June 28, 2021
The Honourable Christine Elliott
Minister of Health
College Park, 5th Floor, 777 Bay St.
Toronto ON M7A 2J3
The Honourable Rod Phillips
Minister of Long-Term Care
6th Floor, 400 University Ave.
Toronto ON M5G 1S5
Dear Ministers Elliott and Phillips:
AMO and the Ontario Association of Paramedic Chiefs (OAPC) are pleased to submit to you our joint Community Paramedic Policy Framework for your consideration and action.
AMO and the OPAC have developed this paper to set out the immediate and future requirements to successfully develop a community paramedicine system in Ontario. We look forward to working with the Ministries of Health and Long-Term Care as valued partners along with Ontario Health to make a community paramedicine system in Ontario a reality.
Through this letter, AMO and OAPC respectfully ask the Ministries of Health and Long-Term Care to establish a working group with us, and the City of Toronto, in order to develop an agreed upon Community Paramedicine policy framework that could start to be implemented, by enabling legislation, by Fall 2022.
We look forward to discussing this with you and your officials soon so that together we can implement the start of a regularized Community Paramedicine program in Ontario.
Sincerely,
Graydon Smith, AMO President, Mayor of the Town of Bracebridge
Peter Dundas, OAPC President, Chief, Peet Regional Paramedic Services
cc: The Honourable Steve Clark, Minister of Municipal Affairs and Housing
Kate Manson-Smith, Deputy Minister, Ministry of Municipal Affairs and Housing
Helen Angus, Deputy Minister, Ministry of Health
Richard Steele, Deputy Minister, Ministry of Long-Term Care
Melanie Fraser, Associate Deputy Minister, Health Services
Amy Olmstead, Executive Lead (Acting), Ontario Health Teams, Ministry of Health
Susan Picarello, Assistant Deputy Minister, Emergency Health Services, Ministry ofHealth
Janet Hope, Assistant Deputy Minister, Ministry of Long-Term Care
Encl: AMO-OAPC Community Paramedic Policy Framework
Community Paramedicine Policy Framework Pape - June 28, 2021
Community paramedicine (CP) programs are a cost-effective choice for the delivery of episodic and continuing community and home-based healthcare in Ontario. They are innovative and agile by design to meet evolving community needs, with the flexibility to adapt services, scope, and scale to changing health system pressures. Essentially, community paramedicine is filling an urgent need to provide clinical support to vulnerable populations in their own homes, keeping our residents living well and improving their quality of life while reducing pressure on the health care system.
However as successful as CP programs are, they are all currently pilot projects aimed at filling the gaps that exist in primary care and home and community care. There is no legislative or policy framework to support them and no permanent provincial funding commitment. As per the Ministry of Health’s recent survey of community paramedicine programs, there are 263 pilot programs within 43 of the 52 municipal/District Social Services Administrative Boards (DSSAB)/First Nations paramedic services throughout Ontario.
This position paper will set out what type of policy frameworks could lay the foundation for community paramedicine to become a permanent component of primary care in Ontario.
Through this paper, AMO and OAPC would ask the Ministries of Health and Long-Term Care (and the City of Toronto) to establish a working group to develop a Community Paramedicine policy framework that could start to be implemented, by enabling legislation, by Fall 2022.
Municipal governments are active players in Ontario’s health system. Although health is a provincial responsibility under Canadian federalism, municipal governments, and District Social Service Administration Boards (DSSABs) co-fund and deliver several health services. They also respond to the health-related needs of their communities to improve local population health outcomes.
The property tax base significantly finances this activity. In 2018, municipal governments spent $2.23 billion for health-related costs. This includes the municipal portions of cost-shared programs such as public health, land ambulance and increasingly, long-term care homes (source: MMAH Financial Information Returns). In other provinces, these health-related costs are provincially funded rather than supported by the local property tax base.
