Abstract
Background
Millions of older US adults fall annually, leading to catastrophic injuries, over 32,000 deaths and healthcare costs over $55 billion.1,2 This study evaluated perceived benefits and limitations to using community paramedicine for fall prevention strategies from the lens of older adults, caregivers and healthcare providers.
Methods
Semi-structured focus groups were held with individuals from three stakeholder groups: 1) community-dwelling older adults (age ≥60), 2) caregivers, and 3) healthcare providers. The Strengths-Weaknesses-Opportunities-Threats (SWOT) framework was used to quantitively analyze stakeholder perceptions of using community paramedicine for fall prevention strategies.
Results
A total of ten focus groups were held with 56 participants representing older adults (n=15), caregivers (n=16), and healthcare providers (n=25). Community paramedicine was supported as a model of fall prevention by older adults, caregivers and healthcare providers. Participants identified strengths such as visibility to home environment, ability to implement home modifications, implicit trust in emergency medical services (EMS), and capacity to redirect resources towards prevention. Additionally, participants acknowledged opportunities such as providing continuity of care across the healthcare spectrum, improving quality and safety of care and potentially reducing unnecessary emergency department use. Participants endorsed weaknesses and threats such as funding, concerns of patients about stigma, and struggles with medical data integration.
Conclusions
The results of this study illuminate the opportunity to leverage community paramedicine to address a variety of perceived barriers in order to design and implement better solutions for fall prevention efforts.
Keywords: Community paramedicine, fall prevention, healthy aging
INTRODUCTION
Falls are a significant public health issue in the United States, with prevalence up to 30% among older adults and annual costs exceeding $50 billion.1,3 Fall prevention strategies such as home modifications and balance/strength training activities can effectively mitigate certain risk factors for falls.4,5 Despite large-scale, evidence-based prevention initiatives, fall-related morbidity, mortality, and costs persist.6
Successful fall prevention efforts require identification of at-risk individuals and activation of resources to put fall prevention evidence into action. Individuals most predisposed to falls are the most likely to benefit from fall prevention, but may be the most challenging to enroll, especially if they have cognitive impairments.5 Unfortunately, accurate self-identification and self-management usually only happens when an individual is healthy, motivated and has higher self-efficacy to engage in prevention activities.7 This paradox poses a challenge to the identification and delivery of interventions for the most vulnerable older adults.
Community paramedicine is an evolving care model that allows emergency medical services (EMS) to assist with public health prevention strategies and redirects emergency resources toward fall prevention and health promotion for vulnerable individuals.8,9 EMS workers have a unique opportunity that many healthcare providers do not: to look, listen and get a feel for patients’ living environments. Although currently underutilized, community paramedicine offers a unique opportunity to systematically identify and predict a community’s most vulnerable residents for falls and deliver consistent, high-quality, evidence-based fall prevention care or facilitate referrals to healthcare teams to address modifiable risks.
Community paramedicine benefits, barriers and facilitators need further exploration to fully understand the utility and impact it might have on public health initiatives such as fall prevention. A current gap in knowledge is stakeholder perspectives about the adoption of community paramedicine for fall prevention. The goal of this study was to identify multi-stakeholder perceptions of a community paramedicine fall prevention model. Based on participants’ feedback, important considerations for design and adoption of community paramedicine programs for fall prevention are discussed.
METHODS
Study Design and Participants
A Strengths‐Weaknesses‐Opportunities‐Threats (SWOT) analysis was conducted using a qualitative study design. SWOT analysis is a strategic planning tool used to systematically examine internal factors (strengths and weaknesses) and external factors (opportunities and threats) of a model to inform future strategies. This qualitative study received approval of an Institutional Review Board (IRB# 2018H0219). Participants for the study were recruited from three stakeholder types: 1) community-dwelling older adults, 2) family members/caregivers of community-dwelling older adults, and 3) healthcare providers who engage in fall prevention, assessment, and intervention activities for community-dwelling older adults. Adults aged 60 and older were eligible to participate as older adult stakeholders, and adults aged 18 and older were eligible to participate as a family member/caregiver or healthcare provider.10–12 Focus groups were held throughout 2018–2019. Previous experience of fall prevention strategies was not required. Participants from any stakeholder group were able to understand English and were cognitively able to provide informed consent. Participants were recruited using posted advertisements at community locations, electronic advertisement at a medical center, healthcare provider referrals, personal referrals, and via informal announcement during public speaking events.
