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Emergency Medical Services
Application to the
Ministry of Health and Long Term Care
Community Paramedicine Initiative
April 2014
Grey County: Colour It Your Way
Table of Contents
Introduction ...................................................................................................................................1
PART I - Expanding Paramedicine in The Community (EPIC) ............................2
Section 1: Contact Information for Lead ....................................................................................2
Section 2: Describe the Proposed CP Activity/Activities............................................................2
Section 3: Demonstrated Need for the Proposed CP Activity/Activities ..................................6
Section 4: Target Population to be Addressed by the Proposed CP Activity ....................10
Section 5: Cooperation and Partnerships that Leverage Resources ......................................14
Section 6: Promote Communication among Core Team Members and The System and
patients .........................................................................................................................................17
Section 7: Tracking and Monitoring Key Performance Metrics .............................................20
Section 8: Sustainability Plan .....................................................................................................25
Section 9: Established Governance and Accountability ...........................................................27
Section 10: Ensuring that there is no Interference with Emergency Response .....................28
Section 11: Funding Requested...................................................................................................30
Section 12: Additional Information ............................................................................................30
Section 13: Appendices ................................................................................................................31
PART II – Grey County Community Paramedicine Program (GCCPP) .........49
Section 1: Contact Information for Lead ..................................................................................49
Section 2: Describe the Proposed CP Activity/Activities..........................................................49
Section 3: Demonstrated Need for the Proposed CP Activity/Activities ................................54
Section 4: Target Population to be Addressed by the Proposed CP Activity ....................58
Section 5: Cooperation and Partnerships that Leverage Resources ......................................59
Section 6: Promote Communication among Core Team Members and the System and
Patients .........................................................................................................................................62
Section 7: Tracking and Monitoring Key Performance Metrics .............................................68
Section 8: Sustainability Plan .....................................................................................................70
Section 9: Established Governance and Accountability ...........................................................72
Section 10: Ensuring that there is no Interference with Emergency Response .....................72
Section 11: Funding Requested...................................................................................................72
Section 12: Additional Information ............................................................................................12
Section 13: Appendices ................................................................................................................73
Introduction
Grey County EMS is pleased to submit its application to the Ministry of Health and Long
Term Care for the Community Paramedicine Initiative. Grey County EMS is a strong
supporter of the concept of community paramedicine in all of its current and future
iterations. We have been actively providing our own Community Referral by Emergency
Medical Services (CREMS) program since 2009 as well as participating on provincial
working groups developing standardized assessment tools and additionally, will be piloting
direct electronic referral submission to the Community Care Access Centre’s (CCAC)
client information system.
Our submission will consist of two parts. Part I – Expanding Paramedicine in the
Community (EPIC) will seek approval and funding for Grey County EMS participation in
the EPIC program as a study site. We believe that the EPIC study will provide definitive
answers in the effectiveness of community paramedic programs in the care and treatment
of the patient group consisting of chronic obstruction pulmonary disease, congestive heart
failure and diabetic patients. Part II – Grey County Community Paramedicine Program
(GCCPP) will seek approval for the expansion for our existing CREMS program. Under
this proposal, Grey County EMS will further expand and enhance additional community
paramedic programs including:
1) Implement the PERIL Assessment Tool for the CREMS Program
2) Pilot Direct ePCR integration with OACCAC Client Health and Related
Information System (CHRIS)
3) Community Paramedicine In-Home Visits
4) Expand CREMS Program to Include Mental Health and Addictions Referrals
5) Emergency Department High Risk Patient Discharge Follow-up
We are confident that our submission will meet the eligibility requirements as set by the
Ministry as we have worked diligently in establishing the key community health care and
support provider partnerships identified throughout the submission template. Our goal is to
evaluate the effectiveness of the EPIC program and the GCCPP initiatives to add to what
we believe will be a volume of information on the benefits of community paramedicine
programs. We are honoured to join our colleagues from across the Ontario EMS
community and our new partners throughout the broader health care and community
support providers in this worthwhile and exciting endeavor.
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PART I - Expanding Paramedicine in the Community
EPIC: Grey County EMS
Section 1: Contact Information for Lead.
Mike Muir
Grey County Emergency Medical Services
595 9th Avenue East
Owen Sound, Ontario
N4K 3E3
519-372-0219 ext. 1242
[email protected]
Section 2: Describe the Proposed CP Activity/Activities.
Implementation Readiness: Ready to launch in 8 weeks for any additional regional
EMS (including training and identifying and enrolling patients)
The Types of Services that will be Provided through the Proposed Activity.
The Expanding Paramedicine in The Community (EPIC) project is a health system
improvement initiative aimed at improving care integration and resource utilization for
Ontarians living with the three of the most common chronic diseases: chronic obstructive
pulmonary disease (COPD), diabetes mellitus (DM) and congestive heart failure (CHF).
The EPIC initiative will integrate community paramedics, specifically trained in chronic
disease management, to conduct home visits for patients diagnosed with one of these 3
chronic diseases under the medical delegation of the patients’ primary care physicians.
Alongside this improvement initiative we have partnered with Rescu at the Li Ka Shing
Knowledge Institute to conduct a full-scale evaluation in order to measure the impact of the
program on key performance indicators such as patient outcomes, resource utilization and
cost-effectiveness. The regional implementation of this innovative program provides a rare
opportunity to combine active system improvement with rigorous outcome measurement in
order to inform future scale-up, sustainability and system-level policy making.
The intervention will consist of an initial visit and 3 scheduled follow-up visits at 3 month
intervals over a one year period by a community paramedic who has received additional
training in chronic disease management (6 week education curriculum developed by
Centennial College) in addition to routine usual care.(Appendix A- EPIC Curriculum) The
initial visit and each follow-up visit by the community paramedic will include a medical
history and physical examination based on disease-specific elements recorded directly into
the electronic patient care record (eMR) for the entire Primary Health Care Team.
Additional visits in-between the 3 month interval can be prompted by the patient, the
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paramedic or the Primary Health Care Team depending on the patient’s health.
During the visit, patients will receive disease-specific education and counseling based on
their education needs. If necessary, the community paramedic may initiate treatment in the
home, based on disease-specific evidence based medical directives and/or may initiate
telephone contact with the primary health care physician in accordance with their medical
directive or at their discretion. (Appendix B – EPIC Medical Directives signed by each
patient’s physician) The community paramedics will directly notify the Community Care
Access Centre (CCAC) and other community resources at the discretion of the
physicians/Primary Health Care Team members. The patient will be able to notify their
Family Health Team or the community paramedic about the need for a subsequent
assessment based on any change in their condition. There are 3 case vignettes in Appendix
C that will provide a pragmatic example of the intervention in de-identified cases.
(Appendix C – EPIC Case Vignettes)
In order to rigorously evaluate the impact of the program, patients enrolled in EPIC will
either receive expanded care through the use of community paramedics, or to continue to
receive standard care through their primary care physician and current community-based
resources. Standard care includes regular physician assessment and treatment and periodic
augmentation of care through community resources (CCAC case manager, nurse
practitioner) at the discretion of the treating physician.
Patients
followed
for 1
year;
Primary
outcome
measure
d at 1
year
A List And Description Of The Roles And Functions Of The Core Members Of The
Team Who Will Be Implementing The Proposal, Including The Roles And Functions
Of Community Paramedics.
The core team members for this project are the EMS Team, the Primary Health Care team
and the project evaluation team. Support and endorsement has been acquired from the local
and regional partners including Sandra Coleman, CEO of Southwest CCAC, Maureen
Solecki, CEO of Grey Bruce Health Services and Dr. Cornelius Van Zyl, Chief of
Emergency Medicine Grey Bruce Health Services – Owen Sound Site (primary destination
hospital) as well as Kelli Gillis, Senior Director, System Design and Integration, Southwest
LHIN.
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Roles and functions of the core team members:
EMS Team
EMS chief
Chief Mike Muir, of Grey County EMS will be responsible for EPIC oversight in the
community. The chief will collaborate with the project partners locally and the University
of Toronto project team ensuring the implementation in the community is on time and
compliant with the project design. The chief will ultimately be responsible for reporting
progress to the local municipality, the LHIN and the MOHLTC.
EMS Project Coordinator
Kevin McNab, Deputy Chief, with accountability for the community medicine portfolio
within Grey County EMS will be responsible for overseeing the recruitment, selection and
training of the paramedics. The training requires local clinical placement within the
Primary Health Care team and simulation training requiring scheduling and coordination
with the Primary Health Care team and Centennial College trainers, respectively to ensure
good exposure for each student. Walter Tavares is the Community Paramedicine Lead at
Centennial College. (Appendix A – EPIC Curriculum) Kevin will work with the project
evaluation team to enroll the patients from the participating Primary Health Care team.
This includes mailing out the enrolment letters to the list of eligible patients identified by
the Primary Health Care team. This entails returning phone calls and ensuring the patient’s
contact information is correctly logged and preference for time of day. Kevin will set up
and oversee the process of booking appointments with the patients and responding to
patient requests for appointments with the community paramedics in addition to the
scheduled calls. Kevin will ensure logistical issues are addressed concerning 1) stocking of
the vehicle, 2) cellular linkage of the community paramedics to the on call Primary Health
Care Physician 24-7 roster and 3) electronic medical record (eMR) linkage directly from
their laptops in the home of the patient to the Primary Health Care teams eMR server and
4) setting up the EPIC 1-800 call line for the public and the Primary Health Care team to
contact the Community Paramedics.
Community Paramedics
The community paramedics are currently being selected and will be primary care with
intravenous skills. They will be responsible for completing a baseline assessment within 3
months of project launch and completion of 3 scheduled visits 90 days apart in addition to
follow up calls requested by the treating physician and any requests by the patient for
additional visits due to exacerbations. The community paramedics will provide medical
interventions in accordance with the EPIC medical directives (Appendix B – EPIC Medical
Directives). They will acquire the baseline patient data from eMR and record the required
data based on each visit and submit the data to the eMR of the Primary Health Care team
and the project database (Appendix E – EPIC Data Variables). They will contact the
physician on call to ask for advice, and consult with the physician to escalate or change the
treatment plan or engage other members of the team such as but not limited to CCAC
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resources, dietician, occupational therapy, palliative care, pastoral care, social work, long
term care placement liaison. If during any of the visits, the paramedic decides it is
appropriate or the patient requests it, the community paramedic will initiate a 911 call. The
community paramedic will acquire patient consent at the baseline assessment and upload a
copy to the project data base. (Appendix F- EPIC Patient Consent) Also at the baseline
assessment the community paramedic will use a quality of life assessment tool and repeat
this assessment at 12 months. (Appendix G – Quality of Life Assessment Tool)
Primary Health Care Team for EPIC
The lead family physician at the Owen Sound Family Health Team (OSFHT) is responsible
for overseeing the implementation of EPIC in their Health Care team.
The lead
individuals from the OSFHT are:
Paul Faguy – Executive Director
Dr. Elyse Savaria– Physician Lead
The OSFHT has a total of 20 primary care physicians, 5 nurse practitioners, 4 RNs, 1
pharmacist, 2 dieticians and 1 respiratory therapist. The OSFHT has a current patient
roster of 35,000 and another 4,000 non-rostered patients. The anticipated patient load will
be 46,000 patients in the next five years. In total Dr. Elyse Savaria has engaged 19
physicians from the Primary Health Care team(s) of OSFHT and they have identified 200
patients using the eMR initially and then by hand reviewing each case to confirm the
patients meet the eligibility criteria for the project. The final 200 patients will be reviewed
by the GBHS team members for confirmation and approval for entry into the project. The
physicians have agreed to sign off the medical directives (Appendix B – EPIC Medical
Directives) and to provide timely oversight (within 24 business hours) review of the
paramedic’s eMR submission to assure safety and appropriate timely care and bidirectional
communication. The Primary Health Care teams have also agreed to provide on call by
telephone to the community paramedics which provides direct access at any time but
especially helpful on nights and weekends.
University of Toronto Project Evaluation Team
Laurie Morrison is the Director of Rescu at the Li Ka Shing Knowledge Institute of St.
Michael’s Hospital and clinician scientist at the University of Toronto. Dr. Morrison will
be the lead evaluator for the project. Paul Hoogeveen is a family physician and medical
director for Simcoe Paramedic Services and Muskoka EMS. Dr. Hoogeveen is the Clinical
Lead for this project bridging the gap between EMS, primary health care teams, the CPSO
and the evaluation team. Together they will oversee in partnership with the regional EMS
chiefs and Primary Health Care leads the implementation and evaluation of EPIC. They
will be accountable monthly to the EMS chiefs and Primary Health Care leads on the
benchmarks for implementation and will provide the benchmark reports based on the data
for each EMS chief to submit to their local health partners and the MOHLTC.
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The project team includes physician leads in Ambulatory Care (Gilliam Hawker) and
Primary Health Care (Jane Philpott, Rick Glazier). The team has partnered with
Centennial College to provide the education and training unique to the project (Walter
Tavares – paramedic pursuing his PhD at McMaster University and faculty at Centennial
College). The team includes a CCAC lead to help bridge the gap between primary care
and Community Paramedicine and CCAC resources (Ms. Kathy Condie – Central CCAC).
The team also includes experts in Health Impact Assessment (Clare Atzema), Health
Economics (Jeff Hoch, Wanrudee Isaranuwatchai), Knowledge Translation and
Implementation (Katie Dainty), Biostatistics (Alex Kiss) and a paramedic pursuing his PhD
at U of T (Ian Drennan).
The project team has created study implementation modules including privacy and ethics
submissions that have been trialed on 5 Primary Health Care teams in York and we know
we are shovel ready for implementation. The project team’s role will be to continually
assess and address data issues in terms of data quality and data timeliness and conduct the
relevant analyses and report back to the EMS superintendent directly overseeing the
paramedics weekly, and the EMS chiefs and the Primary Health Care Teams monthly. The
project team will ultimately be responsible for providing the MOHLTC on behalf of the
EMS with the report at the end of 12 months. The project staff will abstract directly from
medical records at the destination hospital the rates of ED and hospital admission as well
as length of stay.
Section 3: Demonstrated Need for the Proposed CP Activity/Activities.
Implementation Readiness: Now- Needs assessments are complete, the gap and the
target group is defined.
What types of needs assessments have been conducted to determine any local service
gaps?
National and Provincial Needs Assessment
Under our current system patients diagnosed with COPD, CHF or DM have high rates of
health care system utilization and are costing the Canadian health care system billions of
dollars annually. The prevalence of these three chronic diseases is on the rise, with
projections for 2017-2018 that are staggering given our aging population. Under our
current system patients diagnosed with COPD, CHF or DM have high rates of health care
system utilization and are costing the Canadian health care system billions of dollars
annually. [Ontario Action Plan For Health Care, 2014 and Mittman, Respiratory Medicine,
2008]. Vast majority of older adults have at least one chronic disease or condition, and the
number of Ontarians 65 years and older is expected to double over the next two decades.