At its core, paramedic service (land ambulance) is primary health care. Designated upper-tier and single-tier municipal governments co-fund and deliver land ambulance locally using the property tax base. In the north, paramedic services are provided by DSSABs financed by municipal governments. The Ambulance Act governs the delivery of land ambulance. The Ministry of Health (MOH) sets service standards and employee qualification requirements, with monitoring to ensure compliance with provincially set standards.
Community paramedicine involves having paramedics provide primary care in the home (limited scope), clinic-based assessments and medical referrals. This is not a mandated service under the Ambulance Act. However, many municipal governments and DSSABs have supported this useful intervention as a means of mitigating pressures on 911 ambulance response through prevention activities, thereby improving the health and security of local residents. The Province has yet to fund Community Paramedicine as a permanent service.
Since 2007, Local Health Integration Networks (LHINs) have been responsible for determining the role and use of paramedicine in local communities. More recently in 2014, the Province invested approximately $5.9 million dollars annually in CP initiatives. Programs include the Aging at Home Strategy, Health Links and, more recently, Ontario Health Teams and Community Paramedicine supporting persons awaiting Long-Term Care.
Community paramedicine has demonstrated great potential to provide further benefits to residents throughout Ontario. Community paramedicine can also benefit seniors and those living in rural and northern areas where access to primary care is limited. Community paramedicine has also demonstrated its impact on reducing health care costs by diverting patients from emergency rooms, decreasing admission rates, length of stay, and health system costs.
With an appropriate and sustainable provincial funding model of care, municipal governments, First Nations and DSSABs can deliver community paramedicine in a more integrated, coordinated, and effective way. The first CP initiative of $5.9 million was only able to support 30 of 52 municipalities and DSSABs. This funding did not support First Nation Paramedic Services or ORNGE. As a result, municipal governments have been faced with community pressure to fill in gaps in provincial funding, despite multiple attempts to expand the funding and policy support from the Government of Ontario.
Another challenge relates to funding distribution. Because municipal governments and DSSABs are not considered ‘health service providers’ under the Local Health Integrated Network Act, LHINs must transfer funding for community paramedicine to a recognized provider such as a hospital. The hospital then transfers the funding over to the municipal government or DSSAB to deliver the service. As community paramedicine becomes a permanent program that is an integral part of an integrated health care system, a more efficient and practical solution to this administrative work-around should be established to direct funding to municipal governments at 100% of the full program cost.
In its 2019 paper on the municipal role in health, AMO called upon the Province to expand community paramedicine across Ontario to willing municipal partners and to fully fund its implementation, as it is primary care in the home and community.
Municipal governments are deeply involved and invested in the provision of the upstream social determinants of health. They also see the lack of home and community health care especially in rural and northern Ontario. Home and community health care is directly tied to the housing continuum. We need a much broader range of housing to enable people to receive a range of primary health care, including an integrated community paramedicine system, where they are most comfortable. Health at home – for all ages and needs is a societal need and want. Municipal leaders continue to advocate for greater housing diversity throughout the province, which would include supportive and assisted housing. This would reduce the need for individuals to have to seek institutional care, such as long-term care.
Currently the Province has three CP initiatives underway. These include:
1. The current ongoing program through the LHINs available in some communities ($5.9 million).
The following survey data was compiled by the Ministry of Health Emergency Health Services Division in 2020, prior to the implementation of the Ministry of Long -Term Care Community Paramedic Model of Care and the Ministry of Health High Intensity Supports Programs, both investments in excess of $64 million annually. It is important to note that some of the
information presented does not accurately depict the current state of Community Paramedic activities in Ontario. The following graph is intended to represent the number of Community Paramedic Programs by type.
