ASSESSING PARAMEDICS’ PERSPECTIVES ON AN EMERGENCY DEPARTMENT VIRTUAL OBSERVATION UNIT FALL PREVENTION PROGRAM

TL;DR

This study explores paramedics' experiences in a home-based virtual program designed to prevent falls in older adults.

Contribution

The study highlights the untapped potential of paramedics in fall prevention through home visits and virtual care.

Findings

Paramedics gained new skills not typically part of their training.

They provided unique insights into patients' home environments.

Paramedics felt more integrated and valued in patient care teams.

Abstract

Falls are the leading cause of fatal and nonfatal injury for older adults. We created the Emergency Department Virtual Observation Unit (EDVOU) to provide observation level care for older ED patients in their homes and better assess their fall risks. Mobile integrated health (MIH) paramedics visited patients’ homes where they conducted a multicomponent fall evaluation and facilitated an emergency medicine telemedicine consult. We aimed to understand paramedics’ experiences in our EDVOU Fall Program.

We conducted a qualitative study through semi-structured interviews of EDVOU Fall prevention paramedics to determine how comfortable they were with implementing the EDVOU fall program. Interviews were transcribed, independently reviewed by multiple team members, and subsequently coded into themes.

Fifteen of thirty-six (42%) paramedics were interviewed. Three main themes emerged: 1) learning new skills otherwise not included in paramedic training, 2) having unique perspectives and interactions with patients in the home environment where most other clinicians do not have insight, and 3) being more integrated in a team to play a bigger role in patient care.

MIH paramedics had an overwhelmingly positive experience with the program. Paramedics felt they played a pivotal role in fall prevention, as the program allowed them to learn more skills, form and share unique relationships and clinical perspectives given their role, and feel more valued as part of a patient team/care continuum. Paramedics’ unique role of entering the home to provide medical care are an untapped resource in preventative care, particularly as part of a virtual fall program.

Full text

INTRODUCTION

Falls are the leading cause of fatal and nonfatal injury as well as injury-related death for adults 65 years or older, with approximately 1 in every 4 older adults reporting a fall every year and around half being recurrent falls (Akyol, 2007; “Centers for Disease Control and Prevention, National Center for Injury Prevention and Control,” n.d.; R. Kakara et al., 2023; R. S. Kakara et al., 2024). Furthermore, older adults have the highest risk of serious injury or death following a fall(Falls, n.d.). Of the estimated 2.4 million Emergency Department (ED) visits and >700,000 hospitalizations from injury mechanisms among adults ≥65 years old, unintentional falls accounted for 91.8% of incidences(Moreland & Lee, 2021). Despite the frequency of falls and ample ED opportunities to prevent their recurrence, fall risk is rarely assessed in the ED (Davenport, Alazemi, et al., 2020; Tirrell et al., 2015). A study found that physicians and advanced practice providers felt they lacked adequate time in the ED to assess for fall risks due to limited resources and ED crowding (Davenport, Cameron, et al., 2020).

Telehealth/Mobile Integrated Health (MIH) programs present an emerging option for assessment of fall risks (Jiang et al., 2025). We created the ED Virtual Observation Unit (EDVOU) in January 2022 to provide observation level care for ED patients in their homes (Harper et al., 2021; Hayden et al., 2024). Within the EDVOU program, a pilot falls prevention program was created to better assess and manage fall risks for older patients. A crucial aspect of the fall program was the MIH paramedic visits. During these visits to the patients’ homes, which happened one day after ED visit and took on average 30–40 minutes, they conducted a home safety evaluation, a medication safety evaluation, and the Timed Up and Go (TUG) Test, a common functional test to determine fall risk (Jones et al., 2024).

