Expanded scope paramedic programs have been implemented around the world, to both better serve the needs of a specific population and to reduce the use of paramedic services and the ED [1]. Long-term care (LTC) residents have been the focus of many such programs. In this volume of CJEM, Leduc et al. surveyed a number of Canadian paramedic service leaders, and 98% of respondents supported the development of paramedic-based programs to treat LTC residents on-site [2]. LTC residents are felt to be a population well served by such a program for a variety of reasons. LTC residents are often elderly, with high levels of frailty and complex co-morbidities including cognitive impairment, high use of the ED, often times are transported there by paramedics [1, 3, 4]. Transporting these patients to busy EDs can contribute to confusion and anxiety, as well as exposure to illness and adverse events [5]. LTC residents also are a defined group with inherent support structures in the LTC and in some instances even an assigned physician who will follow-up. Emergency departments (EDs) and the entire emergency care system are under tremendous pressure, with safety and quality threatened by prolonged boarding of admitted patients, high acuity and volumes, and patients with non-emergent conditions and nowhere else to go [6]. These factors combine to create conditions that support implementing programs that would better serve both LTC residents and the health system, getting the right care, in the right place, at the right time.

The type of care provided by expanded scope paramedic programs varies from site to site. It can include response to 9-1-1 calls by a single-responder non-transporting paramedic who provides a variety of treatments on-site [7], or scheduled follow-up or monitoring visits for acute and/or chronic health issues or supported discharge after a hospital admission. The Leduc survey respondents felt the top priorities were support for patients being discharged (30.6%), extended care paramedics (24.5%), and respiratory illness treat-in-place programs (20.4%) [2]. Recent reviews support the addition of on-site (acute) care for LTC patients instead of traditional transport to ED via paramedic services [8, 9]. Outreach care is thought to gain most of its efficiency when linked to wider system-level coordination and preventive components. A recent systematic review suggests that reactive ability to treat acute complaints is an important part of these multicomponent services to LTC patients [8]. According to recent Canadian articles, other most promising service components or possibly standalone interventions might be preventive palliative outreach care, pneumonia care pathway, specified training for LTC staff to treat dehydration and infections and multidisciplinary team visits to LTCs [9]. In Finland, an outreach care model to nursing homes, the Mobile Hospital, gave promising results in the suburban area of Espoo. The model was very well accepted in staff interviews (100% of the 21 respondents). Additionally, the non-urgent EMS transfers were significantly reduced and the utilization of ED and hospital resources was reduced in pre-post study setting (unpublished, Kontunen et al.). Some calls from the nursing homes were managed by telephone consultation by the Mobile Hospital, and when deemed necessary, by an on-site visit. Finally, consisting of nurses with special training, the Mobile Hospital unit worked successfully as a communication link between the social workers of the LTCs and the staff of the EMS and the ED. A recent systematic review based on observational studies suggests that using outreach services with acute and preventive components, cost savings (crudely ranging from USD 880 to USD 4054 per LTC bed) might be achieved [8].

Spread and scale of these programs is not without challenges. The evidence base is still small, and measures of effectiveness of these heterogeneous programs would benefit from some common metrics, a point emphasized by Leduc et al. in their findings as well. Although interest and support is shown here by Leduc et al.’s survey, there do remain significant barriers; only 36% of respondents indicated having an active program of this type [2]. The authors present several challenges and opportunities; acknowledging that these responses represent only a fraction of paramedic services in Canada and are heavily weighted to one province, this is an important starting point for broader implementation. The need for changes to the medical oversight system (34% of respondents), the need for changes to legislation (36%) and cost (30%) were seen as the top barriers for program implementation [2].

As Leduc writes: “More evidence is needed to determine what program types are the safest, most effective, and yield the best patient-oriented outcomes in the LTC population” [2]. The potential benefits of expanded scope paramedicine service models can be accomplished if we continue to evaluate and develop the existing models, adopt the best practices and, finally, have the courage to put the new LTC care services to use.