According to the Canadian Standards Association (CSA) Community Paramedic Standard, “programs” would be Home Visits, Wellness Clinics, and Referrals. Remote patient monitoring is better defined as an intervention. High Intensity Needs, CP Long Term Care, Health Links, Ontario Health Teams, etc. are better understood as funding sources or populations of interest.
| Programs | % of all 263 CP programs |
|---|---|
| 1. Education, Prevention and Monitoring | |
| Home and Virtual Visits | 48% |
| Assessment and Referrals | 35% |
| Remote Patient Monitoring | 24% |
| Wellness Clinics | |
| 2. Clinical Interventions | |
| Immunization Clinics | 33% |
| COVID-19 Testing, Swabbing & Mobile Clinics | 23% |
| Palliative Care Programs | 15% |
| Mental Health + Addicitons programs | 12% |
| High Intensity Needs Programs | 6% |
Source: MOH CP survey April 2021. For full details see appendix
Note: A number of CP programs (35%) were unique, localized programs not broadly offered elsewhere in the province. These programs included various patient cohorts and service offerings, including Naloxone kit distribution for overdose patients.
A growing body of research and evidence shows that Ontario’s investment in community paramedicine (CP) programs is achieving evidence-based patient- and system-level benefits that are well understood and reproducible.
Evidence-controlled trials and several observational studies suggest that current community paramedicine models are reducing repeated emergency calls, emergency transports, emergency department visits, and hospital admissions and readmissions, and that they are improving patient quality of life. Additionally, the cost-effectiveness of providing care in the home or community-based care is indisputable and staying at home is the preferred choice of virtually everyone. A chart in the appendix provides further details but the average per diem cost is:
(source: https://www.homecareontario.ca/home-care-services/facts-
figures/publiclyfundedhomecare)
Hospital Bed $842.00/day as of 2011
Long-Term Care Bed $126.00/day as of 2011
Care at Home $42.00/day as of 2011
The average amount per ED visit in Ontario in 2005-2006 was estimated to be $148. This ranged from $111 per visit in the North East LHIN 13 to $219 per visit in Toronto Central LHIN.
[Source: https://www.longwoods.com/content/20411/healthcare-quarterly/cihi-survey-ed-spending-in-canada-a-focus-on-the-cost-of-patients-waiting-for-access-to-an-in-pati#:~:text=Putting%20a%20Dollar%20Amount%20on,LHIN%207%20(Figure%203)]
Note: None of these numbers have been adjusted for inflation.
In the November 2020 National Institute on Aging report, “Bring LTC Home,” the following per diem costs were provided:
Seventy-eight per cent of Ontarians would prefer to have homecare for themselves or loved ones over care in a LTC home (NIA 2020).
In a recent study, it was shown that assessment and referral programs in Toronto have improved access to home care services by 24%, led to an average increase of 17.4 hours in total home care services per person, reduced 911 calls by 10%, and reduced ambulance transports to emergency departments by 7% over the study period.1
The Ontario-based ‘CP@Clinic’ model also demonstrated, through a randomized control trial, that establishing wellness clinics in subsidized housing buildings can reduce 911 calls by 28%, while also improving patient wellbeing and quality of life.2
A home-visit program in Renfrew County has demonstrated its ability to reduce 911 usage by 24%, emergency department visits by 20%, and hospital admissions by 55%.3
The Ontario Community Paramedicine Remote Patient Monitoring (CPRPM) Program demonstrated its ability to provide a 542% return on investment for helping older patients with chronic conditions to remain living at home. It also reduced their need to call 9-1-1 by 26%, visits to the emergency department by 26%, and hospital admissions by 32%. It also improved the efficiency of home visit programs by allowing community paramedics to manage larger caseloads.4
A community paramedicine-enabled hospital discharge program in Sudbury reduced total health care costs per patient by 50% reduction and had an estimated cost avoidance of $10,000 per patient enrolled5.
Community Paramedicine programs are a proven, cost-effective choice for the delivery of episodic and continuing community-based primary health care in Ontario. Community Paramedic Programs are innovative and agile by design to meet evolving community needs, with the flexibility to adapt services, scope, and scale to changing health system pressures.
Community paramedicine, through the current series of pilots, are filling in gaps in home and community-based primary care. Municipal governments are supporting their paramedic services to provide more community paramedicine, especially given its nimbleness in urban, rural, and northern settings.
