Introduction
The population of individuals over the age of 65 is expected to double in the next two decades.Reference Sinha 1 The majority will stay in their homes longer, either from personal choice or because of inadequate health care support.Reference Denton, Ploeg and Tindale 2 Many will require assistance with activities of daily living and in-home care to maintain their independence.Reference Denton, Ploeg and Tindale 2 There is the risk that many of these issues will be detected late, managed poorly or not addressed, with the potential of perpetuating a difficult cycle of poor quality of life for the individual.
In Ontario, Canada, Community Care Access Centers (CCACs) provide individuals with access to government-funded home health care to mitigate these issues. These services include home-based nursing, nutrition and meal assistance, medication assistance, occupational therapy, and social support.Reference Denton, Ploeg and Tindale 2 However, there is evidence to suggest that the complexity of the system and the lack of a central access point means that residents remain uninformed about how to access or navigate these services independently.Reference Denton, Ploeg and Tindale 2
One such strategy to address this issue could involve engaging paramedics in community health care initiatives.Reference Kue, Ramstrom and Weisberg 3 In many instances, individuals who initiate 911 calls often do not require urgent interventions or care in the ED, but rather some level of long-term care directed at addressing their unmet social or medical needs.Reference Kue, Ramstrom and Weisberg 3 Paramedics have demonstrated capacity in identifying individuals at risk of deterioration in the home.Reference Mann and Hedges 4 , Reference Shah, Caprio and Swanson 5 As such, the paramedic community has developed, implemented, and continues to expand programs involving paramedics initiating referrals to community services (referred to as “community referrals by EMS (Emergency Medical Services)” or “CREMS”). Referral programs aim to promote the health and quality-of-life of seniors, improve their access to resources, and reduce 911-system activations and hospital visits.Reference Kue, Ramstrom and Weisberg 3
The purpose of this study was to explore all levels of paramedic interaction with referral programs. By asking paramedics to share their experiences with such programs, we aimed to increase our understanding of the ways in which paramedics experience and participate in community-based referral programs.
Methods
Study design
An in-depth interview based, interpretivistReference Creswell 6 qualitative study design was used to explore paramedic participation in referral programs. We took an interpretivist approach to understand the paramedics’ experiences with the CREMS program. This is an appropriate epistemological framework for determining the meanings and lived experiences of the participants. Participants were interviewed via telephone using a semi-structured interview format conducted by the principal investigator. Consistent with an interpretive study design,Reference Creswell 6 , Reference Charmaz 7 we used open-ended, non-judgmental questions and probes to inquire more deeply where appropriate. Participants were asked to describe and reflect on their views and experience regarding referral programs.
An interview protocol and interview guide was used to assist the process and ensure consistency. Questions were generated through consensus among the research team, and then piloted for clarity, intent, potential biases, and appropriateness. Two pilot interviews were conducted with paramedics from an EMS with an existing referral program. Consistent with our approach, as new themes arose from the interview data, subsequent participants were asked additional questions related to emerging themes.Reference Creswell 6
Sampling
Following ethics approval from the Centennial College Research Ethics Board, we began with purposeful criterion sampling at the individual level. The inclusion criterion was: paramedics who were employed in a service that maintained a referral program and who identified themselves as having enrolled, or having the opportunity to enroll, patients in a referral program. Three EMS with CREMS programs and a professional EMS organization (Ontario Paramedic Association) distributed the study invitation via email. As all EMS services in Ontario with CREMS have a similar program as described above, we aimed to include participants from a variety of services, both male and female, a range of years of experience, method of referral (electronic or paper) and a range in the amount of reported referrals, including a participant who reported making no referrals (see Table 1).
Demographic information of study participants.