In recent years, there has been a movement towards involving paramedics and/or Emergency Medical Service (EMS) personnel in healthcare, particularly in preventative services (Creating New EMS Education Standards, n.d.). The Community Health Assessment Program through Emergency Medical Services (CHAP-EMS) study found that EMS personnel successfully provided diabetes and cardiovascular health prevention through a weekly program (Agarwal et al., 2016). Given the untapped resource and potential benefits of paramedics being on scene to see patients in their homes, Speier et. al performed a literature review on the effectiveness of EMS’s involvement in fall prevention (Speier et al., 2024). They found mixed to successful results for EMS’s role in assessing and referring patients who had fallen or were at risk for falling. They also identified two studies in the United States that established a Community Paramedicine/Mobile Integrated Health (CP/MIH) program, both of which saw a significant decrease in falls and fall-related 911 calls (Camp et al., 2024; Quatman-Yates et al., 2022).

However, there is scant literature documenting paramedics’ perspectives and experiences being involved in fall risk prevention programs, particularly a VOU Falls program. To date, only one study has investigated paramedics’ experiences assisting older adults with falls and found that their experiences were mostly positive, aside from a lack of services and situations that required complex decision-making (Watkins et al., 2024). Yet, there is still little literature looking into paramedics’ perspectives on being the central provider in a fall prevention program that includes an in-person MIH visit and ED telemedicine consult.

Given the gap in literature on MIH paramedics’ perspectives on their central role in an EDVOU Fall Prevention program, our study objective was to better understand their experience. We specifically sought to understand their viewpoint, particularly in performing the multicomponent fall evaluation, to improve this program as well as other potential MIH programs.

METHODS

Study Design

We conducted a qualitative observational case study by interviewing paramedics involved in the pilot EDVOU Fall prevention program. Details of the EDVOU Fall prevention program have been published elsewhere (Jones et al., 2024). In brief, we implemented a pilot EDVOU Falls prevention program in July of 2022 at a tertiary academic ED with 120,000 annual visits and approximately 25% geriatric volume in the Northeast. The study was designed and conducted using the Consolidated Criteria for Reporting Qualitative Research (COREQ) criteria (Choo et al., 2015; Dossett et al., 2021; Ranney et al., 2015).

Subject Selection/Enrollment

All paramedics who staffed the EDVOU/MIH program were included and invited to be a part of this study, which was approved by MGB IRB and deemed exempt. All paramedics were emailed at least three times with invitations to participate in the study. Interviews were held in February and March of 2024.

Data Collection

We designed a semi-structured interview guide (Supplement) to determine how comfortable paramedics were with conducting the home safety evaluation, medication safety evaluation, and TUG test. We invited all 36 paramedics affiliated with the EDVOU to participate in interviews and conducted interviews until we reached thematic saturation. Trained female research assistant AEJ, BS and GW, MS/MPH, medical student conducted and recorded interviews on Zooms or Teams, which were transcribed via a transcription program TranscribeMe! All identifiable information was removed prior to any analyses.

Analysis

Several transcripts were independently reviewed by multiple team members, and subsequently one coded the rest after an agreed upon code list. Each co-investigator independently generated codes using an inductive approach, which were then coalesced using qualitative research methods based on grounded theory. Team members (SWL (MD), AEJ (BS), GW (MS/MPH), KS(MD)) met to discuss common themes generated using the codes. Data analysis occurred in tandem with data collection. Recruitment ended when thematic saturation was reached.

RESULTS

Fifteen paramedics were interviewed. Responses to semi-structured questions can be seen in Table 1. Three overarching themes emerged from our interviews and are as follows: 1) learning new skills otherwise not included in paramedic training, 2) having unique perspectives and interactions with patients in the home environment where most other clinicians do not have insight, and 3) being more integrated in a team to play a bigger role in the care of patients. Quotes from participants can be seen in Table 1.