[Sinhai S. Living Longer Living Well. 2012] The EPIC project responds to an emerging
need for more effective community-based health initiatives in the Canadian health care
system to appropriately care for the increasing number of individuals living with chronic
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diseases, specifically DM, COPD and CHF. Individuals with diabetes are 3 times more
likely to be hospitalized with cardiovascular disease than individuals without diabetes, 12
times more likely to be hospitalized with end-stage renal disease, and almost 20 times more
likely to be hospitalized with non-traumatic lower limb amputations. [Public Health
Agency of Canada. Diabetes in Canada, 2011] There are 500,000 Canadians living with
heart failure with 50,000 new patients diagnosed annually.[Ross, Canadian Journal of
Cardiology, 2006] More than 50,000 hospitalizations a year are attributed to CHF.[Public
Health Agency of Canada, 2009 and Canadian Cardiovascular Society Guideline Update
for the Management and Prevention of Congestive Heart Failure, 2001] Chronic
obstructive pulmonary disease is one of the fastest growing chronic diseases and the fourth
leading cause of death in Canada.[O’Donnell, Canadian Respiratory Journal, 2007] It has
an average hospitalization of 10 days for an exacerbation with an associated cost of
$10,000. [Mitman, Respiratory Medicine, 2008] The total annual cost of COPD to the
Canadian health care system is estimated to be $1.5 billion. [Mitman, Respiratory
Medicine, 2008]
Regional EMS Needs Assessment
The importance of exploring municipal and local needs for expanded paramedic scope of
practice has been recognized by EMS agencies, municipal councils and a number of
Government organizations. EMS agencies in southern Ontario have observed a significant
increase in patient transports over the last 10 years. The demand for paramedic services
continues to increase at a faster rate than population growth and this number is expected to
increase by as much as 48% over the next 10 years is projected to address the anticipated
change in demographics; placing a significant demand on EMS systems. Without a change
in EMS delivery, paramedic services will be unable to keep pace placing unprecedented
pressure on our health care system. Patients with chronic diseases utilize 911 resources at
high rates, accounting for 25% of all patient transports. In order to combat the expected
increase in demand for 911 emergency resources it is imperative that patients with chronic
diseases are effectively managed prior to the development of disease-related exacerbations.
Many of these anticipated changes in health care demand could be mitigated in part by
community paramedicine programs as part of an integrated system.
Local EMS Needs Assessment
In 2013, within the County of Grey, we identified 1,235 respiratory and 1,182 diabetic
patients with chronic disease or complex medical problems accounting for 30% of our 911
calls. We also identified through statistics provided by Grey Bruce Health Services for the
period of April 2012 through December 2013, 156 diabetes, 375 CHF and 563 COPD
inpatient visits. Emergency Department visits for the same time frame were 901 diabetes,
556 CHF and 3,934 COPD patients. Re-admission rates for the time period from April
2012 to September 2013 were 11 diabetes, 22 CHF and 42 COPD patients.
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Have relevant system partners, including Health Links, LHINs, others been involved
or consulted on this analysis?
EPIC was designed 2 years ago by a large team of core members from York EMS the U of
T Project Evaluation Team and the Primary Health Care Teams in York Region.
York EMS Chief: Norm Barrette
York EMS Deputy Chief: Iain Park
York EMS Clinical Supervisor: Chris Spearen
York Region Primary Health Care Team Lead: Dr. Jane Philpott
Sunnybrook Base Hospital: Dr. Paul Hoogeveen, Siobhan Kennedy, Linda Turner
Director Central Community Care Access Centre: Kathy Condie
Centennial College: Walter Tavares
Rescu, University of Toronto: Laurie Morrison and the EPIC team of investigators
With support from the following partners:
Commissioner Community and Health Services, York Region: Adelina Urbanski
Central LHIN CEO: Kim Baker
Health Links lead at Markham Stouffville Hospital: Paul Cappuccio
CEO Markham Stouffville Hospital: Janet Beed
VP Medical Affairs and Emergency Medicine Markham Stouffville Hospital: Dr. David
Austin
Determination of existing health care gaps, including review of the literature on
community paramedicine and local and regional needs-based assessments were developed
in full partnership and consultation with all of the key stakeholders and partners through
representatives on the steering committee. Specifically involved in the development of
EPIC locally were Paul Faguy, ED OSFHT, Dr. Elyse Savaria, Physician Lead OSFHT,
Maureen Solecki, CEO GBHS, Dr. Cornelius Van Zyl, Chief of Emergency Medicine
GBHS, Jane Wheildon, Manager of Critical Care, Respiratory Therapy and Sleep Lab
GBHS, Sonja Glass, Chief Quality Officer GBHS, Kelli Gillis, Senior Director, System
Design and Integration, Southwest LHIN and Sandra Coleman, CEO Southwest CCAC.
All letters of support are included in Appendix D.
How could existing, established resources effectively support identified gaps? Please
explain.
The current health care system, which primary revolves around hospital-based care and
primary care providers, has been unable to provide care for patients with chronic disease
and must evolve.
Ontario government initiatives have identified this and made recommendations for change.
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Ontario’s 2010 Excellent Care for All Act refocused the health care system on the quality
of care it delivers and the best possible use of its resources.
http://health.gov.on.ca/en/public/programs/ecfa/default.aspx/ (last accessed April 5, 2014)
Ontario’s Action Plan for Health Care which focused on better health care access, quality
and value for Ontarians. The action plan calls for increased access to Primary Health Care,
increased support to home care, and timely access to the most appropriate care or “right
care, right time, right place”.
http://www.health.gov.on.ca/en/ms/ecfa/healthy_change/ (last accessed April 5, 2014)
In addition, the Living Longer, Living Well report submitted to the Minister of Health and
Long-Term Care and the Minister Responsible for Seniors on recommendations to inform a
seniors strategy for Ontario listed “exploring the development and expansion of
Community Paramedicine programs across Ontario, especially in northern and rural
communities” as one of its key recommendations.
http://www.health.gov.on.ca/en/common/ministry/publications/reports/seniors_strategy/docs/senior
s_strategy_report.pdf (last accessed April 5, 2014)
The Public Services for Ontarians: A Path to Sustainability and Excellence report called for
an integrated health care system and more efficient health care delivery for “complex
cases”, or the 1% of Ontario’s population that accounts for 34% of its total health care
costs. http://www.fin.gov.on.ca/en/reformcommission/ (last accessed April 5, 2014)
Despite these published calls for action there is limited science to guide decision
makers as to how to address this gap.
Identified Gaps in Science
The integration of community paramedics into health care models has developed
international attention. Studies throughout the United Kingdom, Australia and United
States have shown that community paramedic implementation is feasible, safe and
effective while at the same time improving satisfaction of patients and practitioners and
minimizing health care costs [Bigham, Prehospital Emergency Care, 2013]. Despite this,
and the recognized need for expanded community based medicine, there has been minimal
adoption of community paramedic programs in Canada. In Nova Scotia, a longitudinal
mixed-methods project was undertaken that utilized a nurse practitioner-paramedic-family
physician care model. Community paramedics performed diabetic assessments, wound care,
congestive heart failure assessments, drew blood for subsequent lab tests, and provided
education sessions. Between year 1 (pre-intervention) and year 3 (year following
implementation of intervention), there was a 40% decrease in ED visits, 28% decrease in
family physician visits and a marked decrease in mean total health costs [Misner,
Emergency Medical Services, 2005]. While the evidence supporting community
paramedicine is promising and the call for action loud and clear, a comprehensive
systematic review [Bigham, Prehosp Emerg Care. 2013] identified only a single
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Randomized Controlled Trial from the UK that evaluated the efficacy of community
paramedics [Mason S, BMJ. 2007].
Is there support / consensus among local service providers that the proposed CP
activity is advisable to meet the identified gaps?
There is consensus among local service providers, core team members and key
stakeholders/partners that EPIC meets the identified gaps and addresses the local health
care system needs. Their understanding of the issues and support for this intervention is
well outlined in their letters of support that accompany this application (Appendix D –
Letters of Support). More importantly it is in the best interests of the community to launch
a rigorously measured Community Paramedicine project that has been proven to be
feasible in York Region and do it well with the support of the community leadership and
partners. Once this is in place it is easier to continue to collaborate and layer on future
targeted interventions unique to the population; for example non ambulatory complex care
patients, marginalized populations without primary care, mental health, addiction
rehabilitation and palliative care.
Section 4: Target Population to be Addressed by the Proposed CP
Activity.
Implementation Readiness: <3 months: to identify and recruit eligible patients and to
obtain informed consents
What Is The Anticipated Volume and Type of Patients/Older Adults Who Will
Benefit From The Proposal?
Provincial published statistics
Yearly hospitalization rates in Ontario for CHF are of 296/100,000 [Babinski,
Cardiovaascular Health and Services in Ontario; An ICES Atlas, 1999], and for COPD are
632/100,000 [The Canadian Thoracic Society, The Human and Economic Burden of
COPD: A leading cause of hospital admissions in Canada 2010] and 67/100,000 for DM
[Booth, Diabetes in Ontario: An ICES Atlas, 2003]. One year mortality rates are 10% for
CHF [Ferrero, Chest 2001], 4.4% for COPD [Lowery, Chest 2012] and 8.2% for DM
[Rubin, Journal of Clinical Endocrinology and Metabolism, 1998].
EPIC is currently aimed at improving care for patients diagnosed with either CHF, COPD
or DM. The simplicity of EPIC allows for the community paramedic intervention to easily
be scaled up to other EMS services and community health care teams, and expanded to
cover a broader range of health conditions and populations of individuals to maximize the
number of individuals that could benefit from this intervention.
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What Methods Have You Used To Determine The Target Population For This
Proposal?
Potentially eligible patients will be initially selected by applying broad search filters to the
patient records contained within the Primary Health Care Team’s eMR for all possible
terms related to diagnosis, treatment and monitoring of diabetes, COPD and CHF. All
potentially eligible patients' records will be hand screened by their primary care physician
to ensure they meet all the eligibility criteria and their current marker of disease severity
will be abstracted and verified (example; HgbA1c, FEV1 and left ventricular ejection
fraction). Prior to enrolment, the primary care physicians will assess their patients for
potential project participants and assign those eligible to a risk category grouped by a low
(<20% chance), medium (20-50% chance) or high (>50%chance) risk of presenting to the
ED/hospital within the following 30 days. Only patients ruled as high risk are eligible for
inclusion by their primary care physician will be contacted for project enrolment.
Table 1: Project Eligibility Criteria
Eligibility Criteria
Ineligibility Criteria
Patients are eligible if:
 they are residents of the region
of Grey County,
 they are 18 years of age or older,
 they have been diagnosed (at any
point in time prior to enrollment)
with, and currently receiving
treatment for COPD, HF, or DM
and
 they are identified by the
participating Primary Health
Care Team as high risk for
hospital admission.
Patients are ineligible if:
 they are residents of long-term
care facilities or
 they have cognitive impairment,
uncontrolled psychiatric disease
or language barriers that would
make it difficult to understand
the consent and communicate
with the paramedic during the
scheduled visits, unless the
individual
with
power
of
attorney for personal care
consented and agreed to be at
each visit.
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What Data/Evidence Have You Analyzed To Determine The Service Utilization
Patterns Of This Target Population?
The target population for EPIC was identified using a coded software search of the
electronic medical record (eMR) at each Primary Health Care Team. The eMR filter
searched for low FEV1, high HgbA1C and low Ejection Fraction to identify the three
disease cohorts (COPD, DM and CHF respectively). The primary care physicians went
through the list to ensure all the patients they anticipated to be high risk were indeed
captured by the electronic filter. They also reviewed the final list to identify the
individuals who were high risk defined as non-compliant with medication or missed
appointments or high utilization of the ED and admissions to hospital.
In order to test the feasibility of the treatment plan for the intervention patients, the ease of
patient recruitment, and our ability to measure key performance indicators a feasibility
project of the EPIC protocol has been underway since March 2013 with York Region EMS
and Primary Health Care teams in York Region. To date the EPIC team has recruited 207
patients from two Primary Health Care teams. Of these, 10 patients self-withdrew for a
variety of personal issues and 4 moved out of the region leaving a residual of 193 patients
where 102 were assigned to receive the Community Paramedicine intervention. There are
four scheduled visits conducted over a year at 90 day intervals (scheduled) in addition to
patient initiated requested visits (exacerbation) and physician directed follow up calls
(follow-up). To date 307 visits are completed representing 94% of the required visits
within the time frame. The mean number of days between scheduled visits is 90.3 days
with a standard deviation of 18 days. These data demonstrate the paramedics are able to
schedule their visits and the patients are complying and making time for their visits. In
fact the no show rate for the patients is 2%. The family physician requested 46 follow up
visits representing 15% of all visits. Patient requested visits for exacerbations totaled 11
(4%). The total number of ED visits for all the intervention patients is 10 in one year and
the admission rate to hospital is 0% which we know is a dramatic reduction when
compared to the patients who are not receiving the intervention so we are confident the
project is feasible and suggests it may have a positive impact on the health care system.
Based on the primary health care teams currently enrolling there are 100 eligible patients
per primary health care teams with ~ 5000 patients on their roster.
How Are Existing Local Resources Currently Serving This Target Population?
This target population of EPIC is not well served by the current local resources. They have
been identified by their primary physicians as high risk despite their best efforts in
prevention and treatment. They have exhausted the community resources available to them
in an effort to help them; including specialty referral, social work, physical therapy and
occupational health, CACC resources and dietician. In addition many of these patients are
non-ambulatory and reliant on the EMS transport and the ED for primary care and
acquiring simple lab tests such as Hgb A1C and INR as well as electrolyte testing.
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What Are The Specific Gaps This Proposal Will Help To Address?
EPIC is purposefully aligned with the goals outlined in Ontario’s 2010 Excellent Care for
All Act. By design EPIC is refocusing the health care system on the quality of care it
delivers and the best possible use of its resources. It will augment the care delivered to
patients living with DM, COPD and CHF who are identified by their family physician as
high risk for failure. EPIC is aligned with providing patients with care based on the best
evidence and standards. EPIC will use a tiered chronic care model, paramedics under
physician delegation who can integrate what is being asked of the paramedics with existing
resources in the community, to augment chronic disease management, minimize the
consequences of the disease and reduce hospitalization rates.
EPIC is further aligned with the objectives of Ontario’s Action Plan for Health Care,
which focuses on better health care access, quality and value for Ontarians. EPIC supports
increased access to Primary Health Care, increased support to home care, and timely access
to the most appropriate care or “right care, right time, right place”. By design EPIC
addresses patient needs in the convenience of their home, identifying and treating diseaserelated symptoms before they escalate to emergency health problems, and referring patients
to their family physician when necessary. The tiered response maximizes the full potential
of all health care professionals involved and ensures that the right person gives the patient
the right care at the right time.
EPIC is also well positioned to answer the suggested health care reforms outlined
in Public Services for Ontarians: A Path to Sustainability and Excellence. The report calls
for an integrated health care system and more efficient health care delivery for “complex
cases”, or the 1% of Ontario’s population that accounts for 34% of its total health care
costs. EPIC responds to the call for more efficient care for complex cases by delivering
health care to chronic disease patients in an integrated model that acts to reduce the need
for hospital admissions and emergency medical services activation.
This MOHLTC call for proposals is an important step in providing the evidence on
whether Community Paramedicine will help to address this gap in science. If the various
grant recipients evaluate and report their impact on the target group this will advance the
science and provide the leverage required to adjust the system of care based on evidence.
EPIC is rigorously designed to withstand peer review and provide the highest level of
evidence upon which to inform policy and health care implementation decisions.
Why paramedics in addition to all the other community based resources will address
the gap in care?
Paramedics are accessible 24-7 when current mobile integrated teams are Monday to
Friday daytime hours. The community and integrated teams call 911 when they need
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additional resources, therefore equipping paramedics with a broader skill set will provide a
more integrated and comprehensive response. Current EMS deployment models suggests
that 20% of peak and 10% of weekly staff hours could be refocused on community
paramedicine booked appointments and maintain EMS performance standards [Personal
communication EMS Chiefs Peel, York, Muskoka, November 2013]. Currently, 10% or
more of the current EMS staff are on modified duties (pregnancy, injury), which limits
their lifting ability but would allow them to perform Community Paramedicine assessments
and follow up [Personal communication EMS Chiefs Peel, York, Muskoka, November
2013]. Paramedics are trained to be mobile, community based and use point of care testing
in a challenging home environment without any other health care infrastructure. They are
efficient and effective in this environment every day. They use their surroundings to
capture data that is left unsaid, identify subtle signs of potentially life threatening issues,
reach out to on call physicians to address issues at the bedside before they become
emergencies, and provide comprehensive care as per medical directives.(Appendix B –
EPIC Medical Directives) Extending a paramedic’s current knowledge of chronic disease
as it contributes to life threatening emergencies, to include routine care and prevention of
morbidity and mortality will be a modest investment in education. Moreover, there are
anticipated future year cost avoidance benefits as alluded to previously with the anticipated
48% increase in EMS staff over the next 10 years to address the anticipated change in
demographics.
