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A survey of community
paramedicine course offerings
and planned offerings
A
broad variety of community paramedic (CP)
projects and pilot programmes have been
implemented in the US and internationally
over more than 25 years with the goal of increasing
access to healthcare services for underserved
populations, particularly those in remote and rural
settings, as well as underserved populations in urban
settings. The trend has included programmes that
have expanded the clinical scope of practice of the
paramedic and emergency medical technician (EMT)
(Alaska Community Health Aide Program (ACHAP),
2011; Bigham et al, 2013; Goodwin, 2012a; 2012b;
Tan, 2013), and other programmes that have focused
on expanding the roles of the paramedic and EMT
(Tan, 2013), with only limited, or minimal, changes in
the scope of practice, if any. Those programmes that
have focused on expanding the roles, rather than the
clinical practices of the CP, include expanding the CP
roles to pathway care coordinators, mobile healthcare
clinic staff (for wellness checks, routine non-acute
visits, routine physical examinations, routine blood
pressure and blood glucose checks, etc.).
With the implementation of The Patient Protection
and Affordable Health Care Act (ACA) (US Public
Law 111148; AE 2.110: 111140) in the US, new
and substantially different rules and regulations are
currently taking effect that will signifcantly impact
health care delivery in the US and are projected
to have an impact on healthcare economics in
the US. Many of the new rules and regulations
apply to personal wellness, prevention, decreasing
readmissions to hospitals, and management
of chronic diseases ( Joint Committee on Rural
Emergency Care ( JCREC) and National Association
of State EMS Offcials (NASEMSO), 2010; Haebler,
2012). Other issues addressed in the ACA are
William Raynovich, associate professor, Creighton University, Omaha, NE US; Michael Weber, BS EMS student, Creighton University,
Omaha, NE US; Michael Wilcox, clinical associate professor of emergency medicine, University of Minnesota, Minneapolis, MN US;
Gary Wingrove, strategic affairs manager, Gold Cross/Mayo Clinic Medical Transport, Rochester, MN US; Anne Robinson-Matera,
president, Caring Anne Consulting, LLC, Eagle, CO US; Susan Long, director of clinical and support services, Allina Health EMS,
Minneapolis, MN US.
Email for correspondence: billr@creighton.edu
Abstract
Introduction: This paper reports on the results of a survey that was sent to every
recipient of a standardised Community Paramedic (CP) curriculum. The survey
was sent out to 223 post-secondary educators and Government officials. Out of
223 total surveys, 68 (30.49%) responses were received. Forty-seven of the 68
responses (69.11%) answered the question: When are you planning on giving a
community paramedic course?; 35 of the 47 respondents (74.46%) indicated that
their institution had already conducted a CP course, was currently conducting a CP
course, or are planning on conducting a CP course within the next five years; of the
additional 12 programmes (25.53%), 6 (13.0%) were waiting for state approval,
and the other 6 (13.0%) were unknown as to when they would be offering a course.
Conclusions: At the time of the survey, many CP courses were in planning stages
by programmes that had received the standardised CP curriculum, both in the US
and internationally. It appears that the CP curriculum that has been disseminated
internationally has been broadly accepted and will be widely utilised.
Key words
lCommunity paramedic lCurriculum lEducation lIntegrated mobile
health care lTraining
Accepted for publication 4 April 2014
the shortages of physicians and nurses in many
areas of the US and the disparity of healthcare
services that exist between rural and urban areas
and wealthy and poor populations (Conrad, 1991;
JCREC and NASEMSO, 2010; Haebler, 2012). In
order to fll some of the gaps in healthcare services,
pilot programmes are being funded to seek new
safe, effective and effcient health service delivery
models ( JCREC and NASEMSO, 2010; NASEMSO
et al, 2010; Haebler 2012). A standardised CP
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curriculum was developed by a collaborative
group of physicians, nurses, paramedics and
public health offcials and rural health offcers,
with representation from Canada, Australia, and,
in the US, Minnesota, Nebraska and Colorado. The
parent organisation of the curriculum development
group was the North Central Emergency Medical
Services Institute (NCEMSI). The CP curriculum
development group was formed under the auspices
of the NCEMSI by the Community Healthcare and
Emergency Cooperative (CHEC) (see Box 1 for
CHEC member organisations).