Theme 1: Learning new skills otherwise not included in paramedic training

Interviewees expressed great interest and excitement in learning new skills and high levels of comfort in practicing new skills and the program itself. Specifically, paramedics appreciated learning how to perform the home safety evaluation, medication safety evaluation and TUG Test, tasks not included in their general paramedic training: “It’s the pinnacle of my career as a paramedic where I get to literally work at the highest end of my scope of practice.”[UI 15]

Once paramedics had obtained program training as part of the EDVOU Falls program, paramedics felt comfortable performing such evaluations. A majority of paramedics mentioned “using validated measures such as the TUG test or any other sort of fall assessment… that’s not part of paramedic training, but I would say it was really easy” [UI 2] and being “fairly comfortable… have done it a few times. It’s kind of become a second nature thing to me and my career.” [UI 12] Overall, continuous learning and skill expansion increased paramedic satisfaction.

Theme 2: Having unique perspectives and interactions with patients in the home environment where most other clinicians do not have insight

All paramedics discussed having unique perspectives and interactions with patients given their role as EMS. As they are the first to be on the scene, MIH paramedics have the advantage of seeing patients in their home setting where most other clinicians do not have insight, which highlights the significance of this fall prevention program. Paramedics spoke highly of their unique position of being able to see patients, noting that “it’s one thing to have a patient go into an ER and have a doctor say, ‘alright, take 40 Lasix,’ it’s another thing to make sure that that 40 Lasix got filled… [or] make sure that they have food in their refrigerator.”[UI 4]

This highlights the importance of home medication safety evaluation, which is the home safety portion of the EDVOU Falls evaluation program.

Paramedics also mentioned being able to “tell if their homes are safe for them pre-hospital with the VOU program… assessing the homes and seeing if there’s any trip hazards and fixing them as we can or [linking] the patients with the people that they need to help them make their homes safe.”[UI 5]

Finally, paramedics mentioned being the “eyes on a situation that can hopefully help… [and] get geriatric patients set up for success and to help prevent falls in the future.” [UI 12]

As the ones directly interacting with patients in their home, paramedics also expressed the importance of being able to hear directly from patients regarding their experiences. According to the paramedics interviewed in the study, the program has been well received by patients who have “really enjoyed having us meet them halfway…were grateful to be home,” [UI 6] “saying they love not hearing call bells and you know everything else,” [UI 7] and “really enjoy it.” [UI 12] Paramedics have also found that older patients “managed to learn from the information… stuck a little bit better when they were in their home as opposed to in the hospital… they can kind of focus and they have a more familiar environment.”[UI 6]

When asked about positive experiences, most paramedics mentioned their appreciation of forming unique relationships and interactions with patients. One paramedic mentioned having “worked pre-hospital for years and very rarely get compliments by patients for what [they] do, but since doing VOU, it’s all from all the patients.” [UI 3] One shared that patients “welcome you into their home, and they want to make you breakfast…and she always sent me with a snack and water, so that’s so nice.” [UI 5] Another shared that after several visits, a patient “would open up a little more, a little more, and a little more about his frustration with the healthcare system. I shared with him some of my own personal stories. We got to become more or less friends, and he had a little brighter outlook. I genuinely think that we made an impact on each other. Those types of relationships don’t typically get to happen in the same way in hospital medicine… and through home hospital is, there’s just a different feel. So those are the experiences that I think are really, really valuable when we’re talking about patient-centered medicine from the hospital.”[UI 13]

Many paramedics feel that through this program, they have been able to play a bigger role in the care of their patients. A paramedic recalled recognizing that a particular patient did not have a safe medication system and “recommended to the doctor, ‘could we try to get her a VNA service or something to help her or like a blister pack from her pharmacy?’” [UI 3] One paramedic shared his/her frustrations with the broken system where paramedics “show up, and they have to take them to the hospital… why can’t I just give them 100 of Lasix and just sit here with them for a half hour and just see how they go.. and see how things turn out? … So I think that’s where the VOU’s niche kind of plays a role in it.”[UI 4]

