The COVID-19 pandemic affected racial and ethnic minority groups unequally, putting them more at risk of becoming sick and dying from the condition (Killerby et al, 2020; Stokes et al, 2020). Factors for this disparity revolve around the traditional social determinants of health of where people live, work, worship and play, and the impact on their living conditions, occupation and access to care. People from some racial and ethnic minority groups face multiple barriers to accessing healthcare and, because of various social determinants of health, many underserved communities are disproportionately affected by COVID-19 (Centers for Disease Control and Prevention, 2022).
Mobile integrated health and community paramedicine has served as a strong division of our healthcare workforce for years, providing a bridge between traditional healthcare services and undeserved urban and rural communities (White and Wingrove, 2012; Guy, 2014; O'Meara et al, 2016; Constantine et al, 2021).
A strong feature of this community-based model of care is the academic-community collaboration between health, long-term care, public health, social services and community-based organisations, which is necessary to better reach ‘at-risk’ populations where they are (O'Meara et al, 2016).
In this role, emergency medical technicians (EMTs) and community paramedics (CPs) are equipped and skilled to provide non-emergent community health services such as post-discharge care and chronic disease management, and assure proper healthcare resource use (White and Wingrove, 2012).
The existing mobile integrated health model meant that, when the COVID-19 pandemic emerged and became a crisis, the EMT and CP were already engaged with both the community and the health system (O'Meara et al, 2016; Constantine et al, 2021). EMTs and CPs were positioned to serve as a valuable resource, able to screen and test individuals suspected of having COVID-19 because of a wide geographic reach, a broad and adaptable skill set and close collaborations with local clinical services (Constantine et al, 2021).
Yet, because of the ever evolving knowledge base around COVID-19, many EMTs or CPs may not have had the skills or confidence necessary to provide safe and valid testing of the virus, nor to accurately answer patient questions around the virus, signs and symptoms, exposure risks and quarantine guidelines.
Given the high demand on hospitals and emergency departments during the pandemic, telehealth provides opportunities to increase access to care for those in underserved and under-resourced communities. Telehealth allows patients to connect to healthcare services through videoconferencing, remote monitoring, electronic consultations and wireless communication (American Hospital Association, 2019). Telehealth has been shown to have comparable health outcomes in terms of patient-physician communication as well as patient satisfaction and engagement when compared to the standard face-to-face visits (Clare, 2021).
With the emergence of the COVID-19 pandemic, the healthcare system demonstrated its agility to apply telehealth approaches but exposed gaps in widespread telehealth implementation (Wegermann et al, 2021).
In an effort to meet the needs of health professionals practising in medically underserved communities, many organisations partner with their local area health education centre (AHEC). Administered by the US Health Resources and Services Administration (HRSA) Bureau of Health Workforce, the AHEC programme is a health workforce development initiative focusing on the recruitment and training of students to serve in rural and primary care and in medically underserved communities when they enter practice (HRSA, 2021).
The AHEC programmes across the nation work to advance three specific goals (HRSA, 2021):
AHECs are often successful because of their strong connections with community partners including those in academic institutions, clinical settings and other community-based organisations.
The project discussed herein is closely aligned with the Indiana Area Health Education Centers Network goal to enhance workforce training around the use of telehealth technologies as a response to the COVID-19 pandemic (the third AHEC goal).
The project aimed to provide resources for EMTs and CPs to build the knowledge and skills necessary to use promising practices related to COVID-19 and provide culturally competent care using telehealth.
Promising practices include: how to care for patients with (or susceptible to) coronavirus; proper use of personal protective equipment (PPE); decontamination procedures; identification of correct triage (hospital versus in-person care) for patients; and how to identify when telehealth use is appropriate (i.e. for emergent versus non-emergent issues).
Methods
Between May 2020 and April 2021, the regional AHEC in the northwest portion of Indiana partnered with a local community integrated health service organisation to expand access to COVID-19 antibody testing in medically underserved communities in the northwest portion of the state.
Underserved community settings targeted in the project included public housing complexes, senior centres, homeless shelters and churches.
The purpose of the project was to improve EMT and CP knowledge, confidence and preparedness to use best practices related to COVID-19 and to provide culturally competent care using telehealth. The ever-evolving nature of the pandemic resulted in the project evolving over time to meet the needs of the communities. For clarity's sake, each evolution of the project will be referred to as phases.
This study was reviewed and approved with exempt status by the Indiana University institutional review board (protocol no 12601). The project was conducted for educational, rather than research purposes and thus written consent was not obtained. The project and related study were funded by the US Department of Health and Human Services, Health Resources and Services Administration, Area Health Education Centers COVID programme (grant no T1KHP39172).
Between May 2020 and April 2021, participants for the project were recruited by sharing the opportunity (word of mouth) with employees of the local mobile integrated health provider and the community college that trains EMTs and CPs. Participants did not receive compensation for taking part.