To develop the CP curriculum, the CHEC
developmental group reviewed and collectively
culled, by consensus, the best practices of the
Alaskan Native Health Aid/Practitioner programme
(CHAM/CHAPS) and the Navajo Health Aid/
Practitioner programme (JCREC and NASEMSO,
2010; US Department of Health and Human Services
(USDHHS) et al, 2004; ACHAP, 2011), the Taos County
Community Health Practitioner Project (19952000),
the US Navy Corpsman Training Manual (NAVEDTRA
14319), US Army patient care specialists (STP
8-68W13-SM-TG), the US Air Force, independent
duty medical technicians (AFTM 44158), as well as
the Health Practitioner programme of Australia, and
the rural health practitioner programmes of England,
Canada and several other countries (Emergency
Medical Services Chiefs of Canada (EMSCC), 2006;
Mulholland et al, 2009; JCREC and NASEMSO,
2010; ACHAP, 2011). The Health Aid/Practitioner
programmes of Alaska and the Navajo reservations
have been in existence since the 1950s and are the
longest documented and institutionalised programmes
of this type (OHara-Devereaux and Reeves, 1980;
USDHHS et al, 2004; ACHAP, 2011).
Following the delivery and evaluation of initial
pilot courses in Minnesota and Colorado, the
curriculum was revised to refect student, instructor
and stakeholder feedback. This was accomplished
in 2011 with the convening of a group of
subject matter experts and educators (Minnesota
Emergency Medical Services, 2013). The goals
were to standardise the curriculum, create a more
robust educational format and, ultimately, improve
sustainability for quality programmes in the future.
In addition, a standing curriculum review team was
formed to continuously monitor the curriculum
development, review and approval process for all
future changes to the curriculum.
All of the currently offered and planned CP
programmes have a similar goal, which is to fll
gaps in community health services that are due
to shortages of clinical facilities and professional
practitioners, such as physicians, dentists, nurses,
various therapists, and health aides. These
programmes have successfully demonstrated
the safety, competency, and cost effectiveness
of this approach to flling gaps in healthcare
services in underserved populations by providing
supplemental training to paramedics and then
utilising those specially trained paramedics (Conrad,
1991; JCREC and NASEMSO et al, 2010). It has also
been shown that those specially trained paramedics
can safely and effectively provide chronic,
palliative, and therapeutic community health
services in the US ( JCREC and NASEMSO, 2010;
NASEMSO et al, 2010; Patterson and Skillman, 2013)
and in other countries (EMSCC, 2006; Mulholland et
al, 2009; JCREC and NASEMSO, 2010; ACHAP 2011).
The implementation of community paramedic
programmes have, in certain settings, led to
role conficts and inter-professional tension, as
the term paramedic in the US has been deeply
enculturated and codifed in legislation over the
past 30 years, after the passing of the US EMS Act
of 1973. While in the US, the paramedic primarily
provides emergency response care (911), along
with interfacility transportation, the roles of the
paramedic working in mobile units do not extend
to continuous care, chronic care (e.g. routinely
scheduled home visits), wellness checks (e.g.
routine physical examinations and counseling), and
general public health roles (e.g. health care access
and pathways coordination). While these roles
for the paramedic are generally limited to these
roles in the US, many other nations of the world
utilise the terms paramedic and paramedical
to refer to a broader and more general clinician
who not only provides emergency response and
interfacility transfer health care, but also wellness
visits, chronic care, and routine healthcare services,
according to the International Dictionary of
Medicine and Biology (Landau, 1986; Ruest et al,
2012). As medical and nursing organisations, such
as the National Association of EMS Physicians
Box 1. Community Healthcare and Emergency
Cooperative member organisations
lNorth Central EMS Institute, St. Cloud, Minnesota
lAustralian Centre for Prehospital Research, Brisbane, Queensland, Australia
lCreighton University EMS Education, Nebraska
lDalhousie University, Nova Scotia
lEMS Education, Offutt Air Force Base
lHennepin Technical College, Eden Prairie, Minnesota
lMayo Clinic Medical Transport, Minnesota
lMnSCU Healthcare EducationIndustry Partnership, Minnesota
lRURAL Centre, Halifax, Nova Scotia
lState Offices of Rural Health, Minnesota and Nebraska
lState Offices of EMS, Minnesota and Nebraska
lUniversity of Nebraska Medical Center
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(NAEMSP) and American Nurses Association (ANA)
have engaged in the discussion about the CP roles
and scope of practice, recommendations have
been made to modify the nomenclature to that
of mobile integrated healthcare practice (MIHP)
(Hunt, 2014; NAEMT, 2014). The North Central EMS
Institute Community Healthcare and Emergency
Cooperative (NCEMSI-CHEC), the International
Roundtable of Community Paramedicine and other
organisations have, however, viewed MIHP to be
a misleading term, as the CP practice has been
located in the home and clinics, and does not imply
patient transport. In addition, MIHP is a conceptual
framework where CP is an actual provider of care.