Another commented that this program allows them “to be able to see them in their home, work with a physician to… get a proper diagnosis and a treatment plan and leave them in their home, to me, is like that is like the best part of my job.” [UI 9]

Theme 3: Being more integrated in a team to play a bigger role in the care of patients

With the VOU program, paramedics felt more integrated, respected, and valued by other care team members. One mentioned certain pre-existing challenges, especially that “we’re not really regarded as healthcare professionals… The public still sees us as the ambulance driver, so they don’t always take what you know we say to them as you know pertinent. I think with the mobile integrated health role, when you’re affiliated with a hospital and you have team members that are nurses and doctors … [and] physical therapists and occupational therapists that we have as resources, I think our credibility elevates a little bit and we probably have more pull when we do our home hospital visits.”[UI 9]

One paramedic mentioned that now, “when I go in and introduce myself as a paramedic, they understand, but then they actually see what we do and they’re impressed by the amount of stuff that MIH brings to the table.” [UI 11] A paramedic concluded that “as EMS prehospital medicine continues to evolve where we are now starting to actually be viewed as part of the patient care continuum. I think what we see is prehospital providers is starting to actually be valued where we can sit.”[UI 15]

DISCUSSION

We found that MIH paramedics in the EDVOU Falls prevention program had an overwhelmingly positive experience with the program. The paramedics felt they played a pivotal role in fall prevention, as the program allowed them to learn more skills, form and share unique relationships and clinical perspectives given their role, and feel more valued as part of a patient team/care continuum. This study is one of few to look at the perspectives and experiences of MIH paramedics involved in a geriatric fall prevention program. The findings indicate clinically pertinent roles that they provide for older adults to prevent future falls at their homes.

The EDVOU Fall program involved extra training for paramedics on skills and responsibilities not normally included in paramedic training. More programs seem to be utilizing MIH paramedics and thus expanding their skill sets. A program created in rural New York consisted of a unique collaboration between the Department of Health, the Office for the Aging (OFA), Tri-County Family Medicine, and the University of Rochester who recognized a need for additional EMS training and created an EMS training program on various aging programs, such as trauma and falls (Shah et al., 2010). Quatman-Yates et. al also created and looked into a community paramedic program’s optimization of Community centered Fall Intervention Team (Community-FIT), a fall prevention delivery system (Quatman-Yates et al., 2022). Another study in the UK also conducted a cluster randomized study comparing intervention paramedics to control paramedics with the former having received training on older adult falls (Snooks et al., 2017). All agreed that paramedics needed additional training to play a key role in preventing falls and complement our study’s findings that our MIH paramedics appreciate expanding their skill set.

Our study also highlighted the unique perspective EMS brings to patient care, especially in the MIH programs. Traditionally viewed as first responders to primarily traumatic and medical emergencies, EMS’ roles and responsibilities have evolved to include assessment, referral, education, and communication as a result of the aging population (van Vuuren et al., 2021). Community paramedics programs have been found to positively impact the health of older patients as well as the health system. Paramedics have the unique advantage of interacting with patients in their homes, allowing them to be advocates, mediate between the healthcare system and community, as well as “identify people with risk factors, and opportunities to provide information, brief interventions and [direct] people to locally provided services.” (Schofield & McClean, 2022) Torres et. al highlight that “despite the wide range of vital and highly skilled services that EMS clinicians provide, their contributions are often unknown to, or misunderstood and not acknowledged by, other health care professionals” (“How to Better Value EMS Clinicians as Key Care Team Members,” 2022). Yet, there is a movement towards including EMS in multidisciplinary efforts in fall prevention programs, which has yielded mostly positive and some mixed results (Agarwal et al., 2016; Camp et al., 2024; Creating New EMS Education Standards, n.d.; Quatman-Yates et al., 2022; Speier et al., 2024).

