I arrived at the Community Emergency Services1 (CES) building in Indianapolis around 7:30am on a bitingly cold 10°F morning in February 2018. On this day, I went on a ‘ride along’ with a community paramedic and social worker. The paramedic's name was Mark, a man in his mid-thirties who just four months earlier had earned his certification as a community health worker (CHW). It was at this CHW certification course that I first met Mark. The flicker of ambulance lights leaving the CES building occasionally splashed across my windshield as I waited for Mark and Melanie, his social worker colleague. Not long after, Mark arrived and he reviewed his listing of patients we would be seeing today, and Mark, Melanie and I set off to visit several patients for home visits.
Mark informed me that their patients were referred to CES by the local area hospitals, fire department or the Indianapolis police department. We first met with a middle-aged Latinx woman in her apartment in Indianapolis. She informed us that she is undocumented and spoke limited English. Mark worked diligently with her, asking her if she knew what each medication she took was for and asked her to show him how she takes them. Mark learned that the woman was not taking one of her medicines correctly and showed her how to take it. Mark and Melanie provided the patient with ample time in this appointment, addressing her concerns and helping her with paperwork. The woman replied that she now felt a lot of ánimo [encouragement], whereas before – when she didn't have visits from the community paramedics – she felt very alone. As we left to head to the next patient, I asked Melanie how Mark's approach had changed since taking the CHW certification course. Melanie told me that he'd made changes in his approach to patients – he had restructured his schedule to allot more time for each, allowed the patient to lead the meeting and was ‘more compassionate’.
The concept of CES was to designate a group of paramedics to complete home visits with designated ‘repeat visitors’ to local emergency rooms in Indianapolis. These individuals did not have ‘true’ emergency situations but instead were often seeking care for chronic conditions or social issues. In order to provide more effective care to repeat visitors and keep them from coming to the emergency department, CES was developed to reach out to these individuals (EMS World 2013). The focus would be on providing services out of the hospital via home visits and understanding their health needs. As such, the out-of-the clinic approach of CES’ community paramedics meshed well the approach of the burgeoning CHW workforce.
In 2017, the community-based CHW organisation Community Health Worker's Organization of Indiana (CHWOI) had recently been awarded with a grant to certify 100 CHWs in the new, state-supported certification. CHWs are defined by the American Public Health Association as ‘a frontline public health worker who is a trusted member of and/or has an unusually close understanding of the community served’ (2021). CHWs often are from the communities they work within and share demographic similarities (such as culture, race, ethnicity, gender, and/or sexual orientation) with their clients. Moreover, and perhaps most importantly, many share a lived experience with their clients, which may include previous experience with substance use disorders, mental health disorders or homelessness. Their emphasis is on addressing the social determinants of health affecting their communities and while some may be employed by hospitals and clinics, they work within the community conducting outreach, advocacy and health education. This certification was the first of its kind in Indiana, which provided individuals with the foundational aspects of being a CHW and certification (individuals who completed the course could put ‘CCHW’ [certified community health worker] after their name), and incentivised the hiring of these workers as well as making a set of CHW-specific services Medicaid-reimbursable.
Recognising the potential of combining the community paramedic approach with that of the CHW model, the management of CES decided to partner with CHWOI to certify their community paramedics as CHWs. Despite having a similar approach to providing community-based care, the paramedics who took the class had never heard of the term ‘community health worker’. A number of CES employees completed the certification course in October 2017 and were certified CHWs shortly thereafter. Cross-training represents one way to expand and enhance the services of community paramedics and could be implemented among other first responders. Additionally, at the time of this article's publication, there also appears to be a dearth in the literature relating cross-training healthcare providers as CHWs, its potentials and associated ramifications. I report on how this training shifted the caregiving of these paramedics, the challenges that emerged and potential steps forward for both cross-training and the CHW workforce.
Background
Originally founded in 2012, CES was developed in partnership with a large hospital in Indianapolis. Several studies conducted in Indianapolis had noted an overutilisation of the emergency department was due to the complexity of the healthcare system (EMS World 2013; Miramont et al. 2018). The CES community paramedics conduct their caregiving via home visits to increase self-management, reduce (re)admissions to the emergency room department (especially for ‘non-emergency’ issues), and increase the confidence of their patients in accessing and addressing their health concerns (Miramont et al. 2018). Each morning, these ‘community paramedics’ receive a list of patients to visit and their needs, medications or other health issues that require assistance. These paramedics typically work in teams of two and drive to each patients’ home to help address these needs and potentially identify other needed services.