As paramedics are trained to perform advanced
invasive procedures, e.g. endotracheal intubation,
intravenous access and continuous medication
administration, medication injections, and
electrotherapy, as well as many other advanced
invasive procedures (National Highway Traffc
Safety Administration Emergency Medical Services,
2009), they require only targeted special training
to expand their practice to new palliative, chronic,
and wellness care roles ( JCREC and NASEMSO,
2010; NASEMSO et al, 2010; Patterson and
Skillman, 2013). The CP curriculum developed by
CHEC recommends, for experienced practising
US paramedics, approximately 100120 hours of
didactic instruction and approximately 120160
hours clinical rotations, primarily working in family
practice and public health settings. Additional time
and clinical training settings may be required for
newly trained paramedics or those from non-EMS
backgrounds, such as social services workers,
nurses aides, dental technicians, etc., and less time
may be required for other practitioners who already
have a professional background in providing
community health services, e.g. registered nurses
and midwives ( JCREC and NASEMSO, 2010).
The community paramedic roles go well beyond
the American-centric traditional paramedic role
of serving as an extension of the physician. The
community paramedic practice is oriented toward
non-emergent medical care and the management
and monitoring of chronic disease states and
chronic health issues ( JCREC and NASEMSO, 2010;
NASEMSO et al, 2010). It is noteworthy that the
roles of the community paramedic appear to be an
appropriate ft with the US Affordable Health Care
Act, and its emphasis on preventative health and
the economic savings associated with decreasing
the number of emergency department visits to
acute care hospitals, decreasing unnecessary
hospital readmissions, and more effcient utilisation
of all healthcare providers and resources globally
( JCREC and NASEMSO, 2010; Patterson and
Skillman, 2013).
Methods
This research survey was developed and
delivered by a multi-agency and multi-
disciplinary health care research team, comprised
of four paramedics, three registered nurses and
one family medicine physician, located in three
states and fve agencies in the US. We sent the
survey to 223 individuals throughout the world
who had requested a copy of the CP curriculum.
Of the 223 total surveys sent out, 195 were
sent to US recipients, 17 were sent to Canadian
recipients, 10 were sent to Australian recipients,
and one was sent to a recipient in Ireland. The
respondents included administrative and educator
representatives of accredited post-secondary
educational institutions and Government offcials,
all of whom had previously requested a copy of
the curriculum. As such, this was a population
survey, and not a sample.
We utilised SurveyMonkey to develop and
distribute the survey, rather than a specifc
university-based system, to neutralise a potential
perception that only one educational institution
was conducting the survey. The survey consisted
of 19 questions. Skip logic was utilised, which
permitted respondents to bypass questions
that were not applicable to their agencies.
The Creighton University Institutional Review
Board approved the project as exempt status.
Participation in the survey was voluntary and
anonymity of the subjects was guaranteed. The
survey was initiated 14 October 2013, with a
distribution to 223 subjects. A reminder was sent
out to non-respondents after two weeks and the
survey was closed 19 December 2013.
Results
A total of 223 surveys were sent out and 68
(30.49%) responses were received. Of the 68
responses, 60 were from US recipients, fve were
from Australian recipients and three were from
recipients in Canada. None of the recipients
opted out from any of the questions (i.e.
SurveyMonkey skip logic function). Three
responses indicated that a community paramedic
curriculum was received by an alternate source;
however, these alternate sources were actually
the original CHEC curriculum and all received
the same version of the curriculum from one
member of the CHEC curriculum development
group. Forty-seven of the 68 respondents
(69.11%) answered the question: When does
your educational institution plan on offering
the community paramedic course? Thirty-fve
of the 47 respondents (74.46%) stated that their
institution had already conducted a course, was
currently conducting a course at the time they
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Figure 3. How is the community paramedic programme funded
in your area?
Non-Government funding
Non-Government grant
Local Government grant
State Government grant
Federal Government grant
Fee for service
0
.
0
0
%
5
.
0
0
%
1
0
.
0
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%
1
5
.
0
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%
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%
2
5
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%
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4
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5
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5
0
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36.36%
9.09%
45.45%
18.18%
0%
18.18%
Figure 1. When are you planning on giving a community
paramedicine course?
13%
13%
13%
32%
17%
8%
4%
Taught class in 2013
Offering class in 2014
Within 2 years
Within 3 years
Within 5 years
Waiting on state approval
Unknown time frame for class
Paramedics with at least
20 yearsexperience
Paramedics with at least
15 years experience
Paramedics with at least
10 years experience
Paramedics with at least
8 years experience
Paramedics with at least
5 years experience
Paramedics with at least
3 years experience
Entry-level paramedics (recent
paramedic graduates)
Entry-level EMT providers
(recent EMT graduates)
0% 10% 20% 30% 40% 50% 60% 70% 80%
0%
0%
25%
25%
25%
25%
50%
75%
Figure 2. Years of experience of the paramedics taking the
community paramedic course
responded, or was planning on conducting a
course within the next fve years. (See Figure 1).