Section 5: Cooperation and Partnerships that Leverage Resources
Implementation Readiness: Now: Partnerships are in place and support letters are
provided in Appendix D.
How Will Existing Resources Support the Implementation of the Proposal?
The proposal (budget and implementation) is designed to be independent of current
municipal and MOHLTC resources employed to provide 911 emergency response. This
will be achieved through fiscal use of the project funds and development of new
partnerships with Primary Health Care teams in our community and the support of Health
Links, the LHIN, the CCAC and destination hospital.
Which Organizations Will Be Partners in the Delivery of the Proposed CP Activity?
Our core team (outlined in Section 2 of this application) has partnered with the key lead
organizations and stakeholders in our community and they have provided letters of support
(Appendix D):
LHIN Lead - Kelli Gillis, Senior Director, System Design and Integration
Health Links Lead – No Health Links in Grey County at present
Municipal approval - Brian Milne, Warden Grey County
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SW CCAC Lead – Sandra Coleman, CEO
Destination hospital – Maureen Solecki, CEO
ED chief of Destination hospital – Dr. Cornelius Van Zyl
Base Hospital Physician – Dr. Don Eby
By engaging all of the key stakeholders/partners upfront we have already created the
necessary linkages to make this health system innovation possible.
What is the specific role / function of each partner with respect to the proposed CP
activity / activities?
The LHIN, Health Links and the Municipal government in addition the MOHLTC are the
governing bodies to which our team will be accountable.
Southwest CCAC Region Lead – The engagement of the CCAC is pivotal and established
now in anticipation of funding for this project. The CCAC will be a source of ongoing
identification of patients to the Primary Health Care team as potentially eligible as the
project evolves from launch date. In addition our common goal is to link the CCAC
documentation with the eMR at the Primary Health Care Team such that all those
responsible for care are linked to the patient’s data in a way that enables timely accurate
and informed care. The CCAC will provide the data on utilization of their resources for all
enrolled patients as one of the key performance metrics that we will measure in EPIC.
CEO for the primary destination hospital – Grey Bruce Health Services – Owen Sound Site
is our primary destination hospital and the hospital of record for our measurement of ED
visits, hospital admissions, length of stay. The CEO has committed to allowing us to
review the medical record of the enrolled patients (enrolled means consented) to acquire
these endpoints.
ED chief of our primary destination hospital Grey Bruce health Services – Owen Sound
Site will provide direct access to the ED visit record of the enrolled patients (enrolled
means consented) to acquire the frequency of ED visits which is an important benchmark
for this intervention.
How were the organizations that will be involved in the delivery of the proposed CP
activity engaged in the development of the proposal?
EPIC Protocol Development
The original protocol for EPIC was developed in partnership with key representatives from
the core member teams employed in York region representing core members, stakeholders
and partners:
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EMS Chief: Norm Barrette
Deputy Chief: Iain Park
Clinical Supervisor: Chris Spearen
Primary Health Care Team Lead: Dr. Jane Philpott
Sunnybrook Base Hospital: Dr. Paul Hoogeveen, Siobhan Kennedy, Linda Turner
Director Central Community Care Access Centre: Kathy Condie
Centennial College: Walter Tavares
Rescu, University of Toronto: Laurie Morrison and the EPIC team of investigators
With support from the following partners:
Commissioner Community and Health Services, York Region: Adelina Urbanski
Central LHIN CEO: Kim Baker
Health Links lead at Markham Stouffville Hospital: Paul Cappuccio
CEO Markham Stouffville Hospital: Janet Beed
VP Medical Affairs and Emergency Medicine Markham Stouffville Hospital: David Austin
Local EPIC implementation strategy development.
We reached out to our largest primary health care teams OSFHT, GBHS leaders, our
municipal leads Grey County Council, LHIN lead Kelli Gillis as well as CCAC Lead
Sandra Coleman through telephone and email employing a 3 page summary provided by
the U of T Project Team Lead (Laurie Morrison). We engaged the team through webinars,
exchange of ideas, data and documentation exchanges through conference calls and inperson meetings. We went through the EMS and Primary Health Care checklist for
feasibility to participate in EPIC. We collaborated in the preparation of the application, the
identification of our gaps in care, regional statistics and confirmation that we had a target
population that would potentially benefit from the EPIC intervention to develop our
implementation plan outlined in this application.
Is there a plan to share resources among partner organizations and what types of
resources will be leveraged?
The requested resources outlined in the budget are allocated to cover the project specific
overall start-up costs directly supporting expansion of the EMS service and primary health
care delivery to deliver local Community Paramedicine without compromising their
responsibility to provide 911 response and primary health care delivery to the community.
This is in keeping with the criterion identified on page 4 of the application package.
Essential to the implementation of EPIC is sharing of the IT resources in the Primary
Health Care team to code the filter to identify the patients and develop a virtual linkage for
the paramedics to the eMR of the primary health care team. The EPIC project team has
code written to do this for the two most popular eMR systems in use in the province and
will give this code to all participating Primary Health Care teams. We plan also to work
with the local CCAC if they wish to accept the coded solution to bring them into the virtual
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circle of care through access to the Primary Health Care team eMR.
In addition the current on call system operated by the primary health care teams will
provide the 24-7 support to the paramedics in the community with no additional cost to the
system of care. The estimate call volume is 1-2 calls per week where 98% are day time
hours and usually with the patient’s primary physician.
We plan to share our findings with Health Links and the LHIN such that if the findings are
positive and this study is cost effective it will provide rigorous data to realize these cost
savings through the sustained implementation of Community Paramedicine after the
completion of EPIC.
How will partner organizations stay connected throughout the lifecycle of the project
(e.g. communicate, problem solve, reach consensus on key decisions, etc.)?
The core team and representatives from the local CCAC are already working together daily
by email, telephone and are meeting weekly by webinar prior to launch. The EPIC steering
committee meetings are occurring monthly with our core team and representative from our
local stakeholders/partners (LHIN, Health Links, Destination hospital CEO and ED chiefs)
join the calls as time allows given their other responsibilities within the community. The
Rescu website posts the key performance metrics after each monthly meeting.
(www.rescu.ca) select current studies/epic).
Section 6: Promote Communication Among Core Team Members and the
System and Patients
Implementation Readiness: Now
How Were The Core Team Members Identified In The Description Of The Proposed
CP Activity Engaged In The Development Of The Proposal?
All members of the core team were actively involved in the development and collaboration
of the EPIC project in our region. In addition to the core team members outlined in Section
2, we engaged the following individuals within our community to review the EPIC project,
the target project and the requirements within our community;
LHIN Lead - Kelli Gillis, Senior Director, System Design and Integration
Health Links Lead – No Health Links in Grey County at present
Grey County - Brian Milne, Warden
SW CCAC Lead – Sandra Coleman, CEO
GBHS – Maureen Solecki, CEO
ED chief of Destination hospital – Dr. Cornelius Van Zyl
GBHS - Sonja Glass,
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GBHS – Jane Wheildon
GBHS – Graham Fry
GBHS – Robyn Dykeman
Grey Bruce Health Unit – Sarah Milne
Base Hospital Physician – Dr. Don Eby
Grey County EMS – Wendy Bieman, Deputy Chief Quality Assurance
Grey County EMS – Jeff Adams, Duty Supervisor
The proposal was developed with input from all of the core team members including
revisions and final approval.
How Were The Core Team Members Engaged In The Development Of Operational
Processes Relating To The Proposal?
LHIN Lead - Kelli Gillis, Senior Director, System Design and Integration – review of
submission, comments/feedback and provide LHIN support for EPIC program.
Health Links Lead – No Health Links in Grey County at present
Grey County - Brian Milne, Warden – liaison with County Council for support of EPIC
program.
SW CCAC Lead – Sandra Coleman, CEO - review of submission, comments/feedback and
provide CCAC support for EPIC program.
GBHS – Maureen Solecki, CEO – provide support for EPIC program.
ED chief of Destination hospital – Dr. Cornelius Van Zyl - review of submission,
comments/feedback and provide GBHS support for EPIC program.
GBHS - Sonja Glass, Chief Quality Officer - review of submission, comments/feedback,
needs analysis data review, program support for clinical placement during paramedic
training, access to eMR.
GBHS – Jane Wheildon - review of submission, comments/feedback, needs analysis data
review, program support for clinical placement during paramedic training, access to eMR.
GBHS – Graham Fry - review of submission, comments/feedback, needs analysis data
review, program support for clinical placement during paramedic training, access to eMR.
GBHS – Robyn Dykeman - review of submission, comments/feedback, needs analysis data
review, program support for clinical placement during paramedic training, access to eMR.
Grey Bruce Health Unit – Sarah Milne - review of submission, comments/feedback and
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provide Health Unit support for EPIC program.
Base Hospital Physician – Dr. Don Eby review of submission, comments/feedback.
Grey County EMS – Wendy Bieman, Deputy Chief Quality Assurance review of
submission, comments/feedback, management support, training support, Quality Assurance
support.
Grey County EMS – Jeff Adams, Duty Supervisor review of submission,
comments/feedback, operational support, equipment/supplies, vehicles, etc.
What Mechanism Has Been Established To Promote Timely Communications And
Information Sharing Among Core Team Members Of The Team And The System
And The Patients?
The core team members have developed a virtual solution to allow real time
communication with the family physician the community paramedic and the patient. Each
primary health care team has an eMR and the two most popular eMR platforms are
Practice Solutions and Accuro. The core team has developed an encrypted privacy
compliant software solution to allow the community paramedic access to the eMR of the
enrolled patients. We have also developed a template for reporting on each patient such
that each visit is documented in a comprehensive way. The paramedic prepares and
submits this report while at the patient home and it is flagged for review by the patient’s
family physician within 24 hours. If the family physician wishes to make any changes or
provide feedback they can respond using the eMR and the messages are reviewed by the
paramedic within 24 hours. If however the physician or the paramedic wish a more timely
response they can teleconference with each other and simultaneously review the patient’s
medical record. This allows them to confer about the patient real-time, reviewing
consultant’s notes, laboratory tests and the paramedic’s findings to decide on the most
appropriate action. This is by far the greatest achievement of the EPIC project as
highlighted by the primary care physicians during the pilot. Direct timely high quality
communication is key to helping these complex patients.
The medical directives were developed after discussion with specialty physicians
(cardiology, nephrology, respirology, endocrinology), primary care physicians, medical
directors for EMS, EMS educators and paramedics. Paramedic compliance with the
medical directives (Appendix B – EPIC Medical Directives) is subject to physician review
within 24 hours as outlined above. Physician review dates are time stamped in the eMR
and stored on the server which is abstracted and reported to the project team data base as a
safety endpoint.
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Section 7: Tracking and Monitoring Key Performance Metrics.
Implementation Readiness: Now: The infrastructure is in place to track outcomes and
proven to be timely and accurate.
What Are The Anticipated Results And Timing For Achieving Them?
Key performance metrics are listed below by timing of reporting:
Baseline and at 12 months
1. Baseline characteristics such as gender, age, weight, disease markers.
2. FEV1, HgbA1C, Ejection Fraction within a year prior to enrolment and at 12
months after the intervention
3. Overall health status assessment (quality of life) as measured by the validated
EQ-5D-5L tool at the first visit and at 12 months.
Weekly to EMS Supervisor for Community Paramedics and Monthly to the Core Team
1. Enrolment rate of eligible patients
2. Mean and Standard Deviation (SD) number of community paramedic visits per
enrolled patient
a. Scheduled
i. Mean number of days between scheduled visits (90 is the goal)
b. Follow-up (Safety Metric)
c. Exacerbation
d. Missed visits – patient cancels or missing on arrival
3. Any deviations from medical directive and corrective action (Safety Metric)
4. Mean (SD) number of hours to physician review and archive or follow up
instructions (Safety Metric)
5. Data completion rates by community paramedic (Data quality and timeliness)
At 12 months
1. Mean (SD) number of Primary Health Care visits per enrolled patient
2. Mean (SD) number of CACC visits per enrolled patient
3. Total calls to 911 for enrolled patients
4. Total visits to the ED for enrolled patients
5. Total number of hospital admissions for enrolled patients
6. Length of hospital stay for enrolled patients
7. Economic analysis of the health care costs based on mortality and quality of life
What Mechanisms Has Been Established For Tracking Key Performance Metrics?
EPIC builds on existing measurement tools currently available within EMS, family health
and the hospital. The following data sources will be used to gather data for the key
performance indicators and economic analysis:
1. Family Health Team eMR data
2. Inpatient data abstracted from medical records
3. Patient care records from the local EMS service
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4. ED eMR or paper documentation stored at the destination hospital
A web based privacy compliant encrypted data entry interface has been created for the
paramedic to enter the evaluation data after each patient encounter or data abstracted from
the medical record.(https://epistry.smh.ca) The server resides at St Michael’s Hospital and
is compliant with all requirements for personal health data repositories including back up
every 24 hours.
As outlined in prior sections 4-6, the community paramedic
documentation is also directly linked the Primary Health Care eMR.
Are The Core Members Of The team/Partner Organizations Supportive of this
Mechanism?
The partner organizations are supportive of this application and the key performance
metrics. Their letters of support are stored in Appendix D of this application.
How Will Data Be Collected Across Multiple Sectors (EMS, CCAC)?
Data regarding patient assessment and treatment is currently collected in each Family
Health Team’s eMRs. Currently all providers (Physicians, Social Workers, Dieticians,
Physician Assistants, and Nurse Practitioners) remotely access the eMRs. CCAC and the
community paramedics will be joining the patients’ circle of care and will sign
confidentiality agreements to be provided with eMR access. The community paramedics
will acquire the key performance metrics either through direct interaction with the patient,
or abstraction from the eMR or the hospital medical record. The community paramedics
will enter EPIC specific project variables into the web based encrypted data base called
Epistry (https://epistry.smh.ca) housed by Rescu at St. Michael’s Hospital. The Project
Evaluation team of investigators and staff at Rescu will be responsible for data review, data
collection monitoring and data cleaning. The staff at Rescu oversee and review the data
daily and provide weekly password protected project summaries to the EMS Deputy Chief,
Kevin McNab overseeing the implementation of EPIC and the Community Paramedics.
The IT representatives at all participating Family Health Teams have confirmed that all
project data will be stored on St. Michael’s Hospital research data servers physically
located at 30 Bond St. in St. Michael's Hospital. This server site is in compliance with
PHIPA guidelines.
The core members of the team were actively involved in the development of this data
collecting and tracking mechanism and supportive of this plan.
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What Type Of Quantitative and Qualitative Information Will Be Collected That Will
Demonstrate The Following Outcomes?
Key performance metrics are listed below by timing of reporting:
A. Baseline and at 12 months
1. Baseline characteristics such as gender, age, weight, disease markers.
2. FEV1, HgbA1C, Ejection Fraction within a year prior to enrolment and at 12
months after the intervention
3. Overall health status assessment (quality of life) as measured by the validated
EQ-5D-5L tool at the first visit and at 12 months.