Phase 1: testing events
The initial purpose of the project was designed to have EMTs and CPs engaging with local people during testing events in underserved communities where they would answer questions and administer the COVID-19 antibody finger-stick test. This blood test determines whether a patient has positive antibodies and active coronavirus infection (a positive case of COVID-19). Any community member with a positive test result (with or without symptoms) was referred to a local hospital for additional care.
An initial obstacle faced by participants was a shortage of PPE. To address this, the authors and their organisations collaborated with community partners who had three-dimensional (3D) printers to create and distribute PPE to community organisations. Local residents in the northwest region of the state of Indiana donated the use of their personal 3D printers. The only costs accrued from using 3D printers therefore was for multiple colours of filament and the HEPA filters used for the masks.
Phase two: learning
As with many things, the project evolved as the authors learned more about coronavirus and the needs of the community.
They provided online training modules to give participants additional knowledge and information on the clinical signs and symptoms of COVID-19, the use of PPE, how to perform the antibody finger-stick test on patients, protocols for seeking external versus at-home treatment, decontamination procedures after transportation, changes to the airway management protocol for COVID-19-positive patients, the epidemiology around the viral spread of coronavirus across Indiana with emergency pop-up (temporary) hospital protocols, how to accurately chart someone suspected to have COVID-19, and how to bill for the services so related medical services rendered could be reimbursed. The project team funded participants to engage in online training on how to chart for reimbursement in COVID-19-related cases.
Phase three: telehealth at home visits
Over the course of the project (and pandemic), participants found they increasingly received requests for home visits to care for people who could not travel to the community events or local hospitals (e.g. a lack of capacity at the hospital, an increased risk of contracting COVID-19, mobility issues).
As a result of the increased amount of time participants were spending on home visits, the project evolved further with the addition of a partnership with the local federally qualified health centres (FQHC) to provide telehealth home visits.
A FQHC is a community-based healthcare provider that receives funds from the HRSA to provide primary care services in underserved areas (HRSA, 2018). The FQHC provided access to online training modules for the EMT and CP to increase their knowledge and efficacy in using telehealth during home visits. During these home visits, the EMT and CP would continue to give care such as administering COVID-19 antibody finger-stick tests, blood pressure screening, medication reconciliation, A1C testing and diabetic foot examinations and, at the same time, assist the patient with a telehealth consultation with a local physician.
When the COVID-19 vaccine became available, the partnering FQHCs provided vaccine doses to the EMT participants to assist with community-wide administration during home visits.
Assessing the effect
To measure the potential impacts of the project, the authors used a retrospective pre-post-test (RPP) to assess changes in participant self-efficacy around using promising practices related to COVID-19 and providing culturally competent care using telehealth.
Self-efficacy refers to an individual's belief in his or her capacity to successfully perform or behave in different ways (Bandura, 1971). For example, in health psychology, focusing on self-efficacy often helps people adopt healthful behaviour around healthy eating, physical activity or smoking cessation (American Psychological Association, 2009).
Under the RPP method, participants are asked to rate evaluation items twice at the same time after a project within two specific frames of reference—‘then’ and ‘now’ (Little et al, 2019). Using this evaluation methodology, participants first report their current attitudes or beliefs following a given experience, then are prompted to think back to a specific time before this experience and rate the item again retrospectively.
In this study, the tool asked participants to use a five-point Likert scale ranging from strongly disagree to strongly agree and self-report their level of preparedness to use telehealth equipment and to demonstrate COVID-19 promising practices in a manner consistent with protecting patient and data privacy.
To test any potential statistical significance in the hypothesis, the authors conducted a paired sample t-test to assess the difference in means in participants' pre- and post-test scores. All data were collected with FormAssembly software and stored in a cloud-based Salesforce platform. All statistical analysis was conducted using statistical software (IBM SPSS v. 28). The authors considered two-sided P values of <0.05 as statistically significant. Results of the chi-square test were confirmed using a t-test of independent samples analysis.
Findings
Between May 2020 and April 2021, 49 EMT and CP professionals participated in a pilot project to develop self-efficacy and skills around promising practices related to COVID-19 and provide culturally competent care using telehealth, and to improve access to care for underserved individuals during the COVID-19 pandemic.
The majority of project participants self-identified as Caucasian men from an urban area (Table 1). At 12–15 community events, the EMT and CP conducted approximately 950 COVID-19 antibody tests in underserved communities across the region (on average, there was a 5–7% positivity rate and individuals affected were referred to the local hospital for additional care). The positivity rate shows that, of the approximate 950 COVID-19 antibody tests administered, roughly 48–67 individuals were identified as COVID-19 positive.
| n=49 | % | |
|---|---|---|
| Male | 30 | 61.2 |
| Female | 15 | 30.6 |
| Not reported | 4 | 8.2 |
| Black or African American | 9 | 18.4 |
| More than one race | 4 | 8.2 |
| White | 36 | 73.5 |
| Hispanic or Latin | 4 | 8.2 |
| Not Hispanic or Latin | 45 | 91.8 |
Since partnering with the FQHC to provide the home care and telehealth consultations, the participants have facilitated approximately 150 community testing events to provide antibody testing and COVID-19 immunisations to the general public.
