Community paramedicine · Mobile integrated healthcare · Treatment in place · Transport to alternate destination · Value-based payment
Community paramedicine and treatment in place, built to last past the start-up grant
Community paramedicine and treatment in place let paramedics give the right care in the right place: at home, in the community, or somewhere other than an emergency department. The clinical case for these programs is established. Whether a program survives depends on how it is paid for and governed. The Paramedic Foundation (TPF) designs the program and how its results are measured. TPF also works out the policy and payment route that keeps it running after the start-up money is gone.
Community paramedicine and mobile integrated healthcare mean different things
Solicitations, statutes and board presentations often use community paramedicine and mobile integrated healthcare (MIH) as if they meant the same thing. Mixing them up has costs. The program design cannot be evaluated. The scope-of-practice language does not match the people who actually deliver the service. The payment terms name the wrong contracting party. TPF keeps one set of defined terms and uses it in every deliverable.
Community paramedicine is a model of care in which paramedics use their training and skills in the community. It works outside the usual model of emergency response and transport. A community paramedic works in an expanded scope, with special skills and protocols beyond base paramedic training. The paramedic also works in an expanded role, using existing skills in new ways. The International Roundtable on Community Paramedicine proposed this reference definition, and the Institute of Health Economics reported it (Guo et al., 2017).
Mobile integrated healthcare is health care given outside the hospital, using mobile resources built around the patient. TPF tells the two apart by direction. In MIH, many kinds of health care groups and their staff give the care. They are linked to emergency medical services (EMS) agencies through shared management or clinical work. In community paramedicine, EMS agencies and their staff give the care. They are linked to other health care groups (National Association of Emergency Medical Technicians, n.d.). The current authoritative summary of both is the National Association of EMS Physicians position statement and resource document on mobile integrated health care and community paramedicine (Breyre et al., 2025).
The literature has no formal consensus definition of community paramedicine, and TPF says so plainly. The Institute of Health Economics review found no consensus. It reported that the Roundtable definition above is the one most widely cited (Guo et al., 2017). TPF uses it as a reference standard. TPF notes the lack of consensus wherever it matters to a finding or a recommendation.
Other frameworks draw the line in other ways. The Rural Health Information Hub, for example, splits the two by who staffs the program. It uses mobile integrated healthcare for programs staffed by a mix of paramedics, emergency medical technicians (EMTs), nurses and social workers. It uses community paramedicine for programs staffed by EMS personnel (Rural Health Information Hub, 2026). A program that uses one framework in its statute and the other in its evaluation plan will not be able to reconcile them later.
The clinical case is established, and the barrier lies in how care is paid for
A national analysis looked at emergency department visits in the United States. It estimated that 13.7 to 27.1 percent of all of them could take place at an urgent care center or retail clinic instead (Weinick et al., 2010). Community paramedics are in a position to close part of that gap. They belong to the communities they serve, and they carry built-in trust. They work at all hours. They can assess patients, coordinate care and make referrals outside the hospital.
The evidence for community paramedicine includes fewer hospital readmissions and less use of the emergency department. It also includes better care of chronic disease and documented cost savings. The barrier is separate from the evidence. Medicare’s ambulance fee schedule has historically paid only when a patient was transported to a covered destination. No transport meant no payment, whatever the clinical outcome. That one rule shaped how EMS systems were built, trained, staffed and financed for four decades.
Changing that rule takes work fitted to each jurisdiction. It often includes state legislation and a Medicaid State Plan Amendment, the formal change a state makes to its Medicaid plan, or a waiver. It needs medical oversight that satisfies the state medical board and the local medical director. It also needs a payment arrangement with whichever party actually captures the savings. TPF’s EMS policy and legislative work addresses the payment barrier at the state and federal level. The specialists TPF calls on for that work have run these systems rather than studied them from outside. They can say which statutory language has held up in practice and which payer strategies are realistic in a given state. They also know which clinical governance structures regulators and medical directors will accept.
