1. Definition and Purpose
What is a Model of Care?
A Model of Care broadly defines the way health services are delivered. It outlines best-practice care and services for a person, population group, or patient cohort as they progress through the stages of a condition or event.
Purpose in Paramedicine:
- To provide structured care plans designed to guide clinicians in delivering timely, appropriate, and consistent care.
- To shift the paramedic paradigm away from simple "scoop and run" to "treat and refer" or specialized bypass.
- To reduce unnecessary Emergency Department (ED) presentations and relieve pressure on the broader healthcare system.
- To keep the patient at the center of care, delivering treatment in their home or community when clinically appropriate.
2. Pre-Hospital Clinical Pathways
Clinical pathways are specific, evidence-based algorithms or protocols that operationalize a Model of Care. They direct paramedics to bypass standard local hospitals in favor of specialized definitive care or alternative community resources.
Time-Critical Pathways (Bypass Protocols)
| Pathway | Clinical Trigger | Outcome / Action |
|---|---|---|
| Stroke Pathway | FAST positive assessment (Face, Arms, Speech, Time) within the thrombolytic/endovascular retrieval window. | Stroke Centre Bypass. The patient is transported directly to a facility equipped for immediate CT imaging, thrombolysis, or Endovascular Clot Retrieval (ECR). Pre-hospital notification is mandatory. |
| STEMI Pathway | 12-lead ECG displaying ST-Elevation Myocardial Infarction meeting specific millimeter criteria. | Cath Lab Activation. Direct bypass to a Percutaneous Coronary Intervention (PCI) capable hospital. The paramedic sends the ECG ahead and activates the on-call cardiology team. |
| Major Trauma Pathway | Meeting vital sign criteria (e.g., GCS < 13, SBP < 90), specific anatomical injuries, or high-risk mechanisms. | Direct bypass to a designated Level 1 Major Trauma Service, initiating trauma team activation. |
Specialized & Community Pathways
- Mental Health Pathways:
Goal: Avoid the ED, which is often a noisy, inappropriate, and escalating environment for acute psychiatric distress.
Action: Direct referral to crisis teams, community mental health triage, or joint-response models (like PACER: Police, Ambulance, Clinical Early Response) where mental health clinicians co-respond with paramedics. - Palliative Care Pathways:
Goal: Respect the patient's end-of-life wishes and Advanced Care Directives, maximizing comfort.
Action: Community-based management. Paramedics utilize Authorized Care Plans to administer symptom relief (e.g., subcutaneous analgesia/anti-emetics) and leave the patient at home, referring to community palliative nursing services rather than transporting to a hospital.
3. Paramedic-Led Models of Care
The Extended Care Paramedic (ECP) / Community Paramedicine
The Extended Care Paramedic (ECP) or Community Paramedic model represents a significant evolution in the profession. ECPs receive specialized training to manage low-acuity, sub-acute, and complex chronic conditions safely in the community.
Key Capabilities:
- Wound closure (suturing, skin glue) and advanced wound care.
- Antibiotic prescribing and administration for simple infections (e.g., UTIs, cellulitis).
- Urinary catheter replacement.
- Complex falls assessments and minor fracture/dislocation management.
- Referral Power: Direct referral to GPs, Hospital in the Home (HITH) services, and allied health professionals.
Applying Models of Care in Simulations
In your clinical simulations, applying these models requires a shift in critical thinking from "How do I transport this patient?" to "Does this patient need to be transported at all?"
- Scenario 1 (Palliative): You attend an 85-year-old with terminal lung cancer experiencing breakthrough pain. Instead of loading the patient, you review their Authorized Care Plan, administer subcutaneous Fentanyl for comfort, ensure they are settled, and arrange follow-up with their palliative nurse.
- Scenario 2 (ECP Approach): You attend a 70-year-old who has fallen and sustained a skin tear. Observations are stable, no head injury. You clean and dress the wound, assess the home for trip hazards, and organize a GP review for the next day, avoiding a 6-hour ED wait for the patient.
4. Escalation, Downgrade & Evidence-Based Practice
Escalation and Downgrade Criteria
Clinical pathways rely heavily on rigorous risk assessment to determine the appropriate disposition.
- Escalation (When to step up): Recognizing red flags that require higher acuity services. For example, a patient initially assessed for an ECP "treat and refer" pathway who demonstrates a subtle drop in GCS, a new fever (sepsis risk), or sudden haemodynamic instability must immediately be escalated to urgent ED transport.
- Downgrade (When to step down): Safely deciding that a patient dispatched as a high priority does not require hospital transport. This relies on stable, normal vital signs, a clear and benign history, intact patient capacity to consent, and the availability of safe community resources (e.g., a family member to monitor, and an appointment booked with a GP).
Critical Evaluation: Aligning with Evidence-Based Practice
Why do modern healthcare systems invest heavily in these paramedic-led models?
- Improved Patient Outcomes: Evidence overwhelmingly shows that specific time-critical pathways (like STEMI and Stroke) drastically reduce mortality and morbidity by minimizing the "door-to-balloon" or "door-to-needle" times.
- Healthcare System Priorities (Resource Allocation): Emergency Departments are chronically overcrowded ("ambulance ramping"). By utilizing ECPs and alternative pathways to treat low-acuity patients in the community, acute hospital beds are preserved for truly critical patients.
- Patient-Centered Care: Evidence suggests that elderly and palliative patients have significantly better psychological outcomes and lower risks of hospital-acquired infections (nosocomial infections) when treated safely in their own homes.
- Cost-Effectiveness: A pre-hospital "treat and refer" event is vastly more cost-effective for the healthcare system than an ED admission followed by inpatient ward placement.