An overwhelming number of paramedics interviewed in this study expressed excitement and gratitude for the EDVOU program. Many of them mentioned that prior to the program, their responsibilities, role, and expertise had been misunderstood and undervalued, which parallels findings from another study regarding paramedics’ perceptions of another VOU program (Jung et al., 2023). Yet, through the program, they felt very supported by other members of the program administrative team, much more valued amongst other healthcare providers in the care of their patients, and part of a team where their roles and expertise were highlighted and understood. When interviewed, paramedics in community paramedicine programs enjoyed being able to help patients in a way that differed from traditional EMS roles, building rapport with patients, ensuring a sense of community in which there is improvement in patients’ health and well-being, and being able to witness positive outcomes first-hand (Paramalingam et al., 2024). In particular, paramedics felt that collaboration with providers and different services led to improved career satisfaction, and they felt respected and part of a valued healthcare team. This collaboration provided better coordinated care and showcased paramedics’ clinical skills beyond that of transport and ambulance-driving to other healthcare professions.”

EMS have the potential to be utilized in unique ways and provide more services than their traditional roles, especially in the role of preventative services (Agarwal et al., 2016; Creating New EMS Education Standards, n.d.; Jiang et al., 2025). A literature review done by Bonner et. al highlighted multiple studies that demonstrated a positive impact on recurrent falls, independence due to activities of daily living and patients’ wellbeing when paramedics were involved in referring older adult falls patients to fall-prevention programs (Bonner et al., 2021). A national retrospective cross-sectional study concluded that there is potential for development of community paramedic services and referrals to community intervention programs to provide EMS clinicians with more tools and information on older adult falls (Joiner et al., 2023). A study found that the implementation of Stopping Elderly Accidents, Deaths, and Injuries (STEADI) fall prevention program through EMS services turned out to be effective and cost-saving for addressing older adults’ fall prevention (Camp et al., 2024). These imply that we are currently underutilizing potentially valuable paramedic workforce who can be trained to execute certain clinical tasks well, including those pertaining to older patients at-risk for falls.

Our study seems to imply that programs like our EDVOU are appealing to paramedics as it allows them to expand their skill set, highlights their unique experiences and perspectives in the healthcare continuum, and allows them to feel that they are being better integrated in their patients’ care team. This implies that expanding programs such as the EDVOU Fall program and other geriatric-centric programs could improve care of older patients at a higher level. This type of hybrid program that utilizes in person MIH paramedics along with a telemedicine consult could be a way of incorporating the best of both worlds. Our findings are important as paramedics play an integral role in the provision of healthcare and including their perspective on how they can contribute to patient care is important to inform health policy, patient care and/or systems improvement, especially when contemplating innovative, efficient program design.

LIMITATIONS

One limitation to this study is potential for social desirability bias among interviewed paramedics. All paramedics were invited to be interviewed, and it is quite possible the views of those who consented and participated differed from those who did not. There also could have been bias in the patients who consented to participating in the EDVOU Falls program, which could have influenced paramedics’ experiences. Furthermore, we limited our interviews to paramedics already participating in the EDVOU Falls program; results may not reflect all paramedics. Lastly, due to the small sample size and study conduction through an MIH, findings may not be generalizable to other study settings and locations. We acknowledge that including the perspective of multi-stakeholders could have offered a more comprehensive viewpoint and actionable items; however, we were limited by limited RA time/resources. Nevertheless, this is the first study that described the potential for MIH involvement for fall prevention at home. Future studies should include the viewpoints of other stakeholders.

CONCLUSION

Paramedics with their unique role of entering the home to provide medical care are an untapped resource and can potentially play a pivotal role in preventative care, particularly in fall prevention in older patients. In this study, paramedics reported a positive experience working in an EDVOU fall program given they learned new skills on fall prevention, developed unique relationships with and perspectives of patients, and felt more part of the patient care continuum. Paramedics have a unique viewpoint of patients’ living environments, and future fall prevention programs should consider this as part of their strategy.

Supplementary Material

1