Mobile Integrated Health Model of Care

Mobile Integrated Healthcare provides patient-centered health care visits that are:

  • Delivered in the patient's home or where they're at
  • Based on the patient's needs and preventive services
  • Available 24 hours per day, seven days a week

Purpose

The purpose of this model is to:

  • Enable vulnerable, at-risk individuals and older adults to live safely in their own homes
  • Reduce avoidable use of ambulance and emergency services
  • Reduce the number of patients in the emergency department with non-life-threatening concerns
  • Reduce or delay critical care hospital stays or long-term care wait times

What we do

A community paramedic can respond to 9-1-1 calls and scheduled visits. These at-home visits may include:

  • Taking vital signs like pulse and breathing rate, temperature, blood pressure, blood sugar checks, electrocardiogram
  • Pre-treatment blood work
  • Medication and chronic disease management
  • Monitoring of patients with congestive heart failure, diabetes and / or chronic obstructive pulmonary disease through remote technology to recognize changes
  • Involvement in the patient's Coordinated Care Plan with Home and Community Care Support Services, primary care and other agencies
  • A multi-disciplinary approach that involves other health professionals, such as mental health nurses, occupational therapists, emergency communications nurses in the EMS dispatch centre, and community agencies for health and social needs, such as mental health, elderly falls and chronic health conditions

Refer a patient

For health care professionals only

Primary care physicians, Home and Community Care Support Services, and allied agencies may refer eligible patients to the Community Paramedic High User and Long-Term Care programs.

Eligibility

  • Have visited the emergency department at least five times in the previous year
  • Are on a wait list for long-term care or waiting for an assessment to be eligible for long-term care

Contact

For more information:

In an emergency, always dial 9-1-1.

Types of community paramedic teams

  • Community assessment response team

    The community assessment response team responds to 9-1-1 calls or scheduled visits to address many non-life-threatening, non time-critical calls that can be handled without transporting to hospital.

    Paramedics on these teams:

    • Perform home visits to conduct medical assessments and address underlying medical issues
    • Provide education and make referrals to community agencies or providers better suited to needs
    • Conduct routine-based remote monitoring for early detection of emergency incidents or escalation in medical conditions
    • Help navigate the options in their local community to help with their needs
    • Help with medicine or chronic disease management
    • Participate in a patient's coordinated care plan with allied health or social agencies
  • Emergency communication nurse

    When a 9-1-1 call is determined not to be life-threatening and not time-critical, an emergency medical dispatcher will transfer the call to one of our emergency communication nurses. The nurse will ask for your health card number to access your files and continue to ask further medical questions.

    The certified emergency registered nurse is located in the Niagara Emergency Medical Services dispatch centre and:

    • Has the ability to understand your immediate needs by asking questions based on the highest standard of care
    • Has a solid understanding of the health care options available in your community
    • Will provide medical advice or instructions
    • Will direct you where to go to best meet your needs. For example, this could be a walk-in clinic, pharmacy or visit to your family physician.
    • Is embedded within the ambulance communication centre which allows for seamless integration of health resources
    • May send a paramedic to provide further assessment on scene
  • Falls intervention team

    The falls intervention team responds to 9-1-1 calls to better address the demand for non-life-threatening falls from ground level in real time.

    Staffed with a paramedic and an occupational therapist, the team will:

    • Provide outreach to retirement homes and assisted living homes to look for ways to decrease the number of non-life-threatening 9-1-1 calls
    • Visit patients based on paramedic referrals
    • Perform working medical assessments, address any underlying medical issues and use available lifting equipment to safely lift patients off the ground
    • Complete falls risk screening, mobility, functional and environmental assessments to prevent the risk of future falls
    • Consult with Seniors Services and EMS to determine additional needs. For example, equipment recommendations for ambulances and seniors fall prevention sessions.
  • Mental health and addictions response team

    The mental health and addictions response team responds to 9-1-1 calls to better address the demand for non-life-threatening mental health and addictions challenges in real time.

    The mental health nurse works with the paramedic to:

    • Assess patients experiencing acute mental health or addictions related crises, and find the best resource
    • Begin transport to hospital when appropriate
    • Assist in accessing in-person referrals or follow-ups with Niagara Region or other community programs
    • Provide education
  • Paramedics providing palliative care

    Paramedics providing palliative care respond to 9-1-1 calls and scheduled visits to address the needs of patients at end of life that can be handled without transporting to hospital.

    Paramedics on this team will:

    • Perform medical assessments and provide comfortable end of life care
    • Provide education and make connections to community or social service agencies and health care providers to address the patient's needs
    • Work with community palliative teams to bridge potential gaps in care
  • Street outreach paramedic

    The street outreach team responds to many non-life-threatening, non time-critical calls for those unhoused that can be handled without transporting to hospital. The primary goal of this team is to bridge the gap in accessing fair primary care for the living-rough Niagara.

    Paramedics on this team will:

    • Perform medical assessments and address underlying medical issues for the unhoused
    • Provide education and make connections to community and social service agencies or health care providers to address the patient's needs
    • Help navigate the options in Niagara to help with patient needs
    • Provide support and resources for individuals struggling with addiction
    • Follow-up with patients as needed
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