These paramedics also take time to identify how the social determinants of health complicate their patients’ ability to access health and social service agencies. In particular, they assess the ability of the client to complete daily activities and their transportation, finances, nutritional needs, and living situation (Miramont et al. 2018). Teams typically consist of two individuals: a medical-focused paramedic and a social-focused worker such as a social worker or ‘social care coordinator’. The majority of CES's patients are socially, economically and racially marginalised from the healthcare system and social services agencies. CES has seen success in this medical- and social-focused care with many of their clients (Miramont et al. 2018).
This approach blends with the community health worker model – conducting public outreach, making home visits, addressing the social determinants of health and advocating for the needs of their patients encapsulate much of the work of community health workers. The primary difference is that many CHWs do not hold an advanced degree or training and come from the communities they work within. Community paramedics employed by CES have emergency medical training but are not always from the communities they work within. However, many of the primary functions of the CHW model were identified as a way to bolster the training and approach of these community paramedics – in particular, further training in cultural humility, informal counselling, motivational interviewing, patient-centred care, understanding social impacts on health (i.e. the social determinants of health) and advocacy. As such, CES made the decision to certify their community paramedics as CHWs to further expand their repertoire of skills and enhance their caregiving.
Cross-training first responders, such as paramedics, is a not well-researched area. While some anthropological scholarship has analysed the roles of paramedics (Jusionyte 2018a, 2018b), at the time of publication, I have been unable to find literature on cross-training paramedics as CHWs. There is, however, research and information regarding the training of first responders in other first responder positions, such as police, firefighters and public health professionals (Bennett 2010).
There are myriad studies that examine the impacts of community-based paramedics. In particular, these studies have noted the benefits of providing additional training in public health and the social determinants of health for paramedics in addition to their emergency medical skills or utilising paramedics to conduct community outreach (Agarwal and Brydges 2018; Allana and Pinto 2021; Cockrell et al. 2019; Schulman and Thomas-Henkel 2019; Schwab-Reese et al. 2021). Meryl Schulman and Caitlin Thomas-Henkel (2019) particularly call for the integration of ‘non-traditional’ workers, including CHWs and community paramedics, to screen and assess for the impacts of the social determinants of health.
Gina Agarwal and Madison Brydges (2018) described a programme that utilised ‘modified’ paramedics (paramedics who, due to an injury, were not working on an ambulance) to meet with residents of a low-income elderly community to improve health via a health promotion programme. These paramedics met one-on-one with residents and targeted the social determinants of health. Their interactions revealed that these elderly patients were suffering from social isolation and a lack of connectedness, which are key determinants of health not often incorporated in health-promotion programmes (Agarwal and Brydges 2018).
In their literature review, Krista Cockrell et al. (2019) noted the benefit of paramedics operating in rural Australia addressing the social determinants of health and taking a salutogenic approach to caregiving. The studies they assessed noted that while a paramedic may not be able to change the particular determinant, they had a positive impact on motivating patients who were experiencing them. Similarly, Amir Allana and Andrew Pinto (2021) assert that addressing the social needs of patients can and should be integrated into paramedic training in Canada. By training paramedics to recognise these needs, they argue, the healthcare burden for patients could be reduced and the overall quality of care improved (Allana and Pinto 2021).
As such, integrating cross-training within the community paramedic model clarifies gaps in the provision of care and incorporates a structural competency approach that can better inform the care provided to marginalised populations (Metzl and Hansen 2014). While this training can help expand the scope of care and integrate the social aspects of medicine, it is vital that it does not replace CHWs as a stand-alone workforce. However, cross-training can expand the understanding of care and caregiving outside the clinic and further spread awareness of CHWs and the unique roles they fulfil. As a result, the cross-training helps better inform the care provided by community paramedics but also helps CHWs as they are further integrated within the healthcare system in Indiana.