B. Weekly to EMS Supervisor for Community Paramedics and Monthly to the Core Team
1. Enrolment rate of eligible patients
2. Mean and Standard Deviation (SD) number of community paramedic visits per
enrolled patient
a. Scheduled
i. Mean number of days between scheduled visits (90 is the goal)
b. Follow-up (Safety Metric) – requested by family physician and scheduled
c. Exacerbation- requested by family physician or by patient
d. Missed visits – patient cancels or not at home on arrival
3. Any deviations from medical directive and corrective action (Safety Metric)
4. Mean (SD) number of hours to physician review and archive or follow up
instructions (Safety Metric)
5. Data completion rates by community paramedic (Data quality and timeliness)
C. At 12 months
1. Mean (SD) number of Primary Health Care visits per enrolled patient
2. Mean (SD) number of CACC visits per enrolled patient
3. Total calls to 911 for enrolled patients
4. Total visits to the ED for enrolled patients
5. Total number of hospital admissions for enrolled patients
6. Length of hospital stay for enrolled patients
7. Economic analysis of the health care costs based on mortality and quality of life
Analysis Plan for Key Performance Metrics
Baseline Analysis
All analysis will be done using an intention-to-treat analysis. Baseline patient
characteristics (List A1-3) of enrolled patients in the intervention and control groups within
each disease-specific group will be reported using descriptive statistics, mean/SD or
median/IQR for continuous variables and count/percent for categorical as appropriate.
Tests of significance will be performed using t-tests or Wilcoxon rank-sum test for
continuous variables and chi-square or Fisher’s exact test (expected counts < 5) for
categorical variables as appropriate. Two-sided p-value <0.05 will be used to determine
significant differences in baseline characteristics. These analyses are useful not only to
22
assess the comparability of the treatment group but also to describe the sample of subjects
who were enrolled. Test of normality for each variable will be determined using the
Shapiro-Wilk test p-value <0.05. All tests will be two sided and carried out at a
significance level at 5%.
Primary Analysis
The primary key performance metric (List C5) is one-year measurement of hospital
admissions per patient and this will be compared using both Poisson regression and
negative binomial regression analysis. The two models will be compared using Akaike’s
information criterion (AIC) statistics to assess the goodness of fit of both models. If, in
spite of randomization, differences in baseline characteristics are found using bivariate
analytical strategies, these variables will be included in the regression model. Multiple
imputation algorithms will be developed in order to determine values for any missing data
points [Harrell FE. Regression modeling strategies with applications to linear models,
logistic regression and survival analysis. New York, NY: Springer. 2001].
Secondary Analysis
The secondary key performance metrics (List B 1-5 and C 1-4 and 6), which are largely
count measures, will be compared using similar Poisson regression and negative binomial
models. The proportion of patients who die during the project period will be compared for
the intervention and control groups within each disease-specific group using chi-square
tests as well as a logistic regression model, adjusting for any potential confounding
variables as appropriate.
Safety Analysis
An interim safety analysis will be conducted after 6 months from the last primary
assessment of the first 50% enrolled using data from family health team eMRs and
paramedic documentation on Epistry. Interim analysis will be conducted to evaluate the
intervention for issues relating to patient safety predefined as community paramedic noncompliance with specified protocols and physician interventions post-paramedic
assessment (i.e. clinical visits, house calls, changes to the treatment through the feedback
loop between the primary care physician and the community paramedics).
Apriori Subgroup Analysis
Subgroup analyses will be conducted to determine whether any predefined factors modify
the effect of community paramedic interventions on project outcomes: family health team
allocation, socioeconomic status, living alone, immigrant status, age, gender, distance from
clinic and home care utilization.
Economic Analysis
The objective of the economic analysis will be to compare the relative costs and effects of
the community paramedicine intervention with usual care among participating patients.
Since the key performance metrics are hospitalization, ED visits, primary care visits, EMS
23
utilization which can be expressed in monetary terms (e.g., hospitalization cost), we will
convert the outcomes to dollars and analyze the costs of the two groups. No additional data
collection will be required and the total cost for each patient will include the cost of
intervention and the health care costs incurred during the project period (as defined in the
outcome and data collection sections). We will conduct the analysis from the perspective of
public payer using data from the EPIC project.
Quality of Life Analysis
In addition to these quantitative data, the overall health status of enrolled patients will be
assessed using the EQ-5D-5L, a validated approach to measure quality-adjusted life years
(QALY). QALY, a preference-based utility measure, incorporates both length and quality
of life into a single measure. To estimate QALYs we will convert EQ-5D data collected in
the project to a utility score using a validated algorithm so no additional data collection
will be required. The community paramedics will obtain this information from both the
intervention and control patients through an in-person interview or over the phone at the
convenience of the patient.
How Will Performance Be Monitored And Evaluated?
The web based interface that is being used to capture data also generates reports with the
click of a button on the website. This allows Rescu staff access to the data to monitor data
quality and timeliness, observe for safety and the immediacy of providing written reports
on progress. Evaluation of study progress will be judged against the protocol timelines as
specified by the MOHLTC (now,<3 months, by 12 months)
Reporting schedule is:
Daily: Rescu staff and investigators will monitor data entry for quality and timeliness,
project implementation
Weekly: Rescu staff will provide the EMS Supervisor overseeing the community
paramedics and the community paramedics a report for data completion and quality, and
progress in terms of enrolment, implementation of the intervention on time and compliance
with the protocol and safety issues.
Monthly: Rescu staff will report on all key performance metrics listed in section A and B
to all the core team members and all stakeholders/partners. The results are posted on the
Rescu website as well such that if core members or stakeholders/partners are unable to
attend the monthly webinar and teleconference they will have access to the key
performance metrics.
At 12 months: Rescu staff will report on all key performance metrics to the EMS Chief to
submit to the MOHLTC.
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Section 8: Sustainability Plan
Implementation Readiness:
Now
What Potential Funding Sources Have Been Explored or Identified?
Grey County EMS will work with local and regional health care providers to ensure that
the action plan is clearly aligned with provincial and LHIN priorities. The outcome of the
study will ensure that the seeking of additional funding for ongoing delivery of the
programs will be justified and defendable. Opportunities will include seeking funding
from the Southwest LHIN, CCAC and FEDEV. In the event that additional funding is not
found post study, Grey County EMS will transition the dedicated community paramedic
positions to active duty thus allowing the community paramedics to continue to provide
project services during down time. Grey County EMS is primarily a low call volume
provider with ample downtime to allow for continued participation post study.
The project evaluation team at the University of Toronto has applied for evaluation funding
for this project from the Canadian Institute of Health Research (CIHR) Partnerships for
Health System Improvement Grant. The Ministry of Health has identified our application
to CIHR as a high priority and offered a small collaborative grant ($75,000) on the
condition that we are successful in our CIHR funding application.
Are There Any Funding Commitments From Other Partners That Could Help
Sustain The Proposed CP Activity?
While the evidence supporting community paramedicine is promising and the call for
action loud and clear there has yet to be a convincing project that has evaluated the impact
of community paramedicine on the health outcomes, and health system utilization costs
associated with patients diagnosed with chronic disease. The only published randomized
trial had methodological flaws and was not sufficiently convincing to change practice. It is
expected that EPIC will be able to provide credible answers regarding improving health
outcomes and cost savings for patients with chronic diseases that if positive will transform
health care delivery to these complex patients. Moreover, the project will measure the
improvement in the existing health system, both in time and cost, by delivering quality
patient care at the non-acute level. EPIC will provide decision makers and policy makers
with the evidence necessary to inform policy and program creation at several levels of
health care. A cost effectiveness and outcome evaluation of key performance indicators
important to the system of care should provide the municipalities and the provincial
government with the highest level of evaluation to make decisions to reallocate existing
funding to Community Paramedicine if the intervention works.
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What are the Risks and Mitigation Strategies to Ensure Sustainability?
The potential for cost savings and mitigation of anticipated changes to health care demands
and delivery were stated previously in the section under needs assessment and reiterated
here as it applies to sustainability as well. The importance of exploring municipal and
local needs for expanded paramedic scope of practice has been recognized by EMS
agencies, municipal councils and a number of Government organizations. EMS agencies in
southern Ontario have observed a significant increase in patient transports over the last 10
years. The demand for paramedic services continues to increase at a faster rate than
population growth and this number is expected to increase by as much as 48% over the
next 10 years is projected to address the anticipated change in demographics; placing a
significant demand on EMS systems. Without a change in EMS delivery, paramedic
services will be unable to keep pace placing unprecedented pressure on our health care
system. Patients with chronic diseases utilize 911 resources at high rates, accounting for
25% of all patient transports. In order to combat the expected increase in demand for 911
emergency resources it is imperative that patients with chronic diseases are effectively
managed prior to the development of disease-related exacerbations. Many of these
anticipated changes in health care demand could be mitigated in part by community
paramedicine programs as part of an integrated system.
The simplicity of the intervention means that, if proven useful, community paramedicine
could easily expanded using the EPIC protocol of education and implementation to other
EMS services and integrated within existing community health care teams. High-volume
paramedic services could continue to employ dedicated community paramedics funded
through other projects or use medics on modified duties who would still be able to
physically perform house calls. Currently 10% or more of paramedics are on modified
duties at one time who could be re-focused to apply community paramedicine interventions.
Lower volume services could use down time when there are no 911 calls in order to
provide paramedic house calls. Current EMS deployment models suggest that 20% of peak
and 10% of weekly staff hours could be refocused on community paramedicine booked
appointments and maintain EMS performance standards.
Given the simplicity of the model, building on existing EMS and family health
infrastructure, we foresee this intervention being easily scaled up for application in other
health populations, regions and care models without additional costs through redirection of
currently allocated resources. Using an EPIC model of training, medical directives,
oversight, eMR connectivity could easily be expanded to cover a broader range of health
conditions and populations of individuals. In fact the risks to the program are a function of
its success within the local community. Local community enthusiasm to expand EPIC
prior to the end of the project could have the potential to distract the intervention teams in
each service from the rigorous implementation strategy required to complete EPIC. During
the feasibility trial in York Region, 3 more Primary Health Care Teams have approached
the EMS service to include their DM, COPD and CHF patients in the EPIC project and we
26
have been able to deploy our modular launch strategy in under 6 weeks to facilitate
expansion of the local program. However other requests for expansion may be challenging.
The Central CCAC has recognized how complementary the program is to their services
and York EMS and Rescu are now receiving direct referrals from CCAC to include in the
program. The CEO of the local hospital has a list of multi visit patients that could be
included in the project as well. Both of these requests are mitigated by referring their
patients to the Primary Health Care teams in EPIC and enrolling the patients through the
working practices outlined in the EPIC project. The Mental Health team may see the
success in three chronic disease states and want to add a training module and a medical
directive to address chronic mental illness in the community. Or alternatively nonambulatory patients with end stage disease, or chronic disease from other disease states not
being addressed in EPIC may be referred to the EMS chief in hopes of expanding the
project. We mitigate the potential for risk to completing EPIC through ensuring the
referring partners are aware that our focus is implementing the EPIC project well within
the community and proving it works which will go a long way towards the sustainability of
Community Paramedicine. Once EPIC is done well in the community, it has proven in
York to be the catalyst to other opportunities and funding sources. Everyone involved
from the patients to the partners, becomes the best advocates for EPIC. It is a simple
extension of the EPIC model to work with partners to cover the gamut of patients not well
served by the current system.
Section 9: Established Governance and Accountability
Implementation Readiness: Now
What Is The Governance Structure For The Proposed CP Activity?
How Will The Governance and Accountability Structures Ensure That All Proposed
CP Activities Fall Within Current Legislative Parameters?
EPIC uses a chronic care model in which paramedics provide care under the delegation of
the patient’s primary care physicians. This oversight is important as the Primary Health
Care physician can ensure the integration of this intervention in addition to current
community resources. The EPIC project has multiple levels of governance and quality
review to ensure the safety and accuracy of the intervention being provided. Primary care
physicians will provide community paramedics with medical delegation outlined in the
EPIC medical directives (Appendix B). The medical directives were developed by
basehospital medical directors, primary health care physicians and ambulatory medicine
and specialty physicians. All medical directives are signed off by the primary care
physicians from participating family health teams. In the planning stages for EPIC the
Provincial Medical Advisory Board and Emergency Services Branch of the MOHLTC
were approached to review the EPIC medical directives however it was decided the
27
proposed intervention in EPIC was outside the scope of Emergency Services and Base
Hospital oversight. Thus EPIC is based on medical delegation by the primary care
physician similar to palliative nurses and CACC nursing staff; thus CPSO compliant.
Every participating Primary Health Care physician in the Primary Health Care team signs
off on all the medical directives similar to the Base Hospital medical directive sign off that
is occurring currently for emergency services. In addition, community paramedics have
the ability to call Primary Health Care physicians while at the patient’s home to discuss the
patient’s condition, treatment options and for clinical advice and orders to provide
treatment or diagnostic interventions within the limitations of their medical directives. All
data regarding the patient visit is entered into the eMR (provincial approved software
solutions) of the Primary Health Care team by the paramedic at the time of patient care and
this data is immediately uploaded and linked to the Primary Health Care Team server. The
Primary Health Care physicians review the documentation and treatment encounter within
the required 24 hours. This ensures timely communication and a measure of safety that is
appreciated by the providers, the patients and the Primary Health Care physician. The
project is PHIPA compliant and approved by the Research Ethics Board at the primary
destination hospital in the community as well as the St Michael’s Hospital, where Rescu is
located. High risk eligible patients are initially invited to participate in the project by their
primary treating physician which maintains the circle of care. They complete a response
card indicating their preference to participate or not in the project. Once they have agreed
to participate the paramedic carefully reviews the consent with the patient at the baseline
assessment visit and a signature is obtained and the consent is uploaded and stored on the
Rescu Server with all the other project data.
Section 10: Ensuring that there is no Interference with Emergency
Response
Implementation Readiness: Now
Is There A Risk That The Proposed CP Activity Could Interfere With The Core
Business Of Providing Emergency Response?
The community paramedic role is independent of and will not interfere with the core
business of providing emergency response for the participating EMS service. The
community paramedic is a paramedic with additional training in chronic disease
management strictly employed to provide care to enrolled patients in the EPIC project. The
community paramedics are not taken out of service or detracted from the car count that is
available to provide emergency 911 responses. All day-to-day activities involved in
providing emergency coverage to the region will remain identical as prior to the
implementation of the community paramedicine program in accordance with local policy
and government legislation.
At least one community paramedic will be on duty daily, including weekends. The
community paramedic will only conduct home visits related to the EPIC project and will
28
not interfere with the emergency medical services’ core responsibility of providing
emergency 911 response to the community. While conducting home visits, the community
paramedics will not receive any emergency calls normally answered by a paramedic on
duty. The only time the community paramedics may receive a call outside of their
scheduled visits would be if a patient enrolled in EPIC personally calls the direct EPIC line
to request a visit for a disease-related exacerbation, at which point the community
paramedic can visit the patient and direct the patient to the most appropriate resource at the
discretion of the physician (activate 911, ED/Hospital, or Family Health Team). If a patient
enrolled in EPIC initiates a 911 call they will receive an emergency response ambulance as
per local guidelines, and 911 responses to patients involved in EPIC will not be affected by
the patients’ enrollment in the project.
29
Section 11: Funding Requested
Implementation Readiness: Now: Ready to receive funds
Cost Breakdown: ( maximum of 100 patients in treatment and 100 patients in control) per EMS service/region
Paramedic Team
Item
Supervisor
Community Paramedic 1
Community Paramedic 2
Year 1
Salary+Benefits
$130,000
$109,000.00
$109,000.00
Equipment
Item
Vehicle – unmarked SUV
(vehicle capitalized costs/1 year)
iSTAT
Initial purchase and verification
iSTAT
monthly costs/maintenance
Cell phones for onsite visits
Computers lap tops for onsite visits
General Equipment Bags and Sets
EMS Supplies (test strips, drugs)
Supplies:
Postage / courier costs / Scanning
Year 1
Monthly
TOTAL COST
FTE
0.2
1
1
Total
$109,000
$109,000
Subtotal
In-kind
$109,000
$109,000
$218,000.00
TOTAL COST
Total Months Total
In-kind
$12,325.00
$12,325.00
$12,325.00
$300.00
12
$3,600.00
$3,600.00
$60.00
$3,500.00
12
$720.00
$3,500.00
$720.00
$3,500.00
In-kind
$3,000
$1,200
Subtotal
Total EMS Costs
Research Costs - Rescu
Administration oversight, trial
coordination, data management,
analysis, report generation.