Procedures
Individuals interested in the study contacted research personnel, who confirmed eligibility and coordinated a focus group date, time, and location. At the research encounter, participants provided informed consent. Participants were involved in a single focus group for ninety minutes. Focus groups were conducted using a semi-structured format with a set of pro-forma questions specific to each stakeholder type guiding the conversation. The guide is available in Supplementary Table S1. Two digital recorders were used to document the sessions to allow for transcription of the conversation. After introductions in the focus group, a scripted description of community paramedicine was read aloud (“Community paramedics come to older adults’ homes and assess the older adult and the living environment to provide resources and strategies for preventing falls at home”). Specific questions about the role of community paramedicine in fall prevention were then addressed in individual focus groups.
Data Analysis
Digital recordings were coded verbatim, and transcripts were uploaded into NVivo and used to code for themes. Open coding for themes of each transcript was performed independently by three researchers prior to the next focus group to allow for identification of new questions or prompts. Code books for each stakeholder type were developed and evolved until theme saturation was achieved. To strengthen the analysis and interpretation credibility, multiple analysts and data sources were used to triangulate and have researcher reflexivity/positioning.13,14 The three independent coders met after each transcript review to develop consensus on themes identified in each session and to engage in selective coding processes to develop an understanding of the relationships between identified themes. A fourth senior researcher (CEQ) evaluated the transcript to finalize theme inclusion versus exclusion in the code book if any disagreements arose. Focus groups continued until all three coders agreed theme saturation had been achieved, defined as no new themes emerging during coding of the most recent transcript of a particular stakeholder group. Themes were categorized using the SWOT framework for the analysis of participants’ discussions. Once theme saturation was met, the fourth senior researcher (CEQ) independently evaluated each transcript relative to the code book to confirm theme saturation and SWOT categorizations.
RESULTS
A series of 10 multi-stakeholder focus groups occurred with 15 older adults (mean age 73; range 61–88), 16 caregivers (mean age 56; range 29–76), and 25 health care provider participants (mean age 43; range 32–55). Initially, three focus groups were held for each group. Later, a fourth focus group was held for the healthcare provider group to help ensure adequate theme saturation. SWOT themes identified are summarized in Table 1 and supporting quotes are available as part of Supplementary Table S1.
Table 1.
Summary of SWOT Themes for Community Paramedicine as a Fall Prevention Support Mechanism
| ELEMENTS | THEMES |
|---|---|
| STRENGTHS | • Community paramedics can improve visibility of home environment risks and implement home modifications • Community paramedicine benefits from implicit trust • Community paramedicine has fewer barriers to navigate than other healthcare providers • Community paramedicine has ability to highly personalize care • EMS agencies have capacity to redirect resources towards prevention • Community paramedicine provides an avenue for care for older adults when family members live far away |
| WEAKNESSES | • Patients may be concerned about visibility of an emergency vehicle outside the home during a community paramedicine visit • Community paramedicine is relatively new and will require the development of new skills and operational models • Reimbursement is not currently available to community paramedicine, which can affect community budgets • Community paramedicine has data management, record keeping, and medical record integration challenges with other healthcare providers and systems |
| OPPORTUNITIES | • Community paramedicine could reduce unnecessary medical costs and emergency department use • Communities and EMS agencies could use their emergency response data to identify individuals most vulnerable to falls and design their own community paramedicine programs to address their unique needs • Community paramedicine offers supplemental education and reinforcement of fall prevention ideas and strategies • Community paramedicine builds continuity of care across the healthcare spectrum • Community paramedicine offers community-wide improvement in quality of care and heath system safety |
| THREATS | • Community paramedicine could face lack of leadership investment in its development due to the cultures of EMS and fire systems • Community paramedicine could suffer from inadequate or inauthentic delivery at the individual or operational level • Community paramedicine faces information technology and integration of medical record barriers • Patients may not be willing to utilize community paramedicine services • Community paramedicine may have conflicts of interest or perceived threats by other parts of the healthcare system |
SWOT refers to the Strengths-Weaknesses-Opportunities-Threats framework
Strengths and Opportunities
Participants noted that EMS and community paramedicine can be used to help identify the most vulnerable community members for falls and redirect resources towards prevention. Healthcare stakeholders described how current 9-1-1 triages do not allow for activation of resources for fall prevention. An EMS worker stated, “If they called us because they fall, we go over, [ask], ‘Are you hurt?’ Pick them back up, ‘Okay, see ya later’…you may want to do something extra, but you are on a truck that is a 9-1-1 response truck, that you are on a shift that you’re going to go back and take the next call, and you don’t have the time or the ability or the resources to follow through.”