Theoretical Framing
Two public health frameworks illustrate the approach adopted by CES and further enhanced via the CHW certification course. The socio-ecological model provides framing to assess the various levels of impact that community paramedics (and CHWs) can produce via – especially – their advocacy work. The social determinants of health underscores how the environment and structural factors within, but particularly outside, the hospital that complicate access to care. The community paramedic approach utilised by CES already applied these two framings but was further enhanced via the CHW certification course, which specifically introduced and implemented these within the certification training.
Socio-ecological Model
The socio-ecological model provides a framework to understand the multiple layers of overlap that affect health and well-being from the individual level to the societal level. Though existing in multiple forms, the socio-ecological model typically consists expanding levels that include the individual, interpersonal, community and society (see Figure 1). CHWs can have impacts at each of the various levels, especially via their caregiving and advocacy role. Understanding that CHWs could produce impacts by working more broadly within the community and society – particularly via policy – this framework was integrated within the certification course to help CHWs better understand how an individual's health is shaped by more than just individual health behaviours and to identify different leverage points to address health issues. Community paramedics – especially after earning their CHW certification – sought to affect health at the interpersonal level to address care. The CHW certification provided these workers with additional skills to apply with their patients at multiple levels with the socio-ecological model.
The CHW certification course emphasises the socio-ecological model – particularly how an individual's health is shaped by more than individual behaviours as well as how the CHW can foster positive health impacts at each of the levels.
Citation: Anthropology in Action 29, 3; 10.3167/aia.2022.290302
Social Determinants of Health
The social determinants of health result in iniquitous access to achieving health and well-being, both inside and outside the hospital setting. Addressing these are crucial in order to improve access to care, provide higher quality of care and ensure patients can complete their prescribed treatment plans. The majority of the patients served by CES were disadvantaged economically, ethnically, racially or due to immigration status from the healthcare system. Studies have noted that paramedics are an ‘untapped potential’ to address the social determinants of health (Allana and Pinto 2021). CHWs are well equipped to uncover and address many of the social determinants of health experienced by their clients (Logan and Castañeda 2020). Cross-training community paramedics as CHWs can further enhance their caregiving and ability to address the social determinants of health to further improve the well-being of their clients.
Methods
The findings reported in this article come from participant observation and semi-structured interviews conducted with a subset of participants (n = 6) from a larger sample (n = 49) consisting of community paramedics who completed the CHW certification course. Long-term data collection occurred during 2017–2018, with follow-up interviews and research from 2019 to 2022. Participant observation took the form of assisting in the CHW certification course and shadowing the cross-trained community paramedic-CHWs (n > 300 hours). Throughout my fieldwork, I collaborated with CHWOI and helped to co-run the CHW certification course with the president of CHWO – including the course with the paramedics. Interviews asked paramedic-CHWs to describe how their CHW training affected their approach to caregiving, their thoughts on the certification course and their views of now being a CHW. Semi-structured interviews lasted between 45 and 60 minutes and were transcribed and coded for further data analysis using MAXQDA. All names of individuals and organisations in this article are pseudonyms. Approval for this project was given by the University of South Florida's Institutional Review Board.
Results
Understanding the Social Impacts of Health
A common theme noted among the cross-trained paramedics was that their understanding of health and well-being was broadened. Participants had specific goals set by CES, which included keeping patients from readmitting to the hospital and ensuring a number of patients are seen each day. These paramedics described feeling pressure that sometimes negatively impacted their caregiving – such as not being as patient-centred or simply tolerant towards clients who showed signs of ‘noncompliance’. The CHW certification course readjusted the mindset of these paramedics, offering them a different approach to understanding patients and the social aspects that complicated their ability to adhere to a treatment programme. Mark, a cross-trained paramedic and CHW, was frank with me, stating ‘I probably should have had this [the CHW certification] right away … it set the framework for what we were doing a little bit better instead of learning as we went.’
Participants also noted that the certification had enhanced their approach to caregiving overall. For example, Mark stated that instead of focusing simply on the acute medical issue that the patient presented with, he would take the time to see what environmental factors could be addressed to prevent the same issue happening in the future. Mark asserted that he now partners with the patient to address the social determinant(s) of health affecting them and locates out needed resources. He stated:
I don't want to say I wasn't as compassionate, [but] I certainly wasn't as patient-centred. I was much more Mark-centred … hospital-centred. We've got goals to make and I found that since the community health worker class, I tend to take a step back and go ‘Ok, this is about the patient, this is not about you’ and, at the end of the day, they [the patients] are the ones who have something to benefit or gain from this.