A large number of people across Ontario continue to lack access to a primary care provider – either a family physician or a nurse practitioner. These individuals are called unattached patients. The Ontario Ministry of Health and Long-Term Care implemented the Primary Care Access Survey (PCAS) in 2006 to measure primary care access on an ongoing basis. Analysis of the 2007–2008 PCAS (n=16,560) showed that 7.1% of Ontario’s adults were unattached (Health Care Policy November 2010). In 2021, in communities such as Renfrew County, more than 25% of the population is unattached, with no primary care alternatives. As a result, people call 911 for assistance, or use hospital emergency departments, as their only access to primary care.
More up-to-date data was not found in an internet search (03/2021) and there is also no publicly available information to show that the number of unattached patients in Ontario has declined via the decade long roll-out of LHINs or Ontario Health Links. The recent evolution to Ontario Health and Ontario Health Teams again has increasing primary access as one of its goals. However, given their current focus on hospitals and physicians, there is ongoing concern about the lack of improved patient access to community and home health care.
There is also an uneven distribution of primary care physicians across the province, with fewer doctors available in rural and northern Ontario – this has been an issue for decades. Although many provincial physician compensation and health team programs have been set up to address this ongoing challenge, physician and NP recruitment and retention in rural and northern Ontario continues to be a problem.
A permanent CP program would assist in addressing these inherent health equity issues. Community paramedicine also filled in critical gaps in service related to seasonal surges of influenza, as well as in response to COVID-19, through mobile assessment testing, in-home assessment, and treatment of COVID-19 patients. Community paramedics are a critical part of the vaccination roll-out across Ontario. However, as it is quickly being normalized and expanded, all of these CP programs are occurring as pilot projects dating back to 2007, 2014, and 2017 respectively. There are now three different program types with different funding parameters and criteria under two provincial ministries. It is an ad hoc situation rather than approach that could be more systematic, while remaining adaptable.
The paramedic 911 response program has a legislative base, while community paramedicine does not even have a policy framework, let alone a legislative foundation.
Both the provincial and municipal governments have a significant interest in regularizing community paramedicine to provide legal, policy, funding clarity and sustainability as primary care service in homes and the community increases. That does not mean it needs to be aligned with the medical delegation model for 911 paramedic services for patients who do not have a relationship with a delegating physician or embedded within the constraints of the Ambulance Act. We can and must do better.
The key areas that need to be established within a policy framework include:
1. Legislation
As stated above, an enabling legislative basis for a permanent community paramedicine system is required:
Those items that are identified as requiring regulations will require further consultations and discussion once the enabling legislation is in place.
The first thing to be determined is to identify the most viable means of establishing a legislative basis for a permanent community paramedicine system across Ontario.
The three immediate options and their considerations are:
Whatever the legislative basis for a permanent community paramedicine system, there will need to be transparent agreements on how CP programs will be integrated, coordinated, and work in partnership with Ontario Health, Ontario Health teams, hospitals, Primary Care Providers, and municipal/DSSAB/First Nation paramedic services.
2. Funding Source
The provision and funding of primary care is a responsibility of the provincial government. Canada has thirteen provincial and territorial health care systems that operate within a national legislative framework, the Canada Health Act ,1984. The Act defines the following standards to which provincial health insurance programs must conform in exchange for federal funding: universality (coverage of the whole population on uniform terms and conditions), portability of coverage among provinces, public administration, accessibility (first-dollar coverage for physician and hospital services), and comprehensiveness (defined as medically necessary health services provided by hospitals and physicians) (Marchildon 2005).
Although municipal governments are co-funders of both public health and land ambulance emergency services by provincial legislation, there is a long history of both being initially local activities due to their community focus. There is no such history of local municipal funding for primary care as it has been always been a provincial funding responsibility. The 2020 Ministry of Long-Term Care waitlist program 100% acknowledges this responsibility.
For the initial CP pilot programs, municipal governments which well understood the local needs, often made up for the funding gaps – as the $5.9 million from the LHINs did not fully fund the CP pilots. As well, municipal governments often funded the CP pilot administrative and management costs through in-kind provision through their 911 Paramedic Services.