A common acknowledgement by participants revealed how EMS workers have distinct access into the home that most other healthcare providers do not. Healthcare workers expressed, “Not every house is cookie cutter, and…seeing what they’ve been doing and thinking, ‘Wow, how dangerous that’s been this entire time!’…and to actually physically assess the environment is pretty important to the overall patient care picture.”
It was frequently stated by participants that EMS workers are qualified to assess the home environment for fall risks, and that they would appreciate and act on advice given by community paramedics (CPs) for fall prevention in the home. It was also noted that it was especially effective to watch older adults navigate within their own home and these types of observations can provide personalized prevention strategies for activities of daily living. Older adults in one focus group noted with unanimous agreement, “I think it would be a great idea [to use CPs for fall prevention]. I think they’re very qualified.” From an EMS worker’s viewpoint, “You wouldn’t have that ability [to see inside the home], or [an older adult or caregiver] might forget...from the doctor’s office or even a specific appointment to home [to do home modifications], so it allows us to really be right there, put a night light in, and they’re like, ‘Wow, they make night lights that turn on in the middle of night?”” and “Just being at the location… allows us to right there bring up our concerns.”
Participants felt that there is implicit trust in EMS workers that would facilitate older adult allowance of a stranger into the home and facilitate home modifications. Participants noted, “People love the fire department and the medics– and the police are more threatening to them…but the fire department [and medics] has a whole different feel about it… More supportive.” An older adult stated: “Just the decision on what to buy and how to install it and if it came from them, I would really trust that.” Collectively healthcare providers repeatedly noted how powerful the relationships, trust and connections older adults have with EMS workers. An EMS participant noted, “…Especially older adults…have a respect for police and fire… it allows us to share the knowledge that we know about fall prevention...”
In general participants felt that community paramedicine offers an opportunity to overcome several current barriers to fall prevention. Examples included opportunities for immediate action on suggested home modifications completed by community paramedicine teams without added approvals needed from insurance, companies, or supervisors. As described by an EMS worker, “When you call these [external agencies/resources], how many times do you call to get to customer service…Nobody has the authority to make stuff happen.” Instead, EMS workers are often empowered by their leaders to “Do the right thing, and we’ll talk about it later.” In addition participants envisioned CPs would enable further connection and depth for identifying resources needed for older adults that may not be obvious in environments outside the household. Instead of just placing a referral, CPs can take ownership and act with more certainty that things are being put in place to help.
Using community paramedicine for fall prevention can be personalized by focusing on the individual needs and circumstances of the patient. A CP stated, “I think that we’re experts at having difficult conversations in the home, and [patients] receive it really well from us.” By taking a relational approach, CPs can build trust and establish rapport with patients, which can improve patient outcomes and increase patient engagement in fall prevention efforts. Older adults felt that this personalized approach would be supported and they, “…like the idea of [community paramedics] coming in the house and saying, ‘The way you have your furniture arranged is actually a fall risk…’”
Additionally, CPs can work collaboratively with other parts of the healthcare system to provide a more comprehensive approach to fall prevention. A healthcare worker felt, “Bidirectional communication to the primary care … is kind of golden…that gives them a better picture of the whole situation…it strengthens the whole care provided to that patient.” By taking a personalized approach, CPs can provide tailored interventions and recommendations that are specific to the patient’s unique circumstances and needs.
Community paramedicine offers an opportunity for care when family members live far away by providing an additional layer of support and monitoring for patients who may be at risk for falls or who have other health-related issues. In situations where family members are not able to provide regular in-person care, CPs can conduct home visits to assess the patient’s needs and provide ongoing support. CPs can also provide education and resources to family members, empowering them to take an active role in the care of their loved ones. As one caregiver noted, “…from a distance, for me, it’s peace of mind. I know someone in the community that’s well trained…that will go to my parents’ house, assess their needs, and that that’s a touchpoint that my parents could also have. So especially with parents that are at a distance, that’s like another layer of, ‘Oh, thank goodness!’ Someone else is helping the process.”