TOTAL Per EMS Service
$24,345
$242,345
$57,580
$299,925
Section 12: Additional Information
30
Section 13: List of Appendices for EPIC
Appendix A –EPIC Curriculum
Appendix B – EPIC Medical Directives
Appendix C – EPIC Case Vignettes
Appendix D – Letters of Support
- CEO LHIN (to be received)
- CEO Destination hospital
- ED Chief Destination hospital
- CCAC Director
- Family Health Team Lead (to be received)
31
Appendix A –EPIC Curriculum
CENTENNIAL COLLEGE
Expanding Community Paramedicine in the Community
Curriculum Synopsis
Prepared for
John O'Donnell
(A) - Chief
Hastings-Quinte Emergency Medical Services
111 Millennium Parkway
Belleville, Ontario K8N 4Z5
613-771-9366 ext 224 (office)
613-332-7051 (cell)
613-771-9370 (fax)
CONFIDENTIAL
32
Curriculum Synopsis
The EPIC community paramedicine immersive curriculum focuses on safe primary and
community health care, effective communication and the further development of clinical
reasoning while emphasizing and supporting patient advocacy and safety.
Using didactic
instruction, simulation based practice and focused clinical placements, this specialized program
provides existing paramedics with foundational knowledge, additional assessment, procedural
and clinical reasoning skills necessary for a community based paramedic program that focuses
specifically on congestive heart failure (CHF), chronic obstructive pulmonary Disease (COPD)
and diabetes.
Competencies
Foundations
F1
F2
F3
F4
F5
F6
Describe and integrate into assessment and care plans the physiology
related to CHF, COPD, and DM.
Describe and integrate into assessment and care plans the specific
pathophysiology, related manifestations and implications related to CHF,
COPD and DM.
Describe and integrate into assessment and care plans the role of
comorbidities and their influence on CHF, COPD and DM.
Identify new or progressing complications associated with COPD, CHF and
Diabetes.
Identify and understand the risk factors associated with CODP, CHF and
Diabetes.
Describe and integrate into assessment and care plans the specific
pathophysiology, related manifestations and implications related to chronic
renal failure.
Communication
C1
C2
Demonstrate therapeutic, effective and accurate verbal, non-verbal and
written (EMR) communication with patients and an interdisciplinary
team.
Apply effective interpersonal skills for developing and working within an
interdisciplinary team.
Assessment and Diagnostics
AD1
AD2
AD3
AD4
AD5
Accurately elicit, interpret and integrate relevant health, social and
lifestyle information and perspectives from patients, family and an
interdisciplinary team.
Elicit a complete history for a patient suffering from Diabetes, interpret
findings and integrate into a care plan.
Elicit a complete history for a patient suffering from CHF and interpret
findings and integrate into a care plan.
Elicit a complete history for a patient suffering from COPD and interpret
findings and integrate into a care plan.
Conduct a thorough cardiovascular physical and lab assessment, interpret
33
AD6
AD7
AD8
AD9
findings and integrate into a care plan.
Conduct a thorough respiratory physical and lab assessment, interpret findings
and integrate into a care plan.
Conduct a thorough physical and lab assessment for a patient suffering from
diabetes, interpret findings and integrate into a care plan.
Elicit a complete history for a patient suffering from abdominal discomfort
and interpret findings and integrate into a care plan.
Conduct a thorough abdominal physical and lab assessment, interpret findings
and integrate into a care plan.
Therapeutics
T1
T2
T3
T4
T5
T6
Interpret ECG results and relate them to the patients current medical
issue.
Identify indications for spirometry, interpret findings and integrate into a
care plan.
Identify indications for and perform point of care testing (using iSTAT),
interpret findings and integrate into a care plan.
Identify indications for and perform urine dip and analysis, interpret
findings and integrate into a care plan.
Identify indications for and perform delayed fluid administration and
integrate into a care plan; conduct follow up assessments, interpret findings
and integrate into subsequent care plans.
Identify indications for and integrate into a care plan, insulin sliding scales;
conduct follow up assessments, interpret findings and integrate into
subsequent care plans.
Pharmacology
P1
P2
P3
P4
Describe the pharmacology, including pharmacodynamics,
pharmacokinetics and potential interactions of medications listed in the
EPIC medical directives.
Identify indications, contraindications, considerations, dosing and
administration parameters for medications listed in the EPIC medical
directives.
Select the appropriate medication, integrate into a care plan and safely
administer medications listed in the EPIC medical directives.
Assess the effectiveness and any potential adverse effects of medication
administration and revise care plans as needed.
Integration
I1
I2
I3
I4
Demonstrate effective critical thinking and clinical problem solving skills
to assess and treat patients suffering from COPD, CHF and Diabetes.
Utilize differential diagnosis to determine a working diagnosis.
Develop and implement a care plan for patients suffering from COPD, CHF or
diabetes in collaboration with the patient, family and an interdisciplinary team
and social determinants of health.
Assess and interpret the effectiveness of care plans in collaboration with a
multidisciplinary team.
34
I5
I6
I7
Develop and implement follow-up care plans in collaboration with the
patient, family and a multidisciplinary team.
Identifying varying degrees of distress in patients from CHF, COPD and
Diabetes.
Differentiate between patients requiring CP intervention and those requiring
EMS transport.
Health Promotion
HP1
HP2
HP3
HP4
Identify opportunities for advocacy, health promotion and
disease prevention.
Identify and integrate into assessment and care plans, indicators
of social determinants of health.
Provide patient and family education integrating a
multidisciplinary team and utilizing appropriate adult education
theory and principles.
Demonstrate knowledge and understanding of the psychosocial
influences related to chronic diseases, in specific CHF, COPD
and DM.
Course Learning Outcomes
Pathophysiology and Pharmacology Outcomes
The student will reliably demonstrate the ability to:
1. Explain the underlying physiological processes that govern the cardiovascular, endocrine
system as it relates to control of blood sugar and stress and the respiratory system.
2. Describe the etiology, pathogenesis, clinical manifestations, diagnostics and
pharmacological treatment modalities for hypertension, atherosclerosis, arteriosclerosis,
heart failure, diabetes mellitus and COPD.
3. Analyze diagnostic values and explain the underlying pathophysiological mechanisms.
4. Discuss the service protocols as they relate to each of the above disease conditions and
provide rationale for each proposed step of the protocol.
5. Identify clinical manifestations and client conditions that are governed by each protocol
and identify client states that are beyond the scope of practice for the community
paramedic.
6. Identify what diagnostics would be indicated for a variety of client conditions related to
the pathological states of diabetes, COPD, hypertension and heart failure.
7. Describe the role nutrition plays in the etiology and treatment for each of the above
pathophysiological conditions.
Health Assessment Outcomes
The student will reliably demonstrate the ability to:
1.
Obtain a comprehensive health history for patients suffering from diabetes, congestive
heart failure and chronic obstructive pulmonary disease
2. Conduct a thorough patient assessment using critical thinking skills and the appropriate
assessment tools to determine differential diagnoses for the respiratory, cardiac,
abdominal and endocrine system.
35
3.
Select, integrate and perform a variety of assessments for the respiratory, cardiac,
endocrine, abdominal, and peripheral vascular systems and disease states while
considering physical, developmental and psychosocial
4. Communicate effectively with patients and family members regarding the proposed care
plan for the patient.
5. Document assessment findings accurately using SOAP to ensure continuity of care across
multiple health care providers
6. Integrate reflective practice into professional development.
Simulation / Lab Outcomes
The student will reliably demonstrate the ability to:
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
Obtain a comprehensive health history for patients suffering from diabetes, congestive
heart failure and chronic obstructive pulmonary disease.
Select, integrate and perform a variety of assessments for the respiratory, cardiac,
endocrine, abdominal, and peripheral vascular systems and disease states while
considering physical, developmental and psychosocial changes across the lifespan
Determine when specific diagnostic tests are required, and propose appropriate strategies
for further investigation.
Use a variety of techniques including urine analysis and point of care testing to help
create a differential diagnosis for each patient.
Select, prioritize, integrate and perform procedurals skills associated with the community
paramedic skill set including IV hydration, insulin sliding scales, antibiotic
administration, and home oxygen devices.
Select and integrate appropriate diagnostic and care techniques into a comprehensive
assessment and care plan for pts suffering from diabetes, chronic obstructive pulmonary
disease and congestive heart failure.
Communicate effectively with patients and family members regarding the proposed care
plan for the patient.
Identify common patient follow-up options and integrate them into care plans.
Produce patient care reports to accurately document patient information, assessment
findings, treatments rendered, and chosen care pathways/follow-ups to ensure continuity
of care across multiple health care providers
Integrate reflective practice into professional development.
Clinical Outcomes
The student will reliably demonstrate the ability to:
1. Communicate therapeutically and professionally with patients, family members,
colleagues and other health care providers to enhance patient health and safety.
2. Conduct a thorough patient assessment using critical thinking skills and the appropriate
assessment tools to determine differential diagnoses for the respiratory, cardiac and
endocrine system.
3. Collaborate with other health care professionals in an interprofessional setting to enhance
patient centered care.
4. Interpret health assessment findings to develop and evaluate treatment and follow-up
plans for patients suffering from congestive heart failure, diabetes and chronic obstructive
pulmonary disease.
5. Document and communicate patient care information using current technology,
legislation, regulations, standards, and best practices for interprofessional care.
36
Curriculum Overview
WEEK 1
Theme
General Assessment/Review
Cardiac
Respiratory
YORK REGION
AM
OPERATIONS
Cardiac 1 and diagnostic test
Cardiac 2 - Alterations in
review -Alterations in Human
Human Body Function;
Body Function; Pharmacology;
Pharmacology; [4 hours]
[4 hours]
Alterations in Human Body
Function; Pharmacology; [4
hours]
PM
OPERATIONS
General Health Assessment Health Assessment
Health Assessment
Diagnostic s and Care
Diagnostic s and Care [lab
[inc lass and lab, 3 hrs]
and inc lass, 3 hrs)
Health Assessment
Diagnostic s and Care [inc lass
and lab, 3hrs]
Adult Educ ation and Health
Promotion
Adult Educ ation Princ iples and
Health Promotion [inc lass, 7
hrs]
WEEK 2
Theme
AM/PM
PM
Endoc rinology / Diabetes
Abdo
Integration of Competenc ies Integration of Competenc ies
Clinic al
Endocrinology and PVD Alterations in Human Body
Function; Pharmacology; [4
hours]
Review - Alterations in Human
Immersive Simulation / Case Immersive Simulation / Case
Body Function; Pharmacology;
[8 hours]
Based [7 hours]
Based [7 hours]
[4 hours]
Endoc rinology and PVD Health Assessment
Diagnostic s and Care
[inc lass and lab, 3hrs]
Abdo and Review - Health
Assessment Diagnostic s and
Care [inc lass and lab, 3 hrs]
WEEK 3
Theme
AM/PM
Integration of Competenc ies
VICTORIA DAY
Clinic al
Immersive Simulation / Case
[8 hours]
Based [7 hours]
Integration of Competenc ies
Immersive Simulation / Case
OPERATIONS
Based [7 hours]
WEEK 4
Theme
AM/PM
Clinic al
Integration of Competenc ies
Clinic al
Immersive Simulation / Case
[8 hours]
Based [7 hours]
[8 hours]
Integration of Competenc ies
Clinic al
Immersive Simulation / Case
[8 hours]
Based [7 hours]
Week 5
Theme
AM/PM
Clinic al
[8 hours]
Integration of Competenc ies
Clinic al
Immersive Simulation / Case
[8 hours]
Based [7 hours]
Clinic al
[8 hours]
OPERATIONS
Week 6
Theme
AM/PM
YORK REGION
OPERATIONS
Assessment of Competenc e
Independent Study Day
OSCE Style Prac tic al Exams
37
Assessment of Competenc e
Written Exams
OPERATIONS
Appendix B – EPIC Medical Directives
CHF
Indications
Exacerbation of Congestive Heart Failure
Conditions
Age _> 18 years
LOA : Unaltered from normal
HR : 60-139 bpm
RR : N/A
SBP: Normotension SBP>100 mmHg
Other: Ascertain PMHx of CKD ( eGFR <60ml/min per 1.73m2) and prior history of
use of Furosemide and Nitrogylcerin
Contraindications
Allergy or sensitivities to Furosemide or Nitrogylcerin.
If SBP decreases by 1/3 of initial value or <100mmHg 1 to 2 hours after initiation of
treatment, discontinue Nitroglycerin.
Treatment
Venipuncture for Pretreatment Blood work
Consider Furosemide
No previous Furosemide use and no PMHx of CKD
RoutePO
Dose 40 mg
Dosing Interval- Daily
Max # of doses- 3
Previous Furosemide use and no PMHx of CKD
RoutePO
Dose 2 x previous chronic dose
Dosing Interval- Daily
Max # of doses- 3
PMHx of CKD
RoutePO
Dose consult with FMD
Dosing Interval- Daily
Max # of doses- 3
Consider Potassium:
Hx of low potassium or Pretreatment Bloodwork with low potassium
RoutePO
Dose consult with FMD
Dosing Interval- Daily
Max # of doses- 3
38
Consider Nitrogylcerin:
No previous Nitrogylcerin use and SBP>140mmHg
RouteTransdermal
Dose 0.2mg/hr patch
Dosing Interval- Daily
Max # of doses- 3
Previous Nitrogylcerin use and SBP>140mmHg
RouteTransdermal
Dose Increase chronic dose by 0.2mg-0.4mg/hr patch to a maximum
of 0.8mg/hr patch
Dosing Interval- Daily
Max # of doses- 3
Clinical Considerations
If patient is in Severe Distress, or has ongoing CP, or arrhythmias, hypoxia– EMS
activation.
If any concerns regarding the clinical stability or suitability of the patient for treatment at
home – FMD consultation.
If the patient has Hypotension, hx of CP, hx of arrythmias, or another disease entity –
FMD consultation.
If patient has social issue – FMD re CCAC/CREMS/FHT referral
COPD
Indications
Exacerbation of COPD
Conditions
Age _> 18 years
LOA : Unaltered from normal
HR : 60-139 bpm
RR : N/A
SBP: Normotension SBP> 100 mmHg
Other: Ascertain history of increased dyspnea, increased sputum volume, or increased
sputum purulence, antibiotic use in the last 3 months and most recent Pulmonary
Function test results including FEV1 if available. Ascertain history of diabetes.