CP Program Funders – Overview
| BASE Funding Sources | # of CP programs | % of Base Funded Programs | % offered by municipal paramedic services |
|---|---|---|---|
| Provincial only | 63 | 76% | 19 |
| Municipal only | 10 | 12% | 4 |
| Provincial + Municipal shared | 10 | 12% | 6 |
| Total | 83 | ||
| Project (one-time) Funding Sources | |||
| Provincial only | 61 | 50% | 28 |
| Municipal only | 23 | 19% | 11 |
| Provincial + Municipal shared | 4 | 3% | 3 |
| Hospitals | 4 | 3% | 3 |
| Federal | 5 | 4% | 6 |
| Other (e.g. CAMH) | 26 | 21% | 16 |
| Total | 123 |
Source: MOH CP survey April 2021
AMO, on behalf of Ontario municipal governments, as well as the Ontario Association of Paramedic Chiefs (OAPC), on behalf of the 52 Paramedic Chiefs, has been advocating for the Province to fully fund community paramedicine programs as they are primary care programs for which the Province is responsible. We are looking for a separate stream of committed 100% provincial funding which is not to be simply shifted from the current co-funded 911 emergency services.
It also needs to be noted that not all the municipal paramedic services have had access to provincial funding for the current CP pilots. It is understood that only 33 of the 52 paramedic services have been able to benefit from CP provincial funding which means 19 municipalities have had to fund CP programs themselves or who have not been able to have a CP program to date due to this funding challenge given limited municipal dollars. This is an inequity for these communities that must be addressed through a provincially funded CP program.
A cursory cost-benefit analysis with respect to a CP program reducing demand for emergency departments, hospital beds, or LTC beds accrues directly to the Province and the provincial health care system. Municipal governments would not receive any direct cost savings for a successful CP program.
Community paramedicine does provide for significant cost avoidance and savings for the provincial government as it is proven to reduce the number of people going to the hospital emergency departments, which directly reduces the pressure on “hallway medicine” for the health care system. This would also assist in shared cost-avoidance for both the Province and municipalities/DSSABs as this should decrease 911 pressures. Full analysis of this projected cost avoidance cannot be calculated until the evaluations of the CP pilots have been done and are made available.
In our minds there is only one option. That is for the Province to fully, 100% fund a permanent community paramedicine system with predictable and sustainable funding in a single streamlined manner. Otherwise, it can never become a fully efficient and cost-effective, permanent community paramedicine system that addresses the lack of primary health care access across the province. Expecting municipal governments to continue to contribute to the funding of CP program, directly or in-kind, is both unreasonable and an abdication of the provincial responsibility for primary health care.
Although the provincial Treasury Board does not like to factor in future cost avoidance or projected system savings in its deliberations, the tangible cost savings of a permanent community paramedicine system to the provincially funded health care system (i.e., reduction in emergency department visits, reduction in hospital beds admissions, reductions in alternative level care beds, reductions in the LTC bed waiting lists) can not be understated. Perhaps the structured evaluation of the cost-effectiveness of the Ministry of Long-Term Care wait list program will provide additional evidence to the need for a fully provincially funded permanent community paramedicine system.
3. Medical Delegation
The regulatory framework that has been established for paramedics, principally under the Ambulance Act, does not addressed delegation of medical acts in community paramedicine programs. Each municipal paramedic service has established their own parameters depending on what delegation options were available and practical.
Community paramedics receive the authority to perform certain controlled acts through various authorized health care professionals. This is in addition to the delegations that 911 paramedics receive from their regional base hospitals in the course of their regular duties responding to 911 calls. The table, below, presents the sources of delegation.
| Delegation Source | % of CP Practices Using Delegation Source |
|---|---|
| Base Hospital ** | 21% |
| Hospital Physician | 10% |
| Other Physician | 19% |
| Local Medical Officer of Health | 25% |
| Primary Care Physician | 13% |
| EMS Medical Director | 6% |
| Nurse Practitioner | 3% |
| LHIN Physician | 3% |
| LTC Medical Director | 1% |
Source: MOH CP survey April 2021
Note: Percentages are based the total number of delegated practices identified (72) rather than a percentage of 263 discrete programs due to the MOH survey design.