Mark asserted that it was the CHW course that refocused his caregiving on the ‘whole person’ rather than simply addressing the acute medical issue to keep them from readmitting to hospital. While the latter was an important aspect of the goals established by CES, he now takes a holistic approach to his caregiving.
Similarly, Bob, a paramedic with over 30 years of experience and now a cross-trained CHW, told me how the training ‘opened my eyes and was much needed’ – especially regarding the social aspects of health. Bob explained that the training has helped him to better understand the social determinants of health in addition to drawing on, or guiding patients to, social services to address their other needs. Similarly, Vanessa revealed that the training ‘took medicine and gave it a social twist’. She expounded:
It [the CHW certification] gives you the cross-training, it makes it so that window is bigger to work it and it allows you to keep learning. The day you quit learning in medicine is the day you need to go work for Starbucks.
Like Bob, Vanessa was now able to connect social issues to medical care, which expanded her ability to empathise with clients and look for other opportunities that could impact their well-being in the long run.
Listening, Following Up and Advocacy
Victoria also emphasised the impact of specific skills taught in the course, particularly the listening skills she learned. In the certification course, CHWs are taught to practise O.A.R.S. (open-ended questions, affirming, reflective listening and summarising). This practice, Victoria informed me, taught her to truly listen instead of thinking about what she wants to say to the patient while they are explaining an issue. Additionally, Victoria mentioned that the emphasis on following up (i.e. reaching out to a patient to ensure that a recommended service or resource was met) helped her to ensure proper services were accessed by her patients and, if not, sought ways to acquire the needed service or resource. Likewise, for Mike, the emphasis on following up with patients was his biggest takeaway from the certification course. He stated: ‘I feel like you do catch more because people will say A, B and C happened and I don't know what to do.’ With his new skills as a CHW, he practices following up with patients and pays attention to issues that emerge after recommending a service.
Advocating for patients was another key skill learned by paramedics via the CHW certification course. Mike also described how at the home visits he is able to catch things that would be missed without such visits. Once he noticed a shut-off notice for utilities at a patient's home. He told me that without home visits and following up, he would have missed this and he was able to help his patient avoid the shut-off. Thus, specific skills – particularly listening and following up – provided these paramedics with additional strategies to ensure more effective caregiving and positive health outcomes. During a home visit, one of Vanessa's patients revealed that their furnace had stopped functioning but they were unable to afford a replacement. Vanessa worked with a local non-profit to provide a furnace at no cost to the patient. Speaking up for patients, advocating for their needs and connecting them with resources became important roles fulfilled by these cross-trained paramedics.
Emphasising Patient Autonomy and Empowerment
Emphasising patient agency and compassionate care are included within the core competencies of being a CHW and are extensively covered in the certification course. This specifically affected the cross-trained paramedics and shifted their approach to their patients. For example, in describing his past interactions with patients, Mark stated:
It was more of me disciplining [a patient for noncompliance] – and that's probably a heavier word than I like to use – but now, I'm much more ‘Explain to me why it is you aren't taking your medication?’ or ‘What is it you would like to know that could make it more of a desire to take your medicine? What is it that you're missing?’
Mark extrapolated with one final point: ‘I think the community health worker aspect of it is [that] it's the big picture, it's not going in and telling somebody to take their medication, it's finding out who they are and why they're not taking it.’
Similarly, Victoria explained that ensuring her patients are informed and empowered to make their own choices was crucial in her approach. She had begun advocating for her patients – such as making a phone call on their behalf – but also showing them how to set up their medications or phone them in. Bob noted that many of his patients are well aware of what to do, while others may attend appointments three to four times and still struggle to manage their medication. However, he has continued working extensively with low-income and homeless patients to empower them and provide services or connections to community resources. Health education, as described by Bob, is the crucial element to advocating and increasing the patient's ability to make informed health decisions and a critical approach he garnered from the CHW course.
Mark explained that empowering clients includes advocating for their needs and working within the healthcare system to ensure those needs are met. He works with his clients to ensure they learn about the resources available locally and he follows up to ensure the resources have met their needs. Vanessa told me that she emphasises that patients ‘have a PhD in you [themselves]’. Thus, validation and health education are the primary tools she draws on to encourage patient autonomy and empowerment.
