Juntunen, Michael B.

OBJECTIVE To evaluate the impact of community paramedic (CP)-delivered, in-home diabetes self-management education and support (DSMES) for adults with poorly managed diabetes. RESEARCH DESIGN AND METHODS In a pragmatic, single-arm pilot trial, adults with HbA1c ≥9% and a recent emergency department or hospital visit received a 1-month CP-led DSMES intervention. Outcomes included HbA1c, health care engagement, and patient-reported satisfaction. RESULTS Seventy participants (median age 61 years, 50% rural, 84% with type 2 diabetes) completed the intervention. HbA1c declined from 9.8% to 8.2% at 4 months (P < 0.001). Engagement with primary care, endocrinology, and DSMES improved. Satisfaction was high (mean rating 9 out of 10). CONCLUSIONS CP-led DSMES improved glycemic management and care engagement in underserved populations. This scalable model warrants further study.

Abstract Background Community Paramedic (CP) programs use specially trained paramedics to provide healthcare in the community to increase access to care, reduce unnecessary emergency department visits, and improve timeliness of care. Mayo Clinic in Rochester, MN recently launched a CP Program to provide in-home care for patients who require regular intravenous medications, wound care, diuresis for heart failure, medication reconciliation, care plan compliance/education. CP utilizes i-STAT1 CHEM8+ and Lactate (CG4+) testing (Abbott Point of Care, Abbott Park, IL) to make therapy decisions primarily for heart failure patients based on rapid laboratory results. Having results available at the point of care (POC) eliminates delays between testing and treatments, expediting care for the patient. Prior to using i-STAT, CP traveled to the patient’s residence, drew blood tubes, delivered the tubes to Mayo Clinic, waited for test results, returned to the patient’s home, and provided treatment. In this observational study, we assessed the benefit of in-home POC i-STAT1 testing performed by our CP Program to improve patient care and increase efficiency. Methods Patients within a 40-mile radius of Mayo Clinic were eligible to receive CP service. Whole blood venous specimens were collected and tested using the i-STAT1 CHEM8+ metabolic panel cartridge according to manufacturer instructions to measure: ionized calcium, chloride, glucose, hematocrit, total carbon dioxide, blood urea nitrogen, creatinine, potassium, sodium, anion gap while the i-STAT1 CG4+ cartridge measures lactate. The laboratory information system was used to extract laboratory results, and Excel (Microsoft, Redmond, WA) was used to filter data and perform calculations. Results November 2022 through December 2024, CP performed testing with 353 i-STAT cartridges (3862 tests) on 102 unique patients who each had 1-12 separate orders. Patient ages were 25 to 97 years. 41.2% (1590/3862) of the individual results obtained were outside of our reference intervals (23.0% high, 18.0% low), with 10.8% being ionized calcium, 10.2% chloride, 10.3% glucose, 13.0% hematocrit, 7.6% total carbon dioxide, 18.2% blood urea nitrogen, 16.4% creatinine, 6.7% potassium and 6.9% sodium. Additionally, 0.13% of results were critically high (ionized calcium, potassium, and sodium) and 0.10% were critically low (potassium and ionized calcium). Hypokalemic patients were sent to the infusion therapy center for IV potassium. Patients experiencing hyperkalemia were retested and sent to the emergency department (ED). Hyponatremic and hypercalcemic patients were sent to the ED for further treatment. Abnormal (non-critical) results were reviewed by CP personnel to make treatment recommendations or medication adjustments. Conclusion i-STAT1 home testing performed by CP facilitated rapid therapeutic interventions and expedited decision-making. POC testing has increased the group’s efficiency—alleviating the need to transport specimens to the central laboratory and wait on test results before returning to the patient for treatment. Paramedicine emphasizes a proactive and preventative approach to medicine. We anticipate that this model of care and testing will expand to cover other chronic health conditions due to the program’s early success.

Abstract Introduction: Pragmatic trials aim to speed translation to practice by integrating study procedures in routine care settings. This study evaluated implementation outcomes related to clinician and patient recruitment and participation in a trial of community paramedicine (CP) and presents successes and challenges of maintaining pragmatic study features. Methods: Adults in the pre-hospital setting, emergency department (ED), or hospital being considered for referral to the ED/hospital or continued hospitalization for intermediate-level care were randomized 1:1 to CP care or usual care. Referral and enrollment data were tracked administratively, and patient characteristics were abstracted from the electronic health record (EHR). Enrolled patients completed baseline surveys, and a subset of intervention patients were interviewed. All CPs and a sample of clinicians and administrators were invited to complete a survey and interview. Results: Between January 2022 and February 2023, 240 enrolled patients (42% rural) completed surveys, and 22 completed an interview; 63 staff completed surveys and 20 completed an interview. Ninety-three clinicians in 27 departments made at least one referral. Factors related to referrals included program awareness and understanding the CP practice scope. Most patients were enrolled in the hospital, but characteristics were similar to the primary care population and included older and medically complex patients. Challenges to achieving representativeness included limited EHR infrastructure, constraints related to patient consenting, and clinician concerns about patient randomization disrupting preferred care. Conclusion: Future pragmatic trials in busy clinical settings may benefit from regulatory policies and EHR capabilities that allow for real-world study conduct and representative participation. Trial registration: NCT05232799.

Introduction Diabetes is one of the most common serious chronic health conditions in the USA. People living with diabetes face multiple barriers to optimal diabetes care, including gaps in access to medical care and self-management education, diabetes distress, and high burden of treatment. Community paramedics (CPs) are uniquely positioned to support multidisciplinary care for patients with diabetes by delivering focused diabetes self-management education and support and bridging the gaps between patients and the clinical and community resources they need to live well with their disease. Methods and analysis We will conduct a pragmatic single-arm prospective trial of a CP-led Diabetes Rescue, Engagement and Management (D-REM) programme that seeks to reduce diabetes distress. We will enrol 70 adults (≥18 years) with diabetes who have haemoglobin A1c (HbA1c)≥9.0%, experienced an emergency department (ED) visit or hospitalisation for any cause within the prior 6 months, and reside in areas with available CP support in Southeast Minnesota (Olmsted, Freeborn and Mower counties) and Northwest Wisconsin (Barron, Rusk and Dunn counties). Participants will be identified using Mayo Clinic electronic health records, contacted for consent and enrolled into the D-REM programme. Visit frequency will be individualised for each patient, but will be an average of four CP visits over the course of approximately 1 month. Outcomes will be change in diabetes distress (primary outcome), confidence in diabetes self-management, health-related quality of life, self-reported hypoglycaemia and hyperglycaemia, HbA1c, ED visits and hospitalisations. Outcomes will be assessed on enrolment, programme completion and 3 months after programme completion. Ethics and dissemination The study was approved by Mayo Clinic Institutional Review Board. Findings will be disseminated through peer-reviewed publications and presentations. If demonstrated to be successful, this model of care can be implemented across diverse settings and populations to support patients living with diabetes. Trial registration number NCT04385758 .