Our sample size was based on thematic saturation to ensure that any emerging themes were sufficiently supported with substantial depth and scope.Reference Creswell 6 , Reference Charmaz 7 Based on our chosen methodology and research questions, as well as guidelines and recommendations provided by Creswell,Reference Creswell 6 we anticipated needing 20–30 in-depth interviews. Based on these recommendations, our analysis was conducted as interviews were completed, and rather than identifying a set number of interviews, we planned to use thematic saturation (i.e., the point at which no new information emerged from our interview data) as our end point.Reference Creswell 6 , Reference Morse, Barrett and Mayan 8 Due to initial difficulties contacting participants, we modified our sampling strategy to include snowball sampling.Reference Bryman, Teevan and Bell 9 Contact with the initial group of key informants was achieved through existing contacts with paramedics from regional EMS.
Data analysis
Data analysis proceeded simultaneously with data collection, allowing the research team to identify emerging themes, use these themes to inform future interviews, and achieve saturation.Reference Creswell 6 This method of thematic saturation describes the point at which themes are fully accounted for, understood by, and agreed upon by the researchers, and where no new concepts or themes emerge from further interviews.Reference Morse, Barrett and Mayan 8 Data analysis was conducted manually by the researchers and began with open coding, which allows the codes to emerge from the data. These codes were then organized into categories to reveal patterns and themes.Reference Creswell 6 , Reference Bryman, Teevan and Bell 9 Next, the categories were reviewed repeatedly, described using the collected and emerging data, and re-conceptualized until major themes emerged. Intensive, long-term involvement with the data leading to a thick description of the interviews further supported the analysis.Reference Creswell 6
To support trustworthiness in the interpretation of our data, transcripts were reviewed repeatedly to ensure they did not contain transcription errors. Next, data analysis was performed independently by the research team and any inconsistencies were resolved by joint review and discussion.
Clarifying the backgrounds of the research team is important for the participants and end-users of the data in qualitative research.Reference Creswell 6 Three members of the research team are employed by an EMS in southern Ontario as paramedics, educators or management (MB, WT, CS). Finally, another member of the research team (AB) has a background in the sociology of education.
Results
Data collection began in January 2013 and continued until April 2013. In total, 23 frontline paramedics from six EMS across Ontario participated in this study (see Table 1 for demographic information).
From the interviews, five themes emerged: (a) role confusion, (b) an inadequate knowledge base, (c) inadequate feedback, (d) undefined accountability, and (e) patient advocacy.
Role confusion
One of the major challenges for paramedics, and the most dominant theme, was that referral programs confronted paramedics with an alternative approach to patient care that was in conflict with larger workplace cultural beliefs grounded in emergency response. Many of the participants perceived their role as a paramedic to be defined by responding to emergency calls for help (i.e., consistent with their initial education and certification expectations), and referral programs represented a formal departure from that enduring view. Paramedics indicated that this change towards spending more time assessing and understanding patients’ unmet long-term needs was in direct contrast with traditional values and requirements associated with EMS, such as identifying life threats and transporting all patients without delay (Table 2, quote 1a). Other indicators emerged from the data as well, such as peers having more influence over participants’ participation in the program than performance expectations or standards of care. CREMS was rarely discussed among peers (compared to other aspects of the profession). Frustration was often expressed when others were unaware of the program (Table 2, quote 1b) or failed to participate (Table 2, quote 1c). Furthermore, there was discordance when discussing whether referral programs were part of a separate “community paramedicine” initiative or part of their standard paramedic role (Table 2, quote 1e).
Participant quotes supporting the themes of (1) role confusion, (2) inadequate knowledge base, (3) inadequate feedback, (4) undefined accountability, and (5) patient advocacy.
Referral programs are at the intersection of two competing ideologies, creating challenges and a potential conflict for paramedics, given their dominant and well-established “emergency” role. In our interaction with frontline paramedics and through identification of additional themes discussed next, we recognized how the theme of conflicting roles was likely more robust than we first appreciated. Elements of training, communication, accountability, and patient advocacy all intersect and highlight the importance of role changes in EMS as the trend continues to include preventative and community care.
