Exploring implementation and sustainability of a community paramedicine model to reduce hospitalizations: a pragmatic randomized trial

Community paramedicine models of care may reduce health system burdens and improve access to care, especially in rural areas. Assessment of intervention implementation from the perspective of implementers and users is critical to refine further implementation, support scale-up, and realize sustainability. The parent study was a point-of-care pragmatic randomized trial of a community paramedic (CP) program for patients with intermediate acuity needs (the Care Anywhere with Community Paramedics [CACP] program) versus usual care with the goal of reducing 30-day acute care use. The hybrid effectiveness-implementation design included assessment to explore barriers and facilitators to CACP. Patients in the intervention arm were recruited to complete a survey after the last CP visit, and a sample was invited to an individual interview. All CPs and a sample of clinicians and administrators, purposefully sampled to represent a range of roles and settings with experience using the program, were invited to complete an interview and survey at the end of enrollment, which included questions about program processes, satisfaction with care, and perceptions of CACP sustainability. Surveys were analyzed descriptively, and qualitative data were analyzed using methods of thematic analysis guided by implementation constructs. Between January 2022 and February 2023, 240 patients were enrolled in the trial; 91 of 119 patients in the intervention arm completed a survey after their last CP visit and 22 were interviewed. Surveys were completed by 63 staff, and interviews were completed by 20 staff. Clinicians reported being very satisfied with communication with CPs (n = 34, 82.9%) and implementation of care plans (n = 33, 78.6%). Patients also reported high satisfaction, including with CP ability to answer their questions or connect with the right health care provider (n = 35, 59% Strongly Agree). Staff impressions of program sustainability varied, though, and included CP concerns about the complexity of some referred patients and insufficient time to prepare for visits. The program was successfully implemented in busy clinical settings with high levels of overall satisfaction. While feasible and acceptable, additional staffing, refinement of eligible patient populations, and continued improvements to referral and communication systems may be needed to support program sustainability. ClinicalTrials.govNCT05232799. Registered on 10 February 2022.