Participants also mentioned that community paramedicine can increase the capacity to redirect resources towards fall prevention by identifying high-risk patients and providing targeted interventions to prevent falls. A CP described how going out and providing fall prevention through community paramedicine instead of just treating a patient at a 9-1-1 call is like, “[Hitting a] pause button and [we] have more time… to be able to sit down and figure out the root cause of the problems in the home, or why we keep going out there...” One of the CPs in the cohort said, “Oftentimes when we see them on the 9-1-1 call, it’s two in the morning… people don’t want to talk at that time, or they’re overwhelmed… [but] being able to follow up at a normal business hour… We’re able to go out and re-asses and get an idea of what maybe we can direct them to or, again, what gaps there are that need to be filled.” While overall the stakeholders reached a consensus that community paramedicine has significant strengths and opportunities, they emphasized the importance of allowing the community to build, design, and leverage its own resources, as well as connecting stakeholders and closing gaps.
Weaknesses and Threats
The stakeholders reported several weaknesses of community paramedicine for fall prevention, including the perception of the “Big Red Bus,” which refers to the perception that the only role of EMS is to transport patients to the hospital, and a healthcare provider participant mentioned that “A lot of times [patients] do not like strange people coming into their home.” It was noted that some patients, “Ultimately just don’t want help” and, “You can’t force it on them because of civil procedures.” EMS workers noted that even if they see a problem in a house, they “…don’t have the time to invest in evaluating or checking into that further.” These barriers may persist despite availability of a community paramedicine program.
Participants also noted that the structure for scope and utility of community paramedicine in fall prevention is underdeveloped, which can be a barrier to implementation. One healthcare stakeholder group focused on the difficulty in making community paramedicine sustainable. “You’ve got to prove your concept, and that is difficult to prove. It’s very difficult to research, quantify to be able to go back into the system and justify [the value of community paramedicine].” Several groups focused on the costs of building, staffing and sustaining a community paramedicine program as the current model charges for emergency transport and cannot bill for care. One EMS worker noted, “We don’t get any money for fire prevention. This is EMS prevention. This is critical, and it’s vital to our residents and our community.” There were also further concerns about private EMS versus public EMS usage in communities, with EMS participants wondering how private services may affect public EMS efforts. Further discussion evolved around the paradox of using community paramedicine in healthcare revenue and that the culture of healthcare in general tends to be more reactive than proactive. One participant inquired, “What entity in your healthcare system would set up a program that’s actually keeping people at home, and not transporting them, where I get reimbursement for it, and yet I’m also spending on this… new model?”
Another key challenge for community paramedicine includes data management, record keeping, and record integration for information management. Electronic medical records for EMS are not set up for longitudinal data collection and are often not compatible internally or among other healthcare structures to share relevant patient information. One healthcare focus group discussed how primary care providers often do not know if a patient activated 9-1-1 and how creating an integrated communication system could provide a powerful lens to treating patients. However, as it currently stands, there are significant barriers to bidirectional communication between EMS, CPs, and other healthcare providers in the system.
Participants acknowledged the importance of having the, “…right type of person with the right skills” to provide effective community paramedicine services, and that without building rapport with patients and other healthcare resources in a community, making actionable change is limited. There was consensus that some type of, “…Training [in community paramedicine] needs to be done,” to ensure providers can provide safe fall prevention. They also highlighted the lack of full investment of local leadership and the culture of fire and EMS as potential threats. Participants expressed specific concerns that inadequate or inauthentic delivery at the individual or operational level has the potential to thwart community paramedicine prevention strategies.
DISCUSSION
Community paramedicine is a growing model of healthcare that involves the use of EMS workers to deliver care to patients outside of the emergency setting.15 CPs can work collaboratively with other healthcare providers to offer a more comprehensive approach to fall prevention through early detection, targeted interventions, and improved resource activation.9,16 As a result, there is potential for community paramedicine to reduce unnecessary healthcare utilization by addressing fall risks early and preventing falls from occurring in the first place, decreasing the need for emergency department visits, hospitalizations, and other healthcare services.17 The findings from stakeholder interviews demonstrate that there is high enthusiasm for employing a community paramedicine model for community-based fall prevention strategies.
Stakeholders voiced interest in utilizing CPs for home assessments and early detection for fall risks. They also believed CPs could work collaboratively with other healthcare providers, such as primary care physicians, to provide a more comprehensive approach to fall prevention. There is evidence in the literature that building comparatively novel and innovative models of community paramedicine allows communities to focus upstream on important needs for patients with positive outcomes observed.15 Community paramedicine is well positioned to identify and interact at the intersection of 9-1-1 utilization for falls and community paramedicine prevention efforts, since EMS have the data and, potentially, the bandwidth and resources to invest in fall prevention activities. As study participants discussed, EMS typically benefits from a positive relationship with the community and high levels of trust which can improve adoption of fall prevention strategies.18 Allowing strangers to come into the home environment is sometimes a barrier to assessing the home environment and there is an inherent need for trust from the person providing advice for individuals to move into action for the advice.
