Cost effectiveness and outcomes of a nurse practitioner–paramedic–family physician model of care: the Long and Brier Islands study
Background
In Canada there is a growing awareness of and commitment to finding effective and efficient strategies that address the health needs of rural communities (Romanow, 2002). To be sustainable, new approaches must maximize access to health services that emphasize health promotion and address local health needs with ‘minimum leakage’ (Humphreys et al., 2006: p. 35). Such innovations must also be acceptable to users of these services. This paper discusses the results of a longitudinal three-year study that evaluated an innovative model of rural primary health and emergency care involving collaboration among a nurse practitioner (NP), paramedics and family physicians.
The study was conducted on Long and Brier Islands, a geographically remote area in Nova Scotia on the east coast of Canada. Getting there requires a 45 min drive from the nearest town, a short ferry ride to Long Island, the larger of the two and home to three of the Islands’ four villages, and another to Brier Island. Collectively the Islands are populated by approximately 1240 residents, half of whom are older adults. The Islands had been without resident physician services for many years and, apart from paramedics, the only other resident health care professional was a registered nurse offering foot care services.
Concerned community leaders lobbied for improved access to primary health care services. In response, Emergency Health Services (EHS) decided better use could be made of paramedics who, though stationed on the Islands around the clock, were responding to only one emergency call every third day. Following an education program, paramedics began to assess and manage simple wounds, administer tetanus injections and flu immunizations and perform home assessments. Resident response was positive; nevertheless, they continued their advocacy efforts for a broader range of services (Murray et al., 2002). Thus EHS introduced the NP–paramedic– physician model of care and commissioned an independent evaluation.
Legislation authorizing the role of NPs now exists nation-wide but in 2003 NPs had just been newly implemented in Nova Scotia (Hass, 2006; DiCenso et al., 2007). The safety and effectiveness of NPs in primary care has been established in a systematic review (Horrocks et al., 2002) and it has been shown NPs increase health promotion (Nova Scotia Department of Health, 2004) and access to care by practicing in rural areas designated as under-serviced by physicians (Centre for Rural and Northern Health Research, 2006). In Nova Scotia, rural health board chairs and health professionals identified that NPs could address many of the gaps in rural primary health care services (Martin-Misener, 2006).
The few studies evaluating the role of paramedics in primary health care have been limited to observational, descriptive or retrospective designs. They describe a role for paramedics in screening for domestic violence (American College of Emergency Physicians, 1996; Husni et al., 2000), providing care in sexual assault calls (Greenwood, 2003), managing wounds (Hale and Sipprell, 2000), providing primary injury prevention (Garrison et al., 1997; Kinnane et al., 1997), conducting geriatric assessments (Salinas and Calhoun, 2002; Mason et al., 2003; Shah et al., 2004), assessing children (Foltin et al., 2002) and providing flu immunizations (Mosesso et al., 2003). No studies have evaluated a model of rural primary health care involving NPs, paramedics and physicians.
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