Bringing paramedic skills into everyday health care
Community paramedicine sends paramedics to patients outside emergencies. They manage chronic disease, follow up after a hospital discharge, help people reach behavioral health care, check medications, and screen for the social conditions that drive use of care. The model does the most good where primary care is limited or hard to reach. It also helps where the emergency department has become the default for conditions that do not need it, and where frequent 911 use is eating up system capacity.
In Renfrew County, Ontario, the County of Renfrew Paramedic Service runs a Virtual Triage and Assessment Centre. It combines virtual physician assessment with in-person paramedic care. A population-based study compared the two years before its March 2020 launch with the first year after it. Emergency department visits among county residents fell 34.4 percent. That drop was larger than in comparable rural regions over the same period, which was also the first year of the COVID-19 pandemic (Fitzsimon et al., 2023). The study measured the hybrid model as a whole and does not credit the drop to paramedic care alone. In 2023, the Ontario government announced permanent funding for the centre, with $3.2 million for 2023-24 (County of Renfrew, 2023).
TPF designs community paramedicine programs and builds the way their outcomes are measured. It also builds the legislative and payment plan that keeps them going. Training and education sit alongside that work at CommunityParamedic.org, TPF’s training and education resource site. Colleges, universities and other bona fide educational institutions use it to request the Community Paramedic curriculum from TPF. TPF does not own or co-own the curriculum copyright, which is held by The Paramedic Network. TPF’s role is to ensure the curriculum reaches those institutions.
The right response to the right situation
Treatment in place means a paramedic assesses and treats a patient at the scene and does not transport them. Clinical judgment and the protocol in force must support that decision. Transport to alternate destination means taking a patient to the right place, such as an urgent care center, a behavioral health facility or a sobering center. The nearest emergency department is no longer the default.
CMS ran the ET3 model from January 2021. The model ended early on December 31, 2023, with CMS citing lower than expected participation and interventions. At the end, 147 ambulance participants remained. The final evaluation was published in January 2025. It found that mortality after treatment in place did not differ significantly from comparable low-acuity (less urgent) emergency department episodes. Medicare spending was moderately lower. ET3 interventions were fewer than 1 percent of participating agencies’ Medicare transports. Follow-up emergency department visits and hospitalizations were higher after treatment in place. The evaluation said its design calls for caution in reading the results (CMS, 2025).
For these programs, TPF writes model statutory language and guidance for medical directors. It also builds Medicaid State Plan Amendment strategy and coding frameworks. The work fits the jurisdiction from the first meeting, because the binding limit is almost never clinical.
The legislative window
These measures are before the 119th Congress: the CARE Act of 2025 (S. 3145 and H.R. 2538), the Community Paramedicine Act of 2025 (H.R. 4011), and the Emergency Medical Services Reimbursement for On-Scene Care and Support Act (S. 3730 and H.R. 7277). New York, California and Illinois have enacted structural changes at the state level. TPF tracks these measures and analyzes how they fit with state strategy for the agencies it advises. TPF is not a lobbying organization and takes no position on any of them. The policy page keeps the current status of each bill.
How EMS agencies get paid for care without a transport
Clinical problems rarely end community paramedicine and MIH programs. Most that fail do so when the grant ends, because nothing in the ordinary payment system pays for what the program does. The field has leaned on three sources: grants, hospital in-kind support and local subsidy. None of them is a business model (Rural Health Information Hub, 2026).
The parties that capture the savings are the ones with a reason to pay. They include hospitals facing readmission penalties, and health systems and accountable care organizations that carry total-cost-of-care risk. They also include Medicaid managed care plans and, more and more, commercial payers. The hard part is moving money from those parties to an EMS agency. A payment from a hospital to an organization that influences where patients are taken raises the physician self-referral law and the federal Anti-Kickback Statute right away.
The value-based enterprise is the structure most often used to make that payment defensible. It does not have to be a new legal entity. It can be a medical practice, an independent practice association, a clinically integrated network or an accountable care organization. It can also be two parties with a written agreement. It needs four things. At least two participants must work together toward at least one value-based purpose. They must take part in a value-based arrangement. A body or person must be accountable for financial and operational oversight. A governing document must describe the enterprise and how its participants plan to achieve its value-based purposes (Frier, DiGuglielmo, & DeWitt, 2022; 42 C.F.R. § 411.351).
