Under a grant from the Mother Cabrini Health Foundation, the Home Care Association of New York State/HCA Education and Research (HCA) and the Iroquois Healthcare Association (IHA) have partnered to develop Collaborative Models of Community Medicine and Paramedicine. IPRO, the state-federal regional quality improvement organization, has also been engaged to support the project. This initiative involves a multiyear plan that is currently underway in three rural and small community regions in the state: The North Country, Southern Tier, and Hudson Valley.

Coordinating and optimizing the roles of all core partners in the delivery of care, particularly amid growing care complexity and shortage of resources, is critical to patient access, quality and outcomes. The need for a coordinated response is exacerbated by the chronic and worsening health personnel shortages in the NYS health care system that impair access and continuity of care for medically, socio-economically, and mentally vulnerable individuals living in the community. Coverage and regulatory gaps in the healthcare system have severe consequences on individuals, the community, and priority public health concerns.

A key direction is the development and promotion of collaborative care by hospitals, physicians, home health agencies and core community partners like EMS. While emergency care is traditionally the focus for paramedics and EMTs, they can play further invaluable roles in the overall system, and in partnership with patients’ care teams. They are frequently called into non-urgent medical situations, but in their current role are constrained to emergency response. This puts a burden on emergency care teams and threatens to harm those in true need of urgent or emergency care. By leveraging collaboration between emergency services and other health sector partners, this burden can be reduced while also ensuring patients receive appropriate and efficient care.

Traditionally, developing programs of community medicine that include paramedicine components in NYS has been challenging. Unlike focusing solely on statutory change, this initiative draws upon collaboration. This program is highly community-centered and requires consistent collaboration among providers. When providers collaborate and work together towards a common goal, healthy communities are built.

THE MODELS

Since 2022, core health sector partners and practitioners from local hospitals, home health agencies, physicians and emergency medical service organizations in Jefferson, Broome, and Columbia-Greene counties have been working together with HCA, IHA and IPRO to develop and implement Collaborative models to strengthen care in their communities. The goal of this pilot project is for these regions to optimize resources and work with all key players towards goals to support care transitions, continuity of patient service, and coordinated intervention in vulnerable periods or vulnerable populations in order to avoid ED episodes and visits, reduce hospital readmissions, and avoid unnecessary hospitalizations and unnecessary ambulance transports. The pilots share similar goals but is each tailored to the resources and specific needs of the residents of each respective community. By coordinating the roles and protocols among core hospital, home health, physician and EMS partners, patients in the community will have increased access to care and continuity of service and support, which is particularly vital in resource challenged areas. Each of these three pilot programs will utilize and coordinate all partners to deliver primary and preventative care services to populations such as frail or elderly patients, patients without transportation, etc. Administering preventative care lowers the likelihood that emergency teams will be called to non-urgent situations and preserves emergency care resources.

Health sectors and health personnel must function together to make a collaborative, integrative program of this nature work. Jefferson County has started a successful effort to provide care across the hospital and home care spectrum. The foundation of their success thus far is attributable to their continued education, communication, and trust-building.

The following webinar identifies the elements of their model for other interested communities and organizations looking to meet their patient’s needs in a comparable way.

Webinar Link

Watch the February 10, 2023 webinar, “Jefferson County Mobile Integrated Health: A Blueprint for Collaboration,” here.

–Jefferson County MIH Blueprint Narrative

Related Resources

–Protocol research
–Scope of activity description document
–South Carolina blueprint
–Health & Wellness Community Paramedicine: A New Approach to Health in Rural Communities