Inadequate knowledge base
Participants expressed a limited understanding of referral programs, factors supporting referral programs, and skewed perceptions of patient eligibility despite most participants having received some form of education. Participants shared indicators, and at times expressed directly, that the education they received may have been inadequate to prepare them for the task of referring patients (Table 2, quote 2a). When asked specifically about the education they received, it was clear that significant variation existed, with some receiving training by continuing medical education, email communication, or none at all (Table 2, quote 2b). Some expressed uncertainty that they were adequately referring all patients (Table 2, quote 2e). As a result, frontline paramedics had highly subjective and disparate views regarding appropriate patients for a referral, the types of services that might be available to patients, and in a few cases, the organization to which they would refer patients. When participants discussed the types of patients they referred into the program, responses were typically vague and included, at times, a simple emphasis on older adult patients (Table 2, quote 2c). When discussing the referral program, “I think” and “I assume” were common in the dialogue. Some “made it up” while talking to patients about the program (Table 2, quote 2d). For some, decisions regarding whom to refer were based on their personally held beliefs regarding who was eligible for, or required, care (Table 2, quote 2e). Furthermore, participants did not attribute the skills used to identify patients eligible for referral to education, but to experience with certain patient groups. Participants with more years of experience commented on the benefits of experience when considering patients for referrals (Table 2, quote 2f).
Inadequate feedback
Participants reported receiving feedback from their respective services following a referral; however, the lack of timeliness and the limited details often rendered the feedback unreliable and at times meaningless (e.g., made it difficult to improve performance and accuracy, and to reinforce the program’s success) (Table 2, quotes 3a, 3b). At times, feedback did not occur by design, but instead occurred as a result of seeing the same patient on multiple occasions. Participants who reported that they had observed patients who had received services following a referral expressed positivity towards the referral program and its contribution to patients’ well-being. In contrast, participants who reported returning to patients’ homes and perceived little or no change in service provision, or who observed patient deterioration, expressed negative views of the referral program (Table 2, quote 3c). It is worth noting that although participants stated that they rarely, if ever, received feedback from patient interactions they experienced on a daily basis, receiving feedback from a referral remained an important element of the program.
Undefined accountability
The concept of accountability emerged in a number of ways. Participants felt that they themselves were not held accountable by the program, and that perhaps no one was. At the time of this study, it was not mandatory for paramedics to refer patients and therefore completing referrals was also not recognized as a core responsibility (Table 2, quote 4a). The perceived lack of accountability by the service was reinforced when participants expressed uncertainty that their referral was ever acted upon by their EMS service or CCAC. Participants often described their referral moving “off into a black hole,” with the “hope” that someone would provide care to the patient (Table 2, quote 4b). Combined with a lack of knowledge of the program, and the absence of meaningful feedback, participants often expressed that no one, including the employer, and in some instances CCAC, were accountable to the program. For some participants this resulted in a decrease in their use of the program.
Patient advocacy
Many participants expressed that referral programs were a mechanism that allowed them to enhance their role as patient advocates, often serving as a motivator for participating in the program. Participants acknowledged the importance of their role in providing long-term additional assistance for patients, and that it was their obligation to help (Table 2, quote 5a). Some participants expressed uncertainty about whether informal reports to hospital staff upon transfer of care were having the intended effect; thus, having a formal referral method filled a much-needed void (Table 2, quotes 5b, 5c). Participants’ sense of their role as patient advocates was robust. Participants expressed “hope” in the health care system and that the patients’ needs would be appropriately addressed. This was a common response among participants, suggesting that patient advocacy often replaced or at least mitigated many of the challenges discussed prior.
Discussion
This study explored the experiences of frontline paramedics with referral programs and identified: (1) an incomplete integration of referral programs into what paramedics identify as their role, (2) inadequate education to support the programs, (3) an incomplete infrastructure to support paramedic development in this area, and (4) a perceived absence of accountability with referral programs. However, the study also identified a strong and seemingly ingrained (5) commitment to patient advocacy that may provide a meaningful platform by which to support referral programs.
The introduction of referral programs appears to represent a departure from how many frontline paramedics define their role in the health care system. Paramedic identity appears to be influenced by frequent implicit and explicit messages that paramedics receive. Evidence of this limited or incomplete integration of the CREMS program into paramedic practice may contribute to implementation challenges of community-based care experienced by the profession. However, a reframing of paramedic practice is under way worldwideReference Evans, McGovern and Birch 10 and likely to become increasingly present. Still, this study suggests that incongruent messages impacted how paramedics integrated this relatively new role into their professional identities, and ultimately their patient care.