The results of the self-efficacy assessments are highlighted in Table 2, which depicts the pre-test and post-test means, paired t-test and sample mean and standard deviation. The authors asked the participants to self-report their self-efficacy on feeling prepared for using best practices related to COVID-19. The mean pretest score for using telehealth equipment was 2.78 (where 0 indicates strongly disagree and 4 is strongly agree), while the post-test score was 3.49. The t-test results showed a statistically significant gain (t=–10.000; n=48; P<0.05) and overall results indicate an increase in self-efficacy around using best practices related to COVID-19.
| Pre-test mean | Post-test mean | Overall change in mean | Standard deviation | t(df) | |
|---|---|---|---|---|---|
| I feel prepared to demonstrate best practices related to COVID-19 | 2.78 | 3.49 | 0.71 | 0.500 | –10.000 (48)* |
| I feel prepared to provide culturally competent care using telehealth | 2.78 | 3.49 | 0.71 | 0.677 | –7.385 (48)* |
Paired sample mean (where 0 is strongly disagree and 4 is strongly agree) and standard deviation between pre-test and post-test means
The authors asked the participants to self-report their self-efficacy on feeling prepared to provide culturally competent care using telehealth. The mean pre-test score for providing culturally competent care using telehealth was 2.78 and the post-test score was 3.49. The t-test results showed a statistically significant gain (t=−7.385; n=48; P<0.05), indicating an increase in self-efficacy in the ability to provide culturally competent care using telehealth.
Discussion
The project provided real-world opportunities and access to the resources necessary for CPs and EMTs to meet the needs of underserved communities during a novel pandemic. It sought to build CP and EMT self-efficacy around using promising practices related to COVID-19 and provide culturally competent care using telehealth.
In this case, self-efficacy theory was employed when providing the CP and EMT with training and hands-on experiences designed to raise their confidence levels around caring for those with potential COVID-19 infections and using telehealth equipment when visiting patients at home.
The results highlight the value of training projects such as the one used with this project to better equip EMTs and CPs with the tools and resources to better assess and triage people with concerns around COVID-19 in underserved communities. Equipping professionals with the training and tools to use telehealth addresses the AHEC's mission to develop and maintain a healthcare workforce that is prepared to deliver high-quality care in a transforming healthcare delivery system with an emphasis on rural and underserved areas and communities.
The evolution of the project from its original scope of patient education and antibody testing in underserved communities to the collaboration with FQHCs to provide in-home testing and telehealth services supports existing research (Joshi et al, 2020; Constantine et al, 2021). The use of mobile integrated health and community paramedicine services allowed patients to be assessed for complaints related to COVID-19 as well as for other acute matters (such as problems with existing long-term conditions such as type 1 diabetes, mobility, depression or medication management). It also protected hospital and emergency department resources since care is provided in the home rather than in hospital.
During the COVID-19 pandemic, many clinicians quickly adapted their practice by offering telehealth and virtual office visits, especially for vulnerable populations in rural and medically underserved communities (Tapper and Asrani, 2020). This project provided opportunities for vulnerable populations to connect with both the community paramedicine team and the physician (through telehealth) simultaneously.
The core reason for the success of this project is the cross-sector collaboration between the AHEC, the mobile integrated health service organisation and the FQHC. For the project, the AHEC provided funding and access to training and supplies (such as PPE and testing supplies), the mobile integrated health service organisation provided the opportunity for the participants to engage in the project and the FQHC provided access to COVID-19 vaccinations when they became available.
Limitations
The study had several limitations that may affect its generalisability. Findings are based on one group of EMTs and CPs, and similar projects across the nation may have different results.
The project results rely on the participants' self-reported knowledge and self-efficacy rather than observed assessment by project leaders. While the authors believe the project has a strong potential to positively influence participant self-efficacy pertaining to using telehealth, they cannot discount the bias related to the self-reported nature of the evaluation.
The study did not track the patients with whom the participants interacted, and additional research to track both patient outcomes as well as hospital and emergency department utilisation rates for those patients would be valuable. Doing so could potentially demonstrate whether the increase in self-efficacy among EMTs and CPs around COVID-19 and telehealth best practices resulted in better patient outcomes and reduced healthcare use.
Conclusion
Mobile integrated health and community paramedicine programmes have long been used to close healthcare gaps within underserved communities all over the world.
The project identified a potentially effective strategy for increasing provider knowledge and self-efficacy, resulting in a more effective system for testing and assessing patients suspected of having coronavirus infection.
The addition of observed learning sessions and assessment of applied skills would enrich research around how to further improve patient health outcomes.