Challenges in Cross-Training
Participants noted several drawbacks to the cross-training. Mark was clear that while the CHW training had expanded his awareness in caregiving, he felt strongly that hospitals, clinics and other health organisations would benefit from a full-time, dedicated CHW on staff. However, within the healthcare setting, cross-trained paramedics still ran into a lack of awareness of who CHWs are and their abilities. Mike explained, ‘The first question [from health professionals] is what [is a CHW]? Or who? Or what is that? I don't think there's a lot of knowledge about community health work or even what CES does overall.’ Bob was emphatic that one way to address this issue is by having more healthcare professionals complete the CHW certification: ‘Yes! For the knowledge base of the assets out there for the patients and for the skills to learn how to bring those assets to the patients.’
Additionally, completing the requirements of the course can present issues for already busy healthcare professionals. Tuition for the course is US$1,500 per person and involves seventy hours of training that takes place over two weeks (∼eight-hour days, Mondays through Fridays). However, there is flexibility in how the course can be offered. For the class of paramedics, the training was amended to take place over a month and divided into classes of four hours. CHWOI had earned a grant to train 100 CHWs, so tuition was not an issue for the CES paramedics.
Although the cross-training offered paramedics additional means to motivate patients, particularly via motivational interviewing and advocacy, some paramedic-CHWs were unable to find success with patients. Victoria struggled with patients who would not accept her help or services. It was especially frustrating for her as she noted how she wanted to do everything in her power to help, but some still refused. Bob noted how even with the CHW training, sometimes the social determinants of health experienced by his patients, such as lack of transportation, lack of finances and/or the inability to afford transportation, remain as substantial challenges.
Discussion
Cross-training paramedics as CHWs in Indiana resulted in a variety of positive changes in their caregiving and in enhanced health outcomes for their patients. Completing the CHW certification demonstrates its utility and significant impacts to improving caregiving for these paramedics in addition to having potential benefits for the CHW movement as a whole. It was for these reasons that CHWOI partnered with CES in training their paramedics as CHWs. Cross-training paramedics served as another means of having additional certified CHWs who would further spread awareness of the model within the healthcare system. While not necessarily coming from the communities they worked within, these paramedic-CHWs applied the CHW approach within the relationships they had with their patients and further boost their impacts.
Earning the CHW certification left indelible impacts on the participants’ approach to care. The paramedic-CHW participants described having their eyes opened to how the social determinants of health affect well-being and access to health care, and thus they sought to address not only the acute issue presented but took steps to prevent the same issue from reoccurring. As such, these cross-trained paramedics were now cognisant of the social issues that affect health and were thus able to identify the social determinants of health.
In doing so, they adopted essentially a structural competency approach in their community outreach work (Metzl and Hansen 2014). This approach emphasises that medical professionals recognise and understand the impacts of structural barriers that prevent or hinder patients from accessing the healthcare system or from adhering to a treatment plan. Previous research has noted the benefits and potential of incorporating a structural competency approach for frontline health workers such as CHWs (Kangovi et al. 2018; Logan 2020; Trinh-Shevrin et al. 2019). Moreover, Philippe Bourgois et al. (2017) call for the adoption of a structural vulnerability assessment tool, which would serve as a means to determine how a patient is affected by the social determinants of health. They argue that healthcare professionals, community health workers and other frontline health workers could draw on this tool to assess the needs of a patient and direct them to the relevant health and social services. Community paramedics, as noted in this study, benefited from understanding the negative role social determinants of health play and operationalised a structural competency approach in their caregiving.
Allana and Pinto (2021) note that for paramedics who work in a community or home-based setting – such as those employed by CES – can directly alleviate the impacts of the social determinants of health. Other community paramedic models have shown success in mitigating the impacts of the social issues experienced by individuals. Schulman and Thomas-Henkel (2019) assert the potential for CHWs and community paramedics to not only identify the social determinants of health but also to navigate the local community and connect patients to needed health and social services.