Contraindications
Allergy or sensitivities to Salbutamol, Ipratropium, Prednisone, Clarithromycin,
Cefuroxime, Trimethoprim/Sulfamethoxazole, Doxycycline, Moxifloxacin, or
Amoxicillin/Clavulanate
Treatment
Venipuncture for Pretreatment Blood work
39
Consider Oxygen:
RouteDose -
Nasal cannula
1-6 L/min (FiO2 24% to 44%) to titrate to O2 saturation of 90 to
92% 94%
Max duration- 3 days
Consider Salbutamol:
RouteMDI
Dose and interval 4 puffs QID and 2puffs Q1h PRN
Max # of doses- 8 puffs/ 4 hours and 48 puffs /24 hours for 3 days
Consider Ipratropium:
RouteMDI
Dose and interval 4 puffs QID and 2 puffs Q4h PRN
Max # of doses- 3 days
Consider Prednisone:
RoutePO
Dose 40mg on consultation with FMD
Dosing Interval- Daily
Max # of doses- 3 days
Consider Antibiotic:
Antibiotic selection should be an alternate class to antibiotic used in the last 3
months
Patients with at least two of these three symptoms — increased dyspnea,
increased sputum volume, or increased sputum purulence
RoutePO
Dose Amoxicillin 500mg PO TID or
Clarithromycin 500mg PO BID or
Cefuroxime 500mg PO Q12h or
Trimethoprim 160mg/Sulfamethoxazole 800 mg PO BID or
Doxycycline 100mg PO BID
on consultation with FMD including review of antibiotic use in
the last 3mos
Dosing Interval- Daily
Patients with at least two of these three symptoms — increased dyspnea,
increased sputum volume, or increased sputum purulence and at least one of:
• FEV1 < 50% predicted
• ≥4 exacerbations/year
• Ischemic heart disease
• Use of home oxygen
• Chronic oral steroid use
RoutePO
Dose Moxifloxacin 400mg PO Qdaily or
Amoxicillin/Clavulanate 500mg PO Q8h
on consultation with FMD including review of antibiotic use in
the last 3mos
Dosing Interval- Daily
40
Clinical Considerations
If patient is in Severe Distress – EMS activation.
If any concerns regarding the clinical stability or suitability of the patient for treatment at
home – FMD consultation.
If the patient has any of below –FMD consultation
 Inadequate response of symptoms to outpatient management
 Marked increase in dyspnea
 Inability to eat or sleep due to symptoms
 Worsening hypoxemia compared to baseline
 Worsening hypercapnia compared to baseline
 Changes in mental status compared to baseline
 Inability to Care for oneself (ie, lack of home support)
 Uncertain diagnosis
 High risk comorbidities including pneumonia, cardiac arrhythmia, heart
failure, diabetes mellitus, renal failure, or liver failure
If patient has social issue – FMD re CCAC/CREMS/FHT referral
DM
Indications
Exacerbation of DM in form of hyperglycemia
Conditions
Age _> 18 years
LOA : Unaltered from normal
HR : 60-139 bpm
RR : N/A
SBP: Normotension SBP > 100 mmHg
Other: Ascertain history of increased blood glucose levels and signs and
symptoms of dehydration. Previous glucose control, treatment targets, total daily
insulin use, response to rapid insulin and current carbohydrate intake.
Contraindications
Signs of fluid overload. Allergy or sensitivity to Rapid acting Insulin. Patient has signs
and symptoms consistent with Diabetic Ketoacidosis or Hyperosmolar Hyperglycemic
State or Hypokalemia.
Treatment
Venipuncture for Pretreatment Blood work. Urine dip for ketones.
Consider IV fluids after Potassium level is obtained:
RouteIV
Dose 1L NS on consultation with FMD
Dosing Interval- infusion over 4 to 6 hours on consultation with FMD
Max duration of infusion- 3 days
Consider Rapid Insulin:
RouteSC
41
Dose -
as per Correction Insulin Scale (see below) on consultation with
FMD
Dosing Interval- q Breakfast, Lunch, and Dinner
Max duration- 3 days
Correction Insulin Scale
Choice of Correction Insulin Scale used is patient dependent.
Previous glucose control, treatment targets, total daily insulin use, response to rapid
insulin and current carbohydrate intake should be taken into account for
each patient.
The Low and High Dose Correction Insulin Scales take into account the patient’s
previous sensitivity to insulin. These can be modified by the FMD to suit each
individual patient.
Patient continues to administer their previous insulin doses and type. The use of
the Correction Insulin Scale is in addition a patient’s previous insulin dose.
Correction insulin should always be Rapid acting insulin analogue( Rapid,
Humalog or Apidra)
Blood glucose checked before Breakfast, Lunch, and Dinner.
PreMeal
Glucometry
Blood Glucose
(mmol/L)
14.0 – 15.9
16.0 – 19.9
>20
Additional Rapid Acting Insulin (units)
Low Dose
Algorithm - For pts
requiring less than
or equal to 40 units
of insulin/day
+2
+3
+4
High Dose
Algorithm - For pts
requiring greater
than 40 units of
insulin/day)
+4
+6
+8
Clinical Considerations
If patient is in Severe Distress – EMS activation.
If patient is hypoglycemic, this should be treated as per York EMS Medical Directive (based
on Ontario Provincial Advanced Life Support Patient Care Standards) and EMS activation.
If the patient has signs and symptoms consistent with Diabetic Ketoacidosis or
Hyperosmolar Hyperglycemic State – EMS activation.
If any concerns regarding the clinical stability or suitability of the patient for treatment at home
– FMD consultation.
If patient has social issue – FMD re CCAC/CREMS/FHT referral
42
Appendix D – Letters of Support
43
44
45
46
47
48
Part II – Grey County Community Paramedicine Program (GCCPP)
Section 1: Contact Information for Lead
Mike Muir
Grey County Emergency Medical Services
595 9th Avenue East
Owen Sound, Ontario
N4K 3E3
519-372-0219 ext. 1242
[email protected]
Section 2: Describe the Proposed CP Activity/Activities.
Implementation Readiness: < 3 months
The Types of Services That Will Be Provided Through the Proposed Activity.
Under this proposal, Grey County EMS will further expand and enhance the existing CREMS
program with additional community paramedic programs including:
1) Implement the PERIL Assessment Tool for the CREMS Program
2) Pilot Direct ePCR integration with OACCAC Client Health and Related Information
System (CHRIS)
3) Community Paramedicine In-Home Visits
4) Expand CREMS Program to Include Mental Health and Addictions Referrals
5) Emergency Department High Risk Patient Discharge Follow-up
1. Implement the PERIL Assessment Tool for the CREMS Program.
Since 2009 Grey County EMS has provided a Community Referral by EMS (CREMS) program.
CREMS is available throughout the Grey County provided by Grey County EMS paramedics, 24
hours a day, 7 days per week. The referral service is for patients of any age who frequently call
for EMS services, and others, who would benefit from intervention from community services
such as:




Falls
Diabetics – for linkage, educational assistance
Palliative Care – linkages and professional and support services
General problems with Activity for Daily Living
49



Chronic Conditions – bedridden patients with skin conditions e.g. bedsores, dressing
changes, environmental exacerbation of asthma, CHF, COPD conditions
Cognitive Impairment – services , linkages, day programs
Potential Abuse (elder / financial) – linkages for information / referral
In the spring of 2014 Grey County EMS will be implementing the use of the PERIL scoring of
patients to determine a CCAC referral. Patients with a score of 2/3 or 3/3 will receive an
automatic referral to the CCAC. The PERIL tool is a validated and simple three-item screening
tool that can easily be incorporated into routine practices and allows any paramedic to assess
their patient’s risk of calling 911, being hospitalized, or dying within the next 30 days. Already,
some paramedics in the province are now using the PERIL Risk Assessment Tool to identify
high-risk patients with scores of two or more out of three to determine who should be referred on
for further follow-up in the community through a CREMS Program or other services.
2. Pilot Direct ePCR integration with OACCAC Client Health and Related Information
System (CHRIS).
Between April 2014 and July 2014 Grey EMS will begin using the new provincial standard
Resource Match and Referral (RM&R) eReferral form as agreed upon by all EMS services in
province (March 2014 meeting). The trial will involve an electronic fax from InterDev
Technologies Inc. forwarding to SW CCAC as a one way communication (same process as
current, except different form). At the end of this trial we assume all EMS services will proceed
to send referrals to CCAC using this standard eReferral form template. The standard eReferral
form will include the PERIL Assessment Tool and the Relevant Diagnosis for Referral form.
Between July 2014 and October 2014 a three month trial will begin between SW CCAC, Grey
EMS and Interdev Technologies to transfer eReferral data between the Interdev ePCR and the
CHRIS using the existing Acute Care to CCAC eReferral interface to test electronic referral
between EMS services and CHRIS (technology trial). This 3 month trial will be limited to
InterDev and OACCAC.
3. Community Paramedicine In-Home Visits.
As an expansion of the CREMS program we will include in-home community paramedic visits
resulting from call data surveillance. Patients identified as at risk will include the following:
1) The Patient with a PERIL score of 1 out of the 3 or low risk will be referred to the
community paramedic for an in home assessment.
2) Patient of any age that has utilized EMS greater than two times in the last 30 days.
3) Patients who have required a lift assist and refused transport to the hospital.
4) Patients who have fallen and have refused transport to the hospital.
50
5) Patients who have refused a CCAC referral.
Community paramedics will conduct a home visit and assessment which may lead to a referral to
the CCAC, FHT, local support services, fall prevention program, 310 CCAC and 211.
4. Expand CREMS Program to Include Mental Health and Addictions Referrals.
The Grey County CREMS program would expand its reach to mental health and addictions
patients in the community. We have met with Grey Bruce Mental Health Association and Hope
Grey/Bruce Addiction Services and they have expressed a willingness to accept paramedic
referrals directly to their respective organizations. The current processes in place for community
referrals to CCAC will be incorporated in this new program.
5. Emergency Department High Risk Patient Discharge Follow-up.
Grey County Community Paramedics will work directly with the emergency departments of
GBHS to provide a follow-up program for high risk recidivism patients. The emergency
departments currently provide follow-up services to this patient group. The community
paramedics will provide direct follow-up with the discharged patients. Also included in this
program will be the use of wireless surveillance equipment for monitoring key vital signs.
Future Health Inc. has donated 5 units for use during the program that will be utilized in the
follow-up program.
A List And Description Of The Roles And Functions Of The Core Members Of The Team
Who Will Be Implementing The Proposal, Including The Roles And Functions Of
Community Paramedics.
The core team members for this project are from the EMS Team, OSFHT, GBHS, CCAC, Grey
Bruce Health Unit (Falls Prevention Program), Community Homes Support Services (non
CCAC), Grey Bruce Mental Health Association and Hope Grey Bruce Addiction Services.
Support and endorsement has been acquired from the local and regional partners including
Sandra Coleman, CEO, Southwest CCAC, Sonja Glass, Chief Quality Officer, GBHS, Graham
Fry, Manager of ER, GBHS, Amber Schieck, Health Promoter, Grey Bruce Health Unit, Dave
Roy, Hope Grey Bruce Addition Services, Marie Lerant, Grey Bruce Mental Health Association,
Craig Hennessy, eHealth Lead Southwest CCAC and Joanne Cook, Community Home and
Support Service.
51
Roles and functions of the core team members:
EMS Team
EMS Chief
Chief Mike Muir, of Grey County EMS will be responsible for oversight of all aspects of the
community paramedicine program. The chief will collaborate with the project partners locally
and regionally to ensure that all aspects of the implementation are effective. The chief will
ultimately be responsible for reporting progress to the local, municipality and the MOHLTC
leads.
EMS Project Coordinator
Kevin McNab, Deputy Chief, with accountability for the community medicine portfolio within
Grey County EMS will be responsible for overseeing the operational aspects of the program.
Kevin will be the key contact for all operational issues. Oversight of the community paramedics
working in the program will be the direct responsibility of the EMS Project Coordinator. The
oversight of the OACCAC integration pilot program will be the responsibility of the EMS
Project Coordinator.
Community Paramedics
The community paramedics dedicated to the Grey County Community Paramedic Program
(GCCPP) will carry out the operational functions of the program. Continued paramedic referrals
will be completed by operational staff as per current practice with the use of the new PERIL
assessment tool. Operational paramedics will expand the referral network to include new
partners in the referral circle. The in-home visit community paramedics will come from both the
operational side as well as the dedicated community paramedics participating in the EPIC
program. In-home visit will include follow up with patients refusing an initial CACC or other
program referral. The dedicated community paramedics will also work with GBHS ED staff on
the follow-up of high risk for recidivism patients program. This program will include the
installation of wireless equipment placed in the patient’s home capable of monitoring key vital
signs remotely. Follow-up will occur as part of the program to ensure that the patient has
transitioned to discharge appropriately.
OSFHT
OSFHT will provide electronic resources to allow for follow-up for patients at risk in the
community. Paul Faguy, ED of OSFHT will be the main contact for the program. These include
patients at risk for falls, frequent/extensive users of health care resources, etc.
52
GBHS
Grey Bruce Health Services – ED staff will work closely with the GCCPP in support of the
follow-up of high risk for recidivism patients. Graham Fry, Interim Manager- Emergency and
Dialysis will be the main contact for the program. GBHS will provide training and oversight of
the current follow-up program to the community paramedics. GBHS will also provide ongoing
support and guidance to the community paramedics regarding patient disposition.
CCAC
The CCAC will provide resources to help identify patients at risk in the community that may be
suitable for community paramedic in-home visit. Sandra Coleman, Regional Manager, will be
the main contact for the program. The CCAC also provides the 310-CCAC support number that
links patients with local community support services. Craig Hennessy, eHealth Lead Southwest
CCAC will be the main contact for the ePCR integration with OACCAC Client Health and Related
Information System (CHRIS) project.
Grey Bruce Health Unit (GBHU)
The GBHU will provide assistance with a falls prevention program. They will provide training
and education on fall assessment and prevention for the both the operational paramedics and
dedicated community paramedic providers. Amber Schieck will be the main contact person for
this project.
Community Homes and Support Program (CHSP)
The CHSP will provide an alternative referral program for low to moderate risk patient that do
not qualify for CCAC supports. Examples include Meals on Wheels, In-home Exercise program
and Day Away programs. Referrals will come from both operational paramedics and dedicated
community paramedics.
Grey Bruce Mental Health Association (GBMHA)
The GBMHA will provide additional referral services for patient suffering from mental illness.
Marie Lerant will be the main contact for the program. The GBMHA currently has a Rapid
Response Team consisting of mental health crisis intervention specialists that would be available
throughout Grey County. Referrals will come from both operational paramedics and dedicated
community paramedics.
Hope Grey Bruce Addiction Services (HGBAS)
HGBAS will provide additional referral services for patient suffering from addictions. Dave Roy
will be the main contact for the program. The referral will be made by both the operational
paramedics and dedicated community paramedics.
53
Section 3: Demonstrated Need for the Proposed CP Activity/Activities.
Implementation Readiness: < 3 months
What types of needs assessments have been conducted to determine any local service gaps?
Grey County EMS has completed an analysis of vulnerable populations within the County of
Grey. One of the areas identified was seniors at risk of falls. Since the second quarter of 2013
until March 2014 Grey County EMS tracked 911 calls for patients who had suffered a fall.
During this period of time there have been 400 instances of a fall resulting in a 911 emergency
call. Of these 400 instances 299 were for patients that were greater than 60 years old. Of these
265 patients required transport to the hospital. The findings are similar to that found by the Grey
Bruce Health Unit Falls prevention program which seniors are the fastest growing segment of the
population, meaning the incidence of falls will be increasing. We can assume that by 2017, of the
186,083 population over the age of 65, approximately 62,012 will experience a fall and half of
those will likely experience multiple falls.
The population 65 years of age and older are most prevalent in the central and north regions of
the Southwest LHIN; as a whole, the LHIN has a higher percentage of seniors than the Ontario
Average. Over the next ten years, the population of seniors is expected to increase by 36% in
Grey and Bruce, Huron Perth 31% and in the South by 37% (Statistics Canada – 2006 Census).
Falls are prevalent amongst people over the age of 65 and can significantly change a senior’s
life. Falls have a significant physical, emotional, psychological and financial impact on seniors
and their care providers. The Integrated Provincial Falls Prevention Framework summarized the
literature and highlighted the follow facts:




First and foremost, falls often have a negative impact on the quality of life of seniors
resulting in temporary or permanent disability, change in level of function, loss of
independence, social isolation, and a change in living arrangements; can lead to a host of
other health care issues.