** Should be noted that delegation by base hospital physicians would have been done outside of their base hospital responsibilities to the 911 emergency paramedic program through a different fee for service method.
There exists a potential liability related to the delegation of controlled acts for all involved in the absence of a regulatory college of paramedics – the paramedic, the delegating physician, and the municipal/DSSAB/First Nation employer all share responsibility in the care of a patient. A standardized approach to medical delegation needs to be established for community paramedicine as it is fundamentally different in design and delivery than the base hospital relationship that exists in the 911 system.
Community paramedic delegation typically occurs between the most responsible medical provider (physician and nurse practitioners) for a patient they know and the community paramedic or by a physician affiliated with the Community Paramedicine Program. There is a pre-existing relationship between providers and the patient. It is important to understand that this model is different by design than that of the 911 system, which was established to specifically address the absence of a physician-patient relationship.
Options:
In addition to the medical delegation options, establishing a regional medical advisory council for Community Paramedicine in each Ontario Region (same as ER and Critical Care) is strongly recommended.
Further, standardized community paramedicine clinical guidelines or a community paramedicine operational guideline (currently under development) need to be approved by the Ministry of Health (or the Paramedic College once up and running) and adopted by all municipal/DSSAB/First Nation paramedic services with an accompanying quality assurance and performance indicator reporting mechanism.
A clearly articulated system of medical delegation is required for community paramedicine to reduce any potential risk for the patient, delegating physician, paramedic, and the municipal/DSSAB/First Nation paramedic service. It must be addressed immediately – preferably with a future orientation – that provides for a transitional approach along with mandated regional medical advisory councils and standardized community paramedicine clinical/operational guidelines.
Community paramedicine is here to stay in Ontario. Evidence shows that it is a cost-efficient health care program that can be integrated into home and community health care services that respects Ontarians’ desire to remain at home for as long as possible while delivering better value to the health care system as a whole.
AMO and the OPAC have jointly written this paper to set out the immediate and future requirements to successfully develop a community paramedicine system in Ontario. We look forward to working with the Ministries of Health and Long-Term Care as valued partners along with Ontario Health to make a community paramedicine system in Ontario a reality.
That the Ministries of Health and Long-term Care agree to establish a working group with AMO, OAPC, Ontario Health (and City of Toronto) as partners to develop a community paramedicine policy framework that could start to be implemented, by enabling legislation, in Fall 2022. It is also proposed that standardized community paramedicine clinical/operational guidelines are finalized for use throughout the province in the same time period.
Appendix: Community Paramedicine Programs - as per MOH survey April 2021
| Program | Patient Cohort(s) and Selected Service Offerings | % of All 263 CP Programs |
|---|---|---|
| Programs Geared Toward Education, Prevention & Monitoring | ||
| Home and Virtual Visits |
Patient CoHorts:
Services:
|
48% |
| Assessment & Referral |
Patient CoHorts:
Services:
|
35% |
| Remote Patient Monitoring |
Patient CoHorts:
Services:
|
24% |
| Wellness Clinics |
Patient CoHorts:
Services:
|
6% |
Programs Geared Toward Clinical Interventions
| Immunization Clinics |
Patient CoHorts:
Services:
|
33% |
|---|---|---|
| COVID-19 Testing/Swabbing & Mobile Clinics |
Patient CoHorts:
Services:
|
23% |
| Palliative Care Programs |
Patient CoHorts:
Services:
|
15% |
|
Mental Health & Addictions (MH&A) Programs |
Patient CoHorts:
Services:
|
12% |
| High Intensity Needs Programs |
Patient CoHorts:
Services:
|
6% |
Note: A number of CP programs (35%) were unique, localized programs not broadly offered elsewhere in the province. These programs included various patient cohorts and service offerings, including Naloxone kit distribution for overdose patients.
References