The home visit approach taken by these paramedic-CHWs revealed social issues that complicate adherence to treatment plans, misunderstandings in how to take medicine and the potential to identify other issues that were impacting the treatment plan outside of the clinic that might go undetected by a healthcare professional. Agarwal and Brydges’ (2018) work documented how paramedics working in a one-on-one setting uncovered important social determinants of health (social isolation in particular) that complicated achievement of well-being. Similarly, Laura Schwab-Reese et al. (2021) highlighted the patient perspective and noted how new mothers who were part of a community paramedic intervention were connected to health and social services that aimed to comprehensively improve their and their child's well-being.
The CHW certification course provides a holistic framework for caregiving and, particularly, how health is affected by the social determinants of health across multiple levels. The socio-ecological model provided a framework for cross-trained paramedics to understand and ameliorate health issues experienced by their patients. The advocacy role fulfilled by CHWs functions as a form of caregiving with implications at not only the individual but also the broader community level (Logan and Castañeda 2020; Sabo et al. 2013). Moreover, as shown in the review of the literature by Cockrell et al. (2019), community paramedics adopting a salutogenic approach to healthcare delivery (i.e. focusing on factors that support health, rather than the forces that cause disease) has resulted in improved health education, patient empowerment and improved access to care among remote and rural Australian populations. Similarly, CHWs and promotores de salud adopt this approach and, when paired with advocacy, can enhance caregiving, improve health outcomes (Logan and Castañeda 2020) and affect health at multiple levels of the socio-ecological model (see Figure 1).
As noted by the participants, cross-training not only helped to expand their caregiving and overall approach to their patients but also spread awareness of the CHW model within the healthcare professional workforce. Lack of awareness of CHWs in the healthcare workforce (and general public) complicates the acceptance and integration of these workers in Indiana (Logan 2021). There is the likelihood that cross-trained paramedic-CHWs will spread further awareness of the CHW training and concept within the healthcare workforce in Indiana via contact between these paramedics and other healthcare professionals.
Other challenges that remained following the cross-training include the social determinants of health and other political economic issues that complicated their patients’ ability to achieve health and well-being. While CHWs and cross-trained paramedics represent one means to address structural factors, they must be supported by the passage of policies and laws to specifically redress unequal systemic issues. For example, Polly Ford-Jones and Claudia Chaufan (2017) described that although well-meaning, training paramedics to address the growing mental health needs of their patients is not a viable solution to structural barriers that must be solved via policy. However, they argue that paramedics can help inform the various structural factors that give rise to psychosocial stresses (Ford-Jones and Chaufan 2017). Scholars have also warned the same for CHWs, who represent one means to address the social aspects of health but must not be seen as a solution to issues that must be rectified via policy development (Colvin and Swartz 2015).
Ultimately, cross-training other first responders is a unique opportunity to expand their understanding of environmental factors and how the social determinants of health affect the communities they serve. Even within the professional healthcare workforce, scholars have demonstrated the benefits and the need of training nursing students in community-based settings to garner first-hand experience in how the social determinants of health complicate care outside the clinic (McKinley and Pesch 2020). While cross-training offers a way to hybridize the CHW approach within the model of other first responders, it is essential that the training is not reduced to one-time training and an extra set of letters/qualifications (i.e. CCHW, a certified CHW). Cross-training could open the doors for employers of first responders to hire a full-time, dedicated CHW. It cannot be stated enough that cross-training is not intended to replace the need for CHWs, who come from the communities they work within and would serve as unique, complementary members of the professional health and social services workforces.
Conclusion
Cross-training paramedics as CHWs has considerable implications for improving the caregiving and mindset of these workers. Paramedics emphasised how the CHW certification provided them with a lens to see the social aspects that affect and complicate health for their patients. Paramedics earning their CHW certification provides one avenue to increase exposure within the professional healthcare workforce of what CHWs are and what they do. As such, this provides a secondary benefit for fully fledged CHWs as they are further integrated within the workforce. While cross-training produces benefits for both sets of these frontline healthcare workers, it is vital that the training does not replace the need for CHWs. Ideally, it enhances care provided by first responders while opening the door for employment of full-time CHWs and increasing their presence – and impact – within the workforce and their communities.
Acknowledgements
I want to thank the participants of this research study for dedicating their time and energy to this project. I also want thank the anonymous reviewers and editorial team for their feedback and support.
Note
All names of organisations and individuals are pseudonyms.
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