The structure is useful in this field because it allows for different levels of risk. The physician self-referral regulations set out three value-based exceptions at 42 C.F.R. § 411.357(aa). Paragraph (aa)(1) covers full financial risk. Paragraph (aa)(2) covers value-based arrangements with meaningful downside financial risk, the risk of losing money, to the physician. Paragraph (aa)(3) covers value-based arrangements in general. The Office of Inspector General set matching Anti-Kickback Statute safe harbors. The one at 42 C.F.R. § 1001.952(ee) covers care coordination arrangements to improve quality, health outcomes and efficiency. The one at § 1001.952(ff) covers value-based arrangements with substantial downside financial risk. The one at § 1001.952(gg) covers value-based arrangements with full financial risk. Both sets of rules were published in the Federal Register on December 2, 2020.
The care coordination route does not require the EMS agency to take downside risk. That matters for a rural service with no balance sheet to absorb a loss.
Two limits apply. First, the parties must believe in good faith that the value-based activities will achieve the stated purposes, and ongoing monitoring must show that they do. A structure built mainly to reach the exception, without real commitment to the activity, loses protection (Frier, DiGuglielmo, & DeWitt, 2022). Second, this is legal work. Guidance written for health system executives says plainly that qualified health care counsel should be closely involved from the design stage (Biernat, 2025).
TPF’s part sits on the program side of that line. TPF finds which party captures the avoided cost and puts a number on it. It defines the target patients using criteria that can be checked and set in advance. It designs the value-based activities and the clinical governance around them. It builds the performance measures the arrangement will be judged on, and it models the financial case for both sides. TPF does not give legal advice and does not draft the governing document. Legal opinions and instruments rest with TPF’s counsel and with the client’s health care counsel. Nothing on this page is legal advice.
Start by checking what services already exist
The most common design error in a rural program is duplication. A new service ends up doing what a home health agency, a home visiting program or a community health worker program already does in the same county. That splits a small workforce. It also invites a turf dispute just when the program needs local partners. The Rural Health Information Hub’s Rural Mobile Healthcare Toolkit, published July 30, 2026, treats this as the first question to answer. Assess overlap first, then shape the service to fit the gap that is actually open. The toolkit is a sound public starting point for a community new to this work. TPF points communities to it rather than duplicating it.
The second early question is about the law. Some states still limit paramedic practice by statute to emergency calls, which rules out the model before design begins. Minnesota and Wisconsin both broadened paramedic scope of practice through legislation to make community paramedicine possible (Rural Health Information Hub, 2026). A TPF feasibility assessment first finds where a state stands on that question. The answer decides whether the project is about program design or about legislation.
The toolkit’s program examples show what the work produces at small scale. The Kanawha County Ambulance Authority program in West Virginia reported fewer readmissions and higher Patient Activation Measure scores in its first year. The McDowell County EMS community care paramedic pilot in North Carolina calculated 125 avoided EMS transports and emergency department visits. Eagle County Paramedic Services in Colorado reported 688 mobile integrated health calls, 74 community clinics and 53 behavioral health crisis calls in 2024 (Rural Health Information Hub, 2026).
The programs reported these figures themselves, and they are not independent evaluations. TPF says so when it cites them. A measurement framework exists to close the gap between figures a program reports and evidence that holds up in an evaluation. That is one reason TPF builds the framework before a program launches, instead of after a funder asks for outcomes.
What TPF builds for clients
A project starts with the client’s own call data and rules, and with the specific gaps in access in that community. TPF does not start from a generic model. The first deliverable is usually a feasibility assessment based on local call volume, payer mix and patterns of use. It comes with a review of scope of practice and regulations for the jurisdiction.
From there, a typical project produces six things. A program design document covers scope of practice, referral pathways, who is included and excluded, and how partners fit in. A clinical governance framework is written for a medical director to sign. A payment strategy may use a Medicaid State Plan Amendment or waiver, a value-based arrangement with a health system or payer, or both. A workforce and training plan follows. An outcomes measurement framework is set before launch. A phased implementation roadmap names each decision point. Every deliverable is documented to the standard of the American Psychological Association style, seventh edition (APA 7). TPF designs for lasting local ownership, so the community does not keep depending on an outside contractor.