Although older adults, caregivers, and healthcare workers identified advantages and enthusiasm for adoption of community paramedicine for fall prevention, they also described concerns that align with current evidence in the literature. One major barrier to implementing community paramedicine for fall prevention is funding. This model of care requires additional resources, such as staff training and equipment, which may not be readily available in all communities, particularly those that struggle with funding on a regular basis for even emergency runs. However, for EMS agencies that have access to funds, community paramedicine could have the potential to redirect resources to prevention, as a study participant noted. Currently select EMS agencies have been creative in addressing this, with some community paramedicine programs utilizing social workers to connect residents with local resources, while others provide direct interventions themselves in the form of home hazard assessments, fall risk assessments, and even home modifications.8,9
Other potential disadvantages noted by study participants were the limited scope of practice, regulatory barriers in state and local laws, and lack of reimbursement strategies for community paramedicine19,20. While these described barriers present a challenge globally for adoption of community paramedicine, there are current trials in place to determine how to overcome these barriers and leverage this model to support public health fall prevention and other healthcare needs.16,21,22 Another challenge in fall prevention that community paramedicine may face is patients’ willingness to adopt recommendations for fall mitigation. While this is not entirely unique to community paramedicine interventions and CPs can provide education and assessments for fall prevention, they may not have the authority or resources to implement significant changes to a patient’s home environment. However, it was noted by study participants that implicit trust in EMS workers by the community may facilitate patients’ willingness to adopt home modification strategies.
Limitations and Future Directions
Participants were not screened for prior exposure to fall prevention. The authors of this study were interested in learning what individuals not necessarily exposed to fall prevention may have encountered and their associated perceptions. The data collection for this study was completed prior to 2020, and the COVID-19 pandemic may have impacted stakeholders’ perspectives differently. Also, individuals with cognitive impairment were not included in this study, although it would be beneficial to learn the perceptions and experiences of older adults and caregivers with cognitive impairment. Future studies would benefit from exploring this. Additionally, the study is subject to limitations inherent in its design, including subjective interpretation of data and non-randomized study sample. This study evaluated stakeholders’ self-reported willingness to consider fall prevention activities through the lens of community paramedicine but did not measure actual adoption of community paramedicine. Future work should focus on implementation and adoption of fall prevention activities provided by community paramedics.
Conclusion
Community paramedicine has the potential to be an effective model of care for fall prevention, particularly among high-risk populations. However, there are also potential barriers and limitations to implementing the model, including funding, scope of practice, availability, and regulatory barriers. As with any healthcare intervention, careful consideration should be given to the advantages and disadvantages of using community paramedicine for fall prevention in a particular community or setting. Overall, many stakeholders think if the barriers for community paramedicine are addressed, it could be a successful fall prevention strategy.
Supplementary Material
KEY POINTS:
Falls among older adults are a significant public health issue and can lead to injury, decreased mobility, impaired functionality, and increased healthcare costs.
Community paramedicine is uniquely positioned to develop and deliver fall prevention interventions due to their proximity to fall incidents, community presence and trust, and access to the home environment.
Potential barriers for community paramedicine include funding, older adult concerns about stigma and willingness to adopt changes, and challenges with data integration.
WHY DOES THIS PAPER MATTER?
Perceptions of stakeholders that will be impacted by community paramedicine working in the space of fall prevention is essential to the development of successful fall prevention programs delivered by community paramedics for older adults.
ACKNOWLEDGEMENTS
The authors would like to gratefully acknowledge the Upper Arlington (Ohio) Fire Division for raising awareness of the project.
FUNDING INFORMATION:
This work was supported by the National Institute on Aging under the GEMSSTAR (Grants for Early Medical and Surgical Subspecialists’ Transition to Aging Research) grant (R03AG060177-02); the National Institute on Aging under the Paul B. Beeson Emerging Leaders Career Development Award in Aging (K76AG068435); and the Linda M. Cummins Simpson Research Endowment Fund for Rehabilitation Therapies for Mobility and ADLs.
SPONSOR’S ROLE
The sponsors had no role in the any aspect of the research or preparation or approval of the manuscript.
Footnotes
CONFLICT OF INTEREST
The authors declare no conflicts of interest relevant to this study.
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