The WHO estimates that 1 in 3 seniors are likely to fall at least once per year.
In 2006, almost half of all injury-related deaths amongst seniors in Canada were caused by
falls
Falls in seniors often lead to avoidable emergency department visits, hospitalizations, and
admissions to long-term care homes. 40% of all nursing home admissions are the result of
falls. (CFPC, 2007)
54

Falls cause 90% of hip fractures and nearly 20 per cent of Canadian men and women over 65
who break a hip die within the first year of the injury. (CFPC, 2007)
Health Unit Region
Rate/100,000
*Huron County HU
Middlesex- London HU
*Grey Bruce HU
*Elgin-St. Thomas HU
*Oxford County PH
*Perth District HU
Ontario
2030.7
1230.7
1792.5
1335.7
1850.3
1493.1
1309.5 (942.6- 2371.5)
Interpreting Data from Grey and Bruce:
13% of death from injuries in Canada are attributed to falls, 19% were related to motor vehicle
deaths
Grey Bruce is 70 % higher falls rate than the Ontario Average (Initial Public Health Report,
2009) Grey Bruce is 35% higher than the Ontario average for individuals over the age of 65.
Falls were the leading cause of injury for the total population in 2000-2001. Among seniors 53%
of injurious falls were caused by slipping, tripping or stumbling (on a non-icy surface) 19% of
seniors indicated that they were injured in fall, said they had slipped, tripped on ice or snow.
The South West Health Region has the highest rate of hip fracture hospitalizations of 670/100
000 and is ranked 5th overall in Canada. (Health Indicators 2007).
There are a number of factors that can be used to explain these variations. Rates are adjusted for
differences in population age structures, however differences may exist in demographic
characteristics, the prevalence of hip fracture risk factors, and patterns of health and illness are
largely a result of the consequences of how individuals live work and play. (Health Indicators
2007).
Some risk factors associated with Hip fractures include:
Age, race, and sex (women over the age of 65+ are at great risk for injury) Falls were the leading
cause of serious injury, accounting for 34% of injuries in males and 43% in females. Formally,
the risk of a fall related injury was highest at ages 12 to 19. For females, the risk by age group
was U-shaped; that is, women aged 80 or older and 12- to 19 year-old girls shared the same rate
of fall-related injury. Factors that increase the risk of hip fractures include:




Low BMI, Low Bone density
Osteoporosis and other related diseases
Co morbid medical conditions
Physical/functional and cognitive impairment
55






Prior fractures and family history
Reduced muscle strength and low level of physical activity
Caffeine use, smoking
Prescript medications
Place and type of residence and quality of care
Type of furniture and presence of staircases (women more likely to be injured at home
and more likely to occur doing chores, for men injury were just as likely to occur at home
as in an athletic facility
Grey County EMS has also completed an analysis of patients who call 911 for a lift assist. These
calls have the potential to lead up to falls that result in patient injury. An intervention for these
patients at the time of the lift assist could prevent a fall with injury in the near future. The other
issue with lift assist patients is that the patient generally refuses transport to the hospital and
never enters the health care system until point of injury.
Statistics for the previous three years are as follows:
2011 – Calls for assistance 149 – Refused transport to hospital 135
2012 – Calls for Lift Assistance 137 – Refused transport to hospital 114
2013 – Calls for Lift Assistance 122 – Refused transport to hospital 108
Have relevant system partners, including Health Links, LHINs, others been involved or
consulted on this analysis?
Grey County EMS has had extensive consultations with our community partners as demonstrated
by the success of our current CREMS program and the projects that we are proposing to include
in our community paramedic program. Letters of support for our proposals also speak to the
level of consultation that has occurred. We have worked closely with community partners
CCAC, GBHS, OSFHT and GBHU to identify where system gaps occur and we believe that the
programs that we are proposing with help to alleviate those gaps.
How could existing, established resources effectively support identified gaps? Please
explain.
The GCCPP will utilize existing resources as we move our program forward. The addition of
dedicated community paramedics will allow the program to operationalize and then evaluate the
effectiveness of the proposed programs in a more controlled setting while we incorporate the
same programs into our EMS operations. There are full intentions to utilize operational
paramedics to deliver many of the proposed services during down or slow times. Our program
will utilize on duty supervisory staff to oversee components of the program with no additional
funding requirements.
56
How will the proposed CP Activities meet these gaps?
Based upon Grey County EMS analysis of EPCR data the community paramedic will follow up
with: a patient with a 1/3 PERIL Score, patient with a history of fall with refusal of transport to
the hospital a patient requiring a lift assist no transport to hospital, a patient who refuses a
CCACC referral or a patient who has utilized EMS great than 2 times in 30 days.
Low to Medium Risk the Community Paramedic will






Utilize Screen Tools to determine low, moderate, high risk
Link to community programs - 211, 310 – CCAC
Refer to FHT, Primary Care Physician
Refer to Grey Bruce Falls Prevention Program
Refer to Mental Health and or Addiction Services where applicable
Consult with SWCCAC if appropriate services cannot be located
High Risk - PERIL 2/3, 3/3, Refer to CCAC
 Referral to SWCCAC for assessment within 24 hours
 Refer to FHT, Primary Care Physician
 Mental Health – direct referral
 Addiction Services – direct referral
Is there support / consensus among local service providers that the proposed CP activity is
advisable to meet the identified gaps?
There is consensus among local service providers, core team members and key
stakeholders/partners that the proposed CP activities meets the identified gaps and addresses the
local health care system needs. Their understanding of the issues and support for this
intervention is well outlined in their letters of support that accompany this application (Appendix
D – Letters of Support). More importantly it is in the best interests of the community to launch a
rigorously measured Community Paramedicine project that has been proven to be feasible in
communities across the county and do it well with the support of the community leadership and
partners. Once this is in place it is easier to continue to collaborate and layer on future targeted
interventions unique to the population; for example non ambulatory complex care patients,
marginalized populations without primary care, mental health, addiction rehabilitation and
palliative care.
57
Section 4: Target Population to be addressed by the Proposed CP Activity.
Implementation Readiness: < 3 months
What Is The Anticipated Volume and Type of Patients/Older Adults Who Will Benefit
From The Proposal?
Local Statistics
In 2013, the Grey County CREMS program completed 50 referrals within the program’s
catchment area. We anticipate that this number will increase as currently, 80% of referrals are
completed by 20% of the operational paramedics. The following chart identifies the number of
call completed in 2013 that could be included in the proposed CP activities:
2013
Call Type
Mental Health
Lift Assist
Fall > 60 y/o
Addictions/Intoxication
TOTAL
Call Volume
302
122
299
165
888
The patients included in the above chart (888) may benefit from the CP activities proposed. As
this patient group is a high user of EMS resources and with CP follow-up and referral, their
reliance on EMS may be reduced.
What Methods Have You Used To Determine The Target Population For This Proposal?
The proposal has relied on extensive consultations with community health care and support
providers to assist with determining the target population. We have analyzed current and
retroactive data to determine call volumes and patient demographics.
A survey conducted in 2010 identified during the implementation of the Grey County referral
program provided insight into the calls for Grey County.
Of the 69 falls related calls: between March 1 2010 and October 30, 2010:




74%, or 51 persons were 75 years of age and older, and 50% were over 85 years of age
55% of falls occurred at home;
14.5% or 10 individuals consented to a referral to CCAC;
36.3% or 25 individuals currently had home support. Comments related to home support
services indicated 11 individuals received support from a retirement home, LTCH or
assisted living situation. The remaining individuals experienced a range of support from
58
cleaning (1) , weekly CCAC service (3) CCAC service 2 – 4X weekly (2) ; unknown
CCAC level of service (3, and one individuals had CCAC service previously but had no
service at the time of the fall.
What Data/Evidence Have You Analyzed To Determine The Service Utilization Patterns
Of This Target Population?
The program has analyzed call volumes, repeat calls, falls studies and community referrals. Of
note, from the analysis, we have identified that many of the repeat callers have already received
CACC referrals; however, we did not have information as to the level of support that the CCAC
was able to provide. This program has reviewed the number volumes of ED visits
How are existing local resources currently servicing this target population?
This target population is currently being served by local resources, however based on call
volumes and other data analysis, the identification and referral of the target population to
appropriate resources is lacking. Many of the patients that would benefit from the enhanced
referral services may reduce their reliance on EMS transport to hospital. The ED high risk
patients currently receive a telephone call for follow-up and under the CP initiative will receive
an in-home visit as well as remote vital sign monitoring.
What are the specific gaps that this proposal will help to address?
The specific gaps that this proposal will address include enhancing the current CREMS program
with the use of the PERIL assessment tool which will benefit additional patients not currently
being referred. There will also be a capture of low to medium risk patients that currently do not
meet the criteria for CCAC referral support services. Mental health and addictions patients will
benefit from the services of the Rapid Response Teams. Falls patients are currently being missed
based on call volumes. Hospital discharge patients with high risk of recidivism will receive an
enhanced level of follow-up with in-home remote vital sign monitoring.
Section 5: Cooperation and Partnerships that Leverage Resources
Implementation Readiness: < 3 months
How Will Existing Resources Support the Implementation of the Proposal?
The proposal (budget and implementation) is designed to maximize existing resources already
employed in the GCCPP and also leverage the dedicated community paramedics utilized in the
EPIC program. This will be achieved through fiscal use of the project funds and development of
new partnerships with Primary Health Care teams in our community, the CCAC, local hospitals
59
and other local community support agencies.
Which Organizations Will Be Partners in the Delivery of the Proposed CP ACTIVITY?
Our core team (outlined in Section 2 of this application) has partnered with the key lead
organizations and stakeholders in our community and they have provided letters of support
(Appendix D):
OSFHT - Paul Faguy, ED of OSFHT will be the main contact for the program.
GBHS - Graham Fry, Interim Manager- Emergency and Dialysis will be the main contact for the
program.
CCAC - Sandra Coleman, Regional Manager, will be the main contact for the program.
- Craig Hennessy, eHealth Lead Southwest CCAC - CHRIS integration pilot oversight.
Grey Bruce Health Unit (GBHU) - Amber Schieck will be the main contact person for this project.
Community Homes and Support Program (CHSP) - Andy Underwood will be the main contact
for the program.
Grey Bruce Mental Health Association (GBMHA) - Marie Lerant will be the main contact for
the program.
Hope Grey Bruce Addiction Services (HGBAS) - Dave Roy will be the main contact for the
program.
By engaging all of the key stakeholders/partners upfront we have already created the necessary
linkages to make this health system innovation possible.
What is the specific role / function of each partner with respect to the proposed CP activity
/ activities?
OSFHT
OSFHT will provide electronic resources to allow for follow-up for patients at risk in the
community. Paul Faguy, ED of OSFHT will be the main contact for the program. These include
patients at risk for falls, frequent/extensive users of health care resources, etc.
GBHS
Grey Bruce Health Services – ED staff will work closely with the GCCPP in support of the
follow-up of high risk for recidivism patients. Graham Fry, Interim Manager- Emergency and
60
Dialysis will be the main contact for the program. GBHS will provide training and oversight of
the current follow-up program to the community paramedics. GBHS will also provide ongoing
support and guidance to the community paramedics regarding patient disposition.
CCAC
The CCAC will provide resources to help identify patients at risk in the community that may be
suitable for community paramedic in-home visit. Sandra Coleman, Regional Manager, will be
the main contact for the program. The CCAC also provides the 310-CCAC support number that
links patients with local community support services. Craig Hennessy, eHealth Lead Southwest
CCAC will be the main contact for the ePCR integration with OACCAC Client Health and Related
Information System (CHRIS) project.
Grey Bruce Health Unit (GBHU)
The GBHU will provide assistance with a falls prevention program. They will provide training
and education on fall assessment and prevention for the both the operational paramedics and
dedicated community paramedic providers. Amber Schieck will be the main contact person for
this project.
Community Homes and Support Program (CHSP)
The CHSP will provide an alternative referral program for low to moderate risk patient that do
not qualify for CCAC supports. Jo-Anne Cook, Programs Director North Home & Community
Support Services Grey Bruce will be the main contact for this program. Examples include Meals
on Wheels, In-home Exercise program and Day Away programs. Referrals will come from both
operational paramedics and dedicated community paramedics.
Grey Bruce Mental Health Association (GBMHA)
The GBMHA will provide additional referral services for patient suffering from mental illness.
Marie Lerant will be the main contact for the program. The GBMHA currently has a Rapid
Response Team consisting of mental health crisis intervention specialists that would be available
throughout Grey County. Referrals will come from both operational paramedics and dedicated
community paramedics.
Hope Grey Bruce Addiction Services (HGBAS)
HGBAS will provide additional referral services for patient suffering from addictions. Dave Roy
will be the main contact for the program. The referral will be made by both the operational
paramedics and dedicated community paramedics.
How were the organizations that will be involved in the delivery of the proposed CP
activity engaged in the development of the proposal?
Partner agencies have been involved in discussions with Grey County EMS regarding the
61
development and submission of the development of the proposals. The mental health and
addictions referral have been in the planning stages since 2013. The work for the deployment of
the PERILS assessment tool started in September 2013 and the pilot for the OACCAC
integration started in December 2013. The proposals for the expanded community paramedic inhome visits, and the ED discharge follow-up programs are current “works in progress” with
dialogue occurring over the past few weeks. Community partners have reached out to us and we
have reached out to community partners.
Is there a plan to share resources among partner organizations and what types of resources
will be leveraged?
All resources to be utilized under the expansion of the GCCPP will be shared between all
participating organizations. Community partners have expressed a keen interest in ensuring that
the expanded scope of the GCCPP is successful and at the same time, very interested in
measuring the outcomes of the various initiatives to be implemented. GBHS and the GBHU
will assist with ongoing support during the operational stages and also assist with data evaluation
upon completion of the trial period.
How will partner organizations stay connected throughout the lifecycle of the project (e.g.
communicate, problem solve, reach consensus on key decisions, etc.)
The core team and representatives from the community support partners are already working
together daily by email and telephone during the development of the proposal. We will develop
a communication strategy during the initial start-up phases of the new programs. It is anticipated
that weekly/monthly update meeting will be the preferred schedule of the participating agencies.
Section 6: Promote Communication among Core Team Members and the
System and Patients
Implementation Readiness: < 3 months
How Were The Core Team Members Identified In The Description Of The Proposed CP
Activity Engaged In The Development Of The Proposal?
All members of the core team were actively involved in the development and collaboration of the
EPIC project in our region. In addition to the core team members outlined in Section 2, we
engaged the following individuals within our community to review the GCCPP project, the target
project and the requirements within our community;
OSFHT - Paul Faguy, ED of OSFHT
62
GBHS - Graham Fry, Interim Manager- Emergency and Dialysis
CCAC - Sandra Coleman, Regional Manager
- Craig Hennessy, eHealth Lead Southwest CCAC - CHRIS
Grey Bruce Health Unit (GBHU) - Amber Schieck, Health Promoter
Community Homes and Support Program (CHSP) - Jo-Anne Cook, Programs Director North
Grey Bruce Mental Health Association (GBMHA) - Marie Lerant
Hope Grey Bruce Addiction Services (HGBAS) - Dave Roy
By engaging all of the key stakeholders/partners upfront we have already created the necessary
linkages to make this health system innovation possible. The proposal was developed with input
from all of the core team members including revisions and final approval.
How Were The Core Team Members Engaged In The Development Of Operational
Processes Relating To The Proposal?
LHIN Lead - Kelli Gillis, Senior Director, System Design and Integration, CEO – review of
submission, comments/feedback and provide LHIN support for GCCPP program.
Health Links Lead – No Health Links in Grey County at present.
Grey County - Brian Milne, Warden – liaison with County Council for support of GCCPP
program.
SW CCAC Lead – Sandra Coleman, CEO - review of submission, comments/feedback and
provide CCAC support for GCCPP program.
- Craig Hennessy, eHealth Lead Southwest CCAC – CHRIS – development of software
integration for direct CCAC referral into CHRIS.
ED GBHS – Dr. Cornelius Van Zyl - review of submission, comments/feedback and provide
GBHS support for GCCPP program. Development of patient discharge follow-up program.
GBHS - Sonja Glass, Chief Quality Officer - review of submission, comments/feedback, needs
analysis data review, program support for clinical placement during paramedic training, access to
eMR.
63
GBHS – Jane Wheildon - review of submission, comments/feedback, needs analysis data review,
program support for clinical placement during paramedic training, access to eMR.
GBHS – Graham Fry - review of submission, comments/feedback, needs analysis data review,
access to eMR. Development of ED discharge follow-up program.
GBHS – Robyn Dykeman - review of submission, comments/feedback, needs analysis data
review, access to eMR.
Grey Bruce Health Unit – Amber Schieck - review of submission, comments/feedback and
provide Health Unit support for Falls program.
Base Hospital Physician – Dr. Don Eby and Dr. Mike Lewell reviewed submission,
comments/feedback.
Grey Bruce Mental Health Association (GBMHA) - Marie Lerant, review of submission,
comments, feedback.
Hope Grey Bruce Addiction Services (HGBAS) - Dave Roy, review of submission, comments,
feedback.
Grey County EMS – Wendy Bieman, Deputy Chief Quality Assurance review of submission,
comments/feedback, management support, training support, Quality Assurance support.
Grey County EMS – Jeff Adams, Duty Supervisor review of submission, comments/feedback,
operational support, equipment/supplies, vehicles, etc.
What Mechanism Has Been Established To Promote Timely Communications And
Information Sharing Among Core Team Members Of The Team And The System And The
Patients?
The core team and representatives from the community support partners are already working
together daily by email and telephone during the development of the proposal. We will develop
a communication strategy during the initial start-up phases of the new programs. It is anticipated
that weekly/monthly update meeting will be the preferred schedule of the participating agencies.
Most of the work in this area will be developed as part of the expansion of the program.
64
The following table includes a sample of how information will be shared between partner
agencies.
Project Team Communications
Identify anticipated information needs of steering committee, project sponsor, and project
manager, team members, working groups, partners, stakeholders and others. List strategies
for ensuring that right information is provided to right audience in most suitable and timely
manner. Be sure to identify format and frequency of communication between the project
manager and project sponsor regarding project status, performance, risks, issues, etc.
Audience
Information Needs
Format & Timing
Responsible
To whom? List
recipients of the
information.
What? State what
information will be
communicated?
How? When? How
often? Explain
method and
frequency.
Who? Identify who
will provide
information.
South West
LHIN
Report to the LHIN
statistical data on various
indicators as identified by
the project charter
 Quarterly
 Final Report
 South West
CCAC (Shirley
Koch/Nancy
Dool-Kontio)
 Project
Coordinator
 Quarterly
 Final Report
 Minutes from
meetings
 Project
Coordinator
 Quarterly
 Final Report
 Minutes from
meetings
 Project Lead
Progress reports and
Contribution to the Final
Report
Report Status of work plan
activities (quarterly)
CCAC
Report to the CCAC
statistical data on various
indicators as identified by
the project charter
Progress reports and
Contribution to the Final
Report
Report Status of work plan
activities (quarterly)
Primary Health
- Family Health
Teams,
Community
Health Centres,
GP’s
Report to the FHTstatistical
data on various indicators as
identified by the project
charter
Progress reports and
Contribution to the Final
65
Report
Report Status of work plan
activities (quarterly)
Paramedic
Service
Departments
Report to the County
statistical data on various
indicators as identified by
the project charter
 Quarterly
 Final Report
 Minutes from
meetings
 Project Lead
 Monthly
 Quarterly
 Final Report
 Grey County
EMS
 Project Lead
Progress reports and
Contribution to the Final
Report
Report Status of work plan
activities (quarterly)
South West
CCAC
Work with CCAC to report
on statistical data on various
indicators as identified by
the Project Charter
Progress reports and
contribution to the Final
Report and evaluation
Project Partners
(as established
during
initiative)
Program and project updates
 Quarterly
 Final Report
 Minutes from
meetings
Project
Stakeholders
Program and project updates
 Quarterly
 Project Lead
 Minutes from
meetings
 Annual Newsletter
66
External Communications
Identify anticipated plan for communicating project status, performance, risks, issues, etc. to
external audiences (e.g., public, other health service providers, provincial government). List
strategies for ensuring that right information is provided to right audience in most suitable
and timely manner. Be sure to identify format and frequency of communication.
Audience
Information
Format & Timing
Responsible
To whom? List What? State what
recipients of the information will be
information.
communicated?
How? When? How
often? Explain method
and frequency.
Who? Identify who
will provide
information.
Public
Ongoing program success
and challenges
 Variety of media
venues: both
traditional and social
media
 Civic proclamation
of November Falls
Prevention Month
 Project
coordinator
 Governance Hub
leads within
defined LHIN
boundaries
Public
Leveraging aligned
services and available
resources and how to
access
 News release, PSA
as needed
 Website tools and
resources page
 Project Lead,
Relevant Health
service providers
and field experts
 Governance Hub
leads within
defined LHIN
boundaries
Specific health
care providers
Leveraging aligned
services and available
resources and how to
direct seniors to access
 In-service
 Presentations to
relevant committees
and key network
providers
 Regular email
communication and
network updates
(monthly)
 Webinars and
teleconference
 Project Lead,
Relevant Health
service providers
and field experts
 Governance Hub
leads within
defined LHIN
boundaries
 In-service
 Newsletter
(Annually)
 Dissemination
through networks
(monthly)
 Project Lead,
Relevant Health
service providers
and field experts
 Governance Hub
leads within
Best Practice Resources
Training in resources and
tools through CREMS
online training (website)
Finding Balance Ontario
Website
Primary health
Training in resources and
tools
Best Practice Resources
Finding Balance Ontario
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Health care
facilities /
organizations
implementing
programs and
providing
services
Website
 Webinars /
teleconference
Best Practice Resources
 Newsletter (annually)  Project Lead,
Relevant Health
 Attendance on
service providers
appropriate
and field experts
committees

Governance Hub
 Dissemination
leads within
through networks
defined LHIN
(monthly)
boundaries
 Webinars /
teleconference
defined LHIN
boundaries
Section 7: Tracking and Monitoring Key Performance Metrics
Implementation Readiness: < 3 months
What Are The Anticipated Results And Timing For Achieving Them?
The goal of the expansion of the GCCPP will be to decreasing alternate level of care usage in
hospitals, improving patient co-ordination and system navigation, improving patient local home
supports and increasing overall patient satisfaction. It is anticipated that the results will be seen
between month 6 and month 12 of the project’s duration.
The primary method for tracking outcomes will be through the development of key performance
indicators. Tracking of key performance indicated will be developed by the community partners
during the initial start-up phases of the project.
What Mechanisms Has Been Established For Tracking Key Performance Metrics?
The GCCPP builds on existing measurement tools currently available within EMS, family health
CCAC and the hospital. The following data sources will be used to gather data for the key
performance indicators and economic analysis:
1.
2.
3.
4.
5.
6.
EMS ePCR Data
Family Health Team eMR data
Inpatient data abstracted from medical records
Patient care records from the local EMS service
CCAC CHRIS data
ED eMR or paper documentation stored at the destination hospital
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Are The Core Members Of The team/Partner Organizations Supportive of this
Mechanism?
The partner organizations are supportive of this application and the key performance metrics.
Their letters of support are stored in Appendix D of this application.
How Will Data Be Collected Across Multiple Sectors (EMS, CCAC)?
It is anticipated that will be collected from multiple agencies during the duration of the program.
All data gathered will be reviewed by program partners for accuracy.
What Type Of Quantitative and Qualitative Information Will Be Collected That Will
Demonstrate The Following Outcomes?
Both qualitative and quantitative information will be collected. Quantitative will include number
of referrals performed by operational and community paramedics, repeat calls, reduction/increase
in 911 activated calls, improved health outcomes, improved access to home supports and other
health care supports. Qualitative will include patient satisfaction surveys and an evaluation of
cost savings as a result of the program successes.
Section 8: Sustainability Plan
Implementation Readiness: < 3 months
What Potential Funding Sources Have Been Explored or Identified?
Grey County EMS will work with local and regional health care providers to ensure that the
action plan is clearly aligned with provincial and LHIN priorities. The outcome of the project
will ensure that the seeking of additional funding for ongoing delivery of the programs will be
justified and defendable. Opportunities will include seeking funding from the Southwest LHIN,
CCAC and FEDEV. In the event that additional funding is not found post study, Grey County
EMS will transition the dedicated community paramedic positions to active duty thus allowing
the community paramedics to continue to provide project services during down time. Grey
County EMS is primarily a low call volume provider with ample downtime to allow for
continued participation post program.
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Are There Any Funding Commitments From Other Partners That Could Help Sustain The
Proposed CP Activity?
While the evidence supporting community paramedicine is promising and the call for action loud
and clear there has yet to be a convincing project that has evaluated the impact of community
paramedicine on the health outcomes, and health system utilization costs associated with patients
diagnosed with chronic disease. A cost effectiveness and outcome evaluation of key performance
indicators important to the system of care should provide the municipalities and the provincial
government with the highest level of evaluation to make decisions to reallocate existing funding
to Community Paramedicine if the intervention works.
What are the Risks and Mitigation Strategies to Ensure Sustainability?
The potential for cost savings and mitigation of anticipated changes to health care demands and
delivery were stated previously in the section under needs assessment and reiterated here as it
applies to sustainability as well. The importance of exploring municipal and local needs for
expanded paramedic scope of practice has been recognized by EMS agencies, municipal councils
and a number of Government organizations. EMS agencies in southern Ontario have observed a
significant increase in patient transports over the last 10 years. The demand for paramedic
services continues to increase at a faster rate than population growth and this number is expected
to increase by as much as 48% over the next 10 years is projected to address the anticipated
change in demographics; placing a significant demand on EMS systems. Without a change in
EMS delivery, paramedic services will be unable to keep pace placing unprecedented pressure on
our health care system. Patients with chronic diseases utilize 911 resources at high rates,
accounting for 25% of all patient transports. In order to combat the expected increase in demand
for 911 emergency resources it is imperative that patients with chronic diseases are effectively
managed prior to the development of disease-related exacerbations. Many of these anticipated
changes in health care demand could be mitigated in part by community paramedicine programs
as part of an integrated system.
The simplicity of the intervention means that, if proven useful, community paramedicine could
easily expanded using the GCCPP methods implemented during the program expansion and
implemented to other EMS services and integrated within existing community health care teams.
High-volume paramedic services could continue to employ dedicated community paramedics
funded through other projects or use medics on modified duties who would still be able to
physically perform house calls. Currently 10% or more of paramedics are on modified duties at
one time that could be re-focused to apply community paramedicine interventions. Lower
volume services could use down time when there are no 911 calls in order to provide paramedic
house calls. Current EMS deployment models suggest that 20% of peak and 10% of weekly staff
hours could be refocused on community paramedicine booked appointments and maintain EMS
70
performance standards.
Given the simplicity of the model, building on existing EMS, family health infrastructure and
other community supports, we foresee these interventions being easily scaled up for application
in other health populations, regions and care models without additional costs through redirection
of currently allocated resources.
Section 9: Established Governance and Accountability
Implementation Readiness: < 3 months
What Is The Governance Structure For The Proposed CP Activity?
The governance structure for the expansion of the existing CP programs falls under the existing
community paramedic program provided by Grey County EMS. Grey County Council will
provide final approval for the expanded program via resolution.
How Will The Governance and Accountability Structures Ensure That All Proposed CP
Activities Fall Within Current Legislative Parameters?
All aspects of the expanded GCCPP fall within the current legislative parameters. The GCCPP
does not have an expanded scope of practice requiring additional licensing or medical direction.
Section 10: Ensuring that there is no Interference with Emergency Response
Implementation Readiness: < 3 months
Is There A Risk That The Proposed CP Activity Could Interfere With The Core Business
Of Providing Emergency Response?
The GCCPP will utilize both operational and dedicated community paramedics. Operational
paramedics are currently providing CREMS services as part of their regular duties and it is
anticipated that the expansion will not hamper their ability to respond to emergency calls. The
dedicated community paramedics are independent of and will not interfere with the core business
of providing emergency response for the participating EMS service. All day-to-day activities
involved in providing emergency coverage to the county will remain identical as prior to the
implementation of the community paramedicine program in accordance with local policy and
government legislation.
At least one dedicated community paramedic will be on duty daily, including weekends. The
community paramedic will only conduct home visits related to the GCCPP project and will not
71
interfere with the emergency medical services’ core responsibility of providing emergency 911
responses to the community. While conducting home visits, the dedicated community
paramedics will not receive any emergency calls normally answered by a paramedic on duty.
Section 11: Funding Requested
Implementation Readiness: Now
Funding for Part II – Grey County Community Paramedic Program is primarily “in-kind”.
Dedicated paramedics
Paramedic Team
Item
Supervisor
Year 1
Salary+Benefits
Equipment
Item
Vehicle – unmarked SUV
(vehicle capitalized costs/1 year)
General Equipment Bags and Sets
Year 1
Monthly
TOTAL COST
FTE
Total
In-kind
TOTAL COST
Total Months Total
In-kind
Subtotal
Total EMS Costs
TOTAL Per EMS Service
MOHLTC contribution
In-kind
$0
$0
$0
Section 12: Additional Information
72
Section 13: List of Appendices for GCCPP
Appendix A – Letters of Support
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
100
Emergency Medical Services
595 9th Avenue East, Owen Sound Ontario N4K 3E3
519-376-2228 / 1-800-567-GREY / Fax: 519-376-3706
Dear Don Eby:
Community Paramedicine (CP) refers to a broad and developing field of paramedic
practice focused on proactive and non-emergent activities (within the scope of a
paramedic) that better influences health outcomes. CP allows Paramedics to apply their
training and skills in “non-traditional” roles, largely outside the usual emergency response
and transportation to the emergency department. One of the key recommendations to the
Minister of Health by Dr. Samir Sinha, in his report, Living Longer, Living Well states:
In addition, Grey County EMS identified areas for their priority development:
 Decreasing ALC usage in hospitals

Improving their patient co-ordination and system navigation

Improving their patient local home supports
CP has a role to link with and facilitate each of these program goals. While these programs
include unique elements shaped by local needs and support systems, four broad elements
have become common to them:
 Strong Partnerships with local community services providers to help connect
patients to additional home care or community supports.

Patient Assessments by Paramedics responding to or following-up on 911 calls.
101
Application Declaration
102
An
103
104
105
106
107
108
Applicant declaration, below, should be attached to the application.
On behalf of and with the authority of the Applicant, I/we:
1. Certify that the information that the Applicant has supplied in support of its
application is true, correct, and complete in every respect.
2. Certify that the proposed CP activity does not interfere with core emergency
response and service delivery.
3. Agree that if this Application to deliver a community paramedicine initiative is
selected, the Applicant will agree to amend any applicable Service Accountability
Agreement or other relevant funding agreement that the Ministry may provide or
enter into a new Service Accountability Agreement or other funding agreement as
applicable relating to this initiative.
Name(s), Title(s), and Signature(s) of Authorized Project Leads:
Mike Muir, Chief of EMS,
Name and Signature of EMS Chief:
Mike Muir
Name of Partner Organizations: See Letters of Support
Date: April 17, 2014
109