Maternal care transitions are a growing part of this work. Rural counties that have lost hospital obstetric services still have pregnant and postpartum patients living in them. The trip home from a distant delivering hospital to a county with no obstetric provider is when time-critical warning signs go unseen. TPF designs prenatal and postpartum home visit pathways for community paramedicine networks. The hospital-to-home transition protocols are written with obstetric clinical leaders. The measures report postpartum contact within a stated time after discharge.
That design draws on the specialists TPF calls on in two fields. The first is maternal health policy work. It includes a 2025 national webinar for the Alliance for Innovation on Maternal Health, on emergency medical services collaboration in obstetric readiness. It also includes a 2026 Colorado Perinatal Care Quality Collaborative presentation on rural problem solving. The second is direct field experience in labor and delivery, postpartum and newborn care, public health nurse home visiting, and regional EMS and trauma system leadership.
Who does this work
The specialists TPF calls on for community paramedicine and MIH
Community paramedicine and mobile integrated healthcare is one of the fields where TPF keeps standing specialists to call on. Projects in this area of work draw on the disciplines below. Each project is staffed to fit the work, not a fixed roster.
Community paramedicine governance and program architecture. Clinical protocol development and service bundle design. Physician medical direction for treatment in place and alternative response components. Mobile integrated healthcare and alternative response design. Value-based care and payer alignment. Health economics and return-on-investment analysis. Health services research and continuous quality improvement. Curriculum and career pathway design. Public health and maternal-child health nursing. Maternal care transition design.
The team page gives named profiles, credentials and current roles for all the specialists TPF calls on. TPF names the people proposed for a project in the proposal for that project, where the names can be matched to the scope.
Rural Health Transformation Program (RHTP)
Community paramedicine and MIH under RHTP
The Rural Health Transformation Program’s permitted uses of funds include payments to health care providers and innovative care models. They also include right-sizing rural delivery systems across pre-hospital and emergency service lines. CMS’s award announcement names treatment in place options among the activities states will fund. Whether a community paramedicine or MIH program is funded depends on each state’s approved plan and the terms of its solicitation.
Where a state’s solicitation allows, TPF supports RHTP-funded work. It can work under contract with the state. It can also serve as a technical assistance, implementation or evaluation partner. Where federal funds are involved, the awarding agency designates TPF’s role, as a contractor or as a subrecipient. That designation governs how the federal award rules in 2 CFR Part 200 apply to TPF. The Foundation brings program design experience, clinical credibility and federal compliance systems. These include 2 CFR Part 200 frameworks and subrecipient monitoring design. State agencies and the groups they fund need these from proposal development through delivery and federal reporting.
If your state funds these programs through RHTP subawards and needs an implementation or technical assistance partner, you can start a direct conversation.
About community paramedicine, MIH, treatment in place and alternate destinations
Common questions
What is community paramedicine?
Community paramedicine is a model of care in which paramedics use their training and skills in the community. It works outside the usual model of emergency response and transport. A community paramedic works in an expanded scope, with special skills and protocols beyond base paramedic training. The paramedic also works in an expanded role, using existing skills in new ways. The International Roundtable on Community Paramedicine proposed this reference definition, and the Institute of Health Economics reported it (Guo et al., 2017). The literature has no formal consensus definition, and TPF says so plainly wherever that matters.
What is the difference between mobile integrated healthcare and community paramedicine?
TPF tells them apart by direction. In mobile integrated healthcare, many kinds of health care groups and their staff give the care. They are linked to EMS agencies through shared management or clinical work. In community paramedicine, EMS agencies and their staff give the care. They are linked to other health care groups (National Association of Emergency Medical Technicians, n.d.). The current authoritative summary is the National Association of EMS Physicians position statement on mobile integrated health care and community paramedicine (Breyre et al., 2025). Other frameworks draw the line by who staffs the program. A program should pick one framework and use it the same way in its statute, its contracts and its evaluation plan.
