despite ongoing challenges with wider health system recognition of this expanded role.23 A recent scoping review examining factors that could support paramedics’ role within a responsive, local healthcare system noted the need for a cross-cutting service organisation.24 In our study, community paramedics were seen as connectors, linking residents with services and connecting themselves with other healthcare organisations in the community. Other work examining role acceptance and integration from the perspective local CP decision makers and funders suggests a standardised CP approach and clarity regarding oversight as factors that can support the integration of the CP role.25
Despite the rigour taken with this study, there are several limitations to be acknowledged. First, not all locations of the CP@clinic programme took part in a focus group. It is possible that the more remote locations that did not partake had different experiences of this programme. Our sample also contained a higher proportion of female participants (93%) than those from the main trial (79.9%).7 As well, this sample was Caucasian and English speaking which is not reflective of the general older adult population within social housing buildings. Given this, care must be taken when assessing programme needs for those from different cultures, identify as male, or who are not able to converse in English. Researchers who aim to conduct similar research should consider this potential impact on transferability of findings. Further research with less accessible populations in remote regions as well as the inclusion of more female and culturally diverse residents would be helpful.
CP@clinic was successful in creating a supportive and friendly environment to facilitate health behavioural changes. Two related elements, programme structure and personal benefits, contributed to the perceived value of CP@clinic. Structural elements created the foundation for personal goal setting and attainment. Ongoing implementation of CP@clinic would allow residents to continue to build their chronic disease management knowledge and skills.
Data availability statement
Data are available upon reasonable request. Limited deidentified data are available upon request to the lead author.
Patient consent for publication
Ethics approval was received from the Hamilton Integrated Research Ethics Board (#14-645). Participants gave informed consent to participate in the study before taking part.
This post was originally published on https://bmjopen.bmj.com