Further, optimizing referral programs may remain challenging without improving educational strategies to support them. We identified numerous direct and indirect references to limited knowledge and understanding regarding a number of elements believed to be vital for referral programs, and participants linked these deficiencies to inadequate education. Indeed, others have identified limited education in this area at the entry to practice and ongoing professional development levels,Reference O’Meara, Ruest and Stirling 11 and the need for further or better training to improve accuracy or appropriateness in referral programsReference Kue, Ramstrom and Weisberg 3 and screening.Reference Shah, Caprio and Swanson 5
Another salient theme emerging from the data was the strong desire by paramedics to receive meaningful feedback and improve communication regarding referrals made. In cases where feedback lacked detail or was delayed it did little to improve paramedics’ use or understanding of the CREMS program. Despite many challenges that likely exist, (e.g., privacy legislation, logistical challenges), the paramedic and health care community will need to find innovative strategies to optimize feedback, or place greater emphasis on continuing education and make clear what paramedics can expect and why.
In addition, there appeared to be a perception by frontline paramedics that there was a lack of accountability for referral programs at any level. On an individual level, a missed opportunity to report a referral was seldom identified. Likewise, when a referral was made, it was unclear who was responsible for the referral and what quality indicators were in place to ensure appropriate and timely follow-through. When referrals were missed without consequence, or when referrals seemed to disappear once made, this may have further reinforced the perceived lack of accountability to the program and resulted in questions regarding its relevance.
Despite these challenges, the seemingly engrained concept of patient advocacy may serve as an opportunity to support referral programs going forward. Referral programs appear to fill a void for both paramedics and patients, and therefore represent a clear opportunity. However, many of the challenges discussed above compete with or are in conflict with this desire to serve patients. Still, paramedics recognize patient advocacy as a fundamental role in their daily practice.
Implications
By examining the incorporation of community health initiatives through the perspective of paramedics, this study illuminates the complexity and robustness of paramedic culture and operations and its potential impact on community-based programs. This exploratory study highlights the need for intervention and future research on how paramedics’ role and identity are changing as EMS continues to include or expand community paramedicine initiatives. This study identified educational difficulties as part of this change, suggesting that greater emphasis on initial and ongoing educational strategies should be explored. Future research should also address whether the current lack of education about the program has resulted in hesitation to participate in the program, missed opportunities, or inappropriate referrals, leading to an ineffective program. Furthermore, we recommend that EMS implementing a referral program, or those with current programs, take a paramedic-centered approach, and consider factors such as accountability to the program (such as implementing mandatory referrals and a clear explanation regarding who is responsible for the program) and a method to address feedback (or explain why it is not possible).
Limitations
It is important to note the limitations to this study. First, only one participant reported making zero referrals. One possible explanation for this is that paramedics who are interested in CREMS would be more likely to participate in the study, compared to those who are not. Thus, identifying specific barriers to engaging in CREMS programs will require additional research. Furthermore, due to limitations in our initial enrollment strategy, we adopted a snowball sampling strategy. Snowball sampling is a common strategy in qualitative research, but can be associated with an increased risk of bias. However, only seven of the 23 participants were contacted using this method. Furthermore, this group ranged in their perceptions of the program, years of experience, and reported referrals. Lastly, this exploratory qualitative study did not attempt to make generalizations about population, but rather exposed key concepts worth exploring in more detail.
Conclusion
In summary, the implementation of referral programs, while grounded in a need and opportunity to serve patients in a constrained health care system, presents challenges and opportunities for the paramedic profession. While paramedics view referral programs as a welcome opportunity to address patients’ needs in their everyday practice, this new role has not yet been fully incorporated into the profession. The success of referral programs may be limited if role confusion, inadequate knowledge and understanding, opportunities for continued development, and accountability indicators are not adequately addressed.
Competing Interests: None declared.