What is treatment in place, and how does it differ from standard EMS?
Treatment in place lets paramedics assess and treat patients at the scene without taking them to an emergency department. It is used when that is clinically appropriate and has proper medical oversight. Standard EMS is usually paid only when it transports a patient. Treatment in place is paid for the clinical service itself, where a payer or program covers it. The final evaluation of the CMS Emergency Triage, Treat, and Transport (ET3) model found that mortality after treatment in place did not differ significantly from comparable low-acuity emergency department episodes. It also found more follow-up emergency department visits and hospitalizations after treatment in place.
How can an EMS agency be paid for care that does not involve a transport?
Outside a Medicare demonstration or a state Medicaid pathway, payment usually has to come from a party that saves money when patients use less care. That can be a hospital, a health system, an accountable care organization or a payer. The value-based enterprise is the contract and regulatory structure most often used to make that payment defensible. It works within the physician self-referral law and the federal Anti-Kickback Statute. It needs at least two participants working toward a value-based purpose, and a value-based arrangement. It also needs a body or person accountable for financial and operational oversight, and a governing document (Frier, DiGuglielmo, & DeWitt, 2022). The care coordination safe harbor at 42 C.F.R. § 1001.952(ee) does not require the EMS agency to take downside financial risk.
Forming one is legal work. TPF designs the program, the definition of the target population, the measures and the financial case. TPF does not give legal advice or draft the governing document.
Can community paramedicine programs be funded through RHTP?
They can be, depending on the state. The Rural Health Transformation Program’s permitted uses of funds include payments to health care providers and innovative care models. They also include right-sizing rural delivery systems across pre-hospital and emergency service lines. Whether a given community paramedicine or mobile integrated health program is funded depends on the state’s approved plan and the terms of its solicitation. See the RHTP page for ways to work with TPF.
Where should a rural community start?
Start with a needs and readiness assessment that shows which gap the program fills. Check for overlap with home health, home visiting and community health worker programs already working locally. The Rural Health Information Hub Rural Mobile Healthcare Toolkit, published July 30, 2026, is a sound public starting point. The second step is a review of the state paramedic scope-of-practice statute, because some states still limit paramedic practice to emergency calls.
What does TPF produce for a community paramedicine program design project?
TPF produces a needs and feasibility assessment. It writes a program design document that covers scope of practice and referral pathways. It also produces a reimbursement and payment strategy and a workforce and training plan. The last two pieces are an outcomes measurement framework and a phased implementation roadmap. All deliverables are documented to APA 7 standard. The South Carolina study, Community Paramedic Impact Survey: An Analysis of Four South Carolina Programs (Nudell et al., 2023), is an example of the evaluation method TPF uses.
Does TPF own the Community Paramedic curriculum?
No. The Paramedic Network holds copyright in the international Community Paramedic curriculum. TPF does not own or co-own that copyright. TPF’s role is to ensure the curriculum reaches bona fide educational institutions. Institutions request it from TPF through CommunityParamedic.org, TPF’s training and education resource site.
To plan a community paramedicine, MIH, treatment in place or alternate destination program, start a conversation →
References
Biernat, R. (2025, October 24). A guide to value-based enterprises for health system executives. Forvis Mazars. forvismazars.us
Breyre, A. M., Sloane, B., Bourn, S., Dilbert, M., Eddy, J., Friend, J., & National Association of EMS Physicians. (2025). Mobile integrated health care and community paramedicine: A position statement and resource document of NAEMSP. Prehospital Emergency Care. https://doi.org/10.1080/10903127.2025.2541899
Centers for Medicare & Medicaid Services. (2025, January). Emergency Triage, Treat, and Transport (ET3) Model final evaluation report. https://www.cms.gov/priorities/innovation/data-and-reports/2025/et3-model-final-eval-rpt
County of Renfrew. (2023, March 24). Ontario announces permanent funding for Renfrew County Virtual Triage and Assessment Centre. countyofrenfrew.on.ca
Currