Response to Community Paramedicine
Thank you for your e-mail correspondence on December 5, 2013 inviting the Registered Nurses’ Association of Ontario (RNAO) to participate in the Ministry of Health and Long-Term Care’s consultation on community paramedicine (CPM).
RNAO is unwavering in its support to afford seniors the opportunity to live prosperously within their homes and communities. Indeed, “ageing in-place” has long been part of RNAO’s policy platforms. To this end, we already launched the Elder Health Coalition in 1998 which was appointed in 2003 as an advisory to then Ministers George Smitherman and John Gerretsen when they focused on building a vision for elder care in Ontario.
RNAO is also eager to contribute to system cost-savings and effectiveness, including preventing the use of unnecessary ambulance transfers to emergency departments. To this end, we have developed the Enhancing Community Care for Ontarians (ECCO) model which places the person at the centre of a health system that is anchored within primary care. The ECCO model reduces duplication in the system by enabling the LHIN to perform regional system planning, funding, monitoring and evaluation across all sectors. The model also involves transitioning the functions of Community Care Access Centres to existing areas of the health system. This transition would enable primary care to serve as the co-ordinating centre of the system by leveraging the tremendous human resource capacity of the existing 4,000 registered nurses (RNs) who practise in this area, combined with the 3,500 care co-ordinators who currently practise within the CCAC. Undoubtedly this model has the potential to positively transform the patient/client experience and outcomes through increased access to comprehensive services, while maximizing the cost-effectiveness of the system.
As it relates to community paramedicine, we are concerned over the engagement process and the program itself. First, RNAO was informally notified about the consultation from Dr. Samir Sinha on December 2, 2013 as he became aware with concerns from RNAO published in the Renfrew Mercury in response to an article about CPM (See attached). As we indicated to Dr. Sinha, that was the first time we were informed of the consultation. No mention of the consultation was provided to us directly or at recent meetings of Ontario’s Joint Provincial Nursing Committee. We are also extremely concerned that, to the best of our knowledge, Dr. Debra Bournes – our provincial Chief Nurse Officer – was also not engaged on these consultations.
We find the lack of transparency in this process to be alarming. Complicating matters, you have indicated that consultations were already held over November 25th, 26th and 29th. It is extremely concerning that the voice of Registered Nurses was excluded from this vital discussion. Moving forward, we urge you to include RNAO at the forefront of all consultations and decision-making processes. It is simply unacceptable to us to be consulted ‘after the fact’.
Second, we are concerned over the emergence and potential expansion of CPM programs. Our responses to your questions are found below:
- Please consider the barriers and opportunities that exist relating to Scope of Practice.
RNAO is concerned that the current educational curriculum used to train paramedics is not conducive to CPM. The content of this curriculum is focused on preparing paramedics to serve as first-responders in emergency situations. It is not consistent with supporting health promotion, disease prevention, and health education. These conflicting interests represent polar opposite ends of the spectrum. Additionally, it is not clear how the role of CPM is compliant with the legislative and regulatory framework governing the practice of paramedicine.
- Please consider the barriers and opportunities that exist relating to Impact on System Resources.
RNAO is very concerned that the implementation of CPM will duplicate and hamper efforts to strengthen Ontario’s primary care setting. Much of the role of CPM referenced in the slide deck can be effectively provided through the 4,000 Registered Nurses (RNs) who currently practise in primary care, in collaboration with over 3,000 RNs who practise in home health-care, and the range of other providers offered through support service agencies. Transitioning the functions of CCACs (as part of RNAO’s ECCO model), including 3,500 care co-ordinators (who are regulated health professionals) to primary care will immediately and substantively increase the human resource capacity to reduce unnecessary 911 calls and ambulance transfers to emergency departments. This transition will enable complete co-ordination of care and facilitate seamless transitions and navigation through the system. RNAO is also very concerned over the impact that CPM will have on home health-care providers and community support agencies that have countless years of experience providing this type of service.
It is also unclear how the CPM system will adapt to the fact that paramedics must be ready to respond to an emergency at any instant. The CPM process may impede this ability, especially if a paramedic is visiting a person at one side of town and has to abruptly end the visit to travel to another end of town to respond to an emergency.
- Please consider the barriers and opportunities that exist relating to Funding CP programs.
No new funding should be allocated to CPM programs. Instead, increased investments in the community should be allocated to the well-established roles in primary care, home health-care organizations and community support agencies; all of whom regularly report being under- funded. The provision of new funding to a CPM program will serve to duplicate investments which have already been made to date.
- Please consider the barriers and opportunities that exist relating to Governance Model and Accountability/Quality/Safety framework.
Another one of RNAO’s grave concerns relates to the CPM program’s ability to provide clients with continuity of care and caregiver, as well as system connectedness. Paramedics are not regulated health professionals and this in and of itself decreases the level of accountability they can assure the public and Ontario’s health system. In addition, they are often employed part- time or casual and work shifts. It would be extremely challenging to offer consistency in care provider within any CPM program. Moreover, it is not clear how CPM programs will interact with primary care providers. To achieve patient safety, it is vital that this link exists. Lack of continuity of care and caregiver is directly linked to lower accountability and outcomes.
- Please consider the barriers and opportunities that exist relating to Performance Tracking /Monitoring/Evaluation.
It is unclear what scientific evidence exists to date to support implementing a CPM program in Ontario. If a CPM program were to be implemented, it would be essential that a rigorous evaluation framework be developed that captures outcome measures at the person, community and broader population level. Moreover, it will be imperative to ensure that the impact on system resources will be accurately captured and articulated.
- Please consider the barriers and opportunities that exist relating to Partnerships/Support/System Integration.
As previously identified, RNAO believes that the CPM program will duplicate and interfere with the existing services offered through home health-care and community support agencies, and that it is these services that must be strengthened – not develop a new program. In addition, the slide deck you provided references that CPM programs can be used to facilitate referrals to CCAC and other agencies. There are already a number of opportunities for referral to these programs and it is not clear how the CPM program will enhance this process.
- Please consider the barriers and opportunities that exist relating to Operationalizing CP programs.
It is not clear how the CPM program will impact emergency response capacity. RNAO would be concerned that CPM programs would interfere with the province’s response capacity. In the event of an emergency every second counts and it is imperative that each community has sufficient resources dedicated to emergency response.
- Please consider the top three barriers and opportunities to maximizing the success of CP.
A summary of RNAO’s concerns related to the expansion of community paramedicine include:
- Paramedics are not currently trained to fulfill the roles and responsibilities demanded through CPM programs;
- CPM programs will duplicate existing efforts underway, creating inefficiencies and confusion;
- No new investments should be made to create or expand CPM programs;
- The staffing models governing paramedicine will challenge the ability to offer continuity of care and continuity of care-provider, both essential elements of quality care and outcomes;
- CPM programs will further contribute to lack of system integration and connectivity between primary care and the broader system; and
- CPM programs will impact the capacity of Ontario’s emergency response capabilities.
We strongly urge the Ministry of Health and Long-Term Care to conduct a thorough review of CPM programs, engaging all relevant partners and stakeholders including RNAO. We request that our feedback be considered and acted upon.
Should you have any questions regarding our feedback please contact my office.
Dr. Doris Grinspun, RN, MSN, PhD, LLD(hon), O.ONT. Chief Executive Officer
Registered Nurses' Association of Ontario
Rhonda Seidman-Carlson, President, Registered Nurses’ Association of Ontario
Dr. Samir Sinha, Lead, Ontario Senior’s Strategy
Debra Bournes, Provincial Chief Nursing Officer, Ministry of Health and Long-Term Care