Only four respondents answered a question about
the median years of experience of students taking
a CP course. Three of the responses indicated
that the experience level of those taking the CP
course was fve years, and other experience levels
were spread evenly with one each from one year
of experience to 20 years of experience. Forty-six
respondents answered a question about the range
of ages of the majority of their CP students. Of
these 46 respondents, the largest age range group
was reported by ten respondents (21.74%) to be
between 25 and 45 years, and for the ages between
30 and 45 years was reported by six respondents
(13.04%) (See Figure 2).
We asked a question about how the respondents
anticipated CP programmes in their communities
would be funded after the programmes were
offered. Fifty-seven of 68 respondents (83.8%)
did not answer this question. Eleven (16.17%)
responded to this question, with fve (45.45%)
indicating that the main source of funding was
anticipated to be fee-for-service, four (36.36%)
indicating non-Governmental agency as the main
funding source, two (18.18%), each indicating
an even split between federal Government grant
and local Government funding, and one (9.09%)
indicating a state Government grant as the funding
source. No respondents indicated that they
anticipated any non-Governmental grants for a
funding source for a CP course (See Figure3).
These percentages total more than 100%, i.e.
127.27%, as respondents reasonably anticipate more
than one source of funding.
We asked: How did their institution plan
on funding their CP course? Forty-four (44)
respondents answered this question. Of these
44 responses, 36 respondents (81.82%) indicated
that student tuition would be the main funding
source. Fourteen respondents (31.82%) indicated
that they anticipated Government would be
funding their programmes. Two respondents
(4.55%) indicated that they anticipated receiving
non-Government grants to fund their CP courses.
Seven respondents indicated that they anticipated
non-Governmental support, other than grants, to
fund their CP courses.
We asked the respondents to identify the types of
agencies that they projected their future CP students
who complete their courses would be associated
with. Forty-three (43) responded to this question,
with 22 (51.16%) indicating that they expected
those completing the training would be working
for a Fire Department EMS agency and 20 (46.51%)
projecting that their students would be working at
a for-proft EMS agency. The results indicated that
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a majority of the students would be practising in a
combination of rural, suburban, and urban areas,
with 32 of the 47 (68.09%) projecting practice in
rural settings, 25 (51.19%) in suburban settings, and
29 (61.70%) were projected to practice in urban
areas. (See Figure 4). The results add up to 182.9%,
as the respondents projected that students would
work in multiple settings, even within the same
organisation, at times.
Delimitations and limitations
This survey was sent to all individuals that
had requested and received the NCEMSI-CHEC
community paramedic curriculum (Version 3.0),
and thus, is a total target population study. The
survey was conducted solely as an internet-based
(SurveyMonkey) survey, with one initial email
distribution and one follow up reminder request to
non-respondents. The survey was closed
19 December 2013. A limitation of the study is
that all but one of the authors are members of
the organisational group (NCEMSI-CHEC) that
was responsible for developing and disseminating
the survey; thus, a bias in favour of promoting
the results may be construed. This potential bias
was, however, negated to the extent possible by
the inclusion of one disinterested author and due
diligence to report all of the data received without
any biased interpretations. No responses were
excluded.
Another limitation of this survey is that 68 of
a total of 223 recipients of the CP Curriculum
responded for a response rate of only 30.49%.
Although we did send one email follow-up request,
we did not send paper surveys or make telephone
or other modes of contact, which might have
increased the response rate. Thus, a selection bias
may exist, where those non-respondents have
categorically tended to be doing something that is
different than the response group.
Conclusions
The authors concluded that the current NCEMSI-
CHEC standard CP curriculum that is being
disseminated internationally at no charge to
accredited post-secondary educational institutions
is contributing to the implementation and
standardisation of community paramedic education.
The CP curriculum is already being integrated
internationally into many of the two-year and four-
year undergraduate degree programmes (OMeara
et al, 2014). Based on the expressed trending intent
to offer more CP courses over the next three years
by additional institutions, the authors concluded
that the CP curriculum is beginning to establish
a broad base acceptance that can be seen in the
United Kingdom, Canada, Australia and the United
States. Lastly, the feedback received from the
respondents has helped to inform the curriculum
development group about possible changes that
can be made to improve the curriculum.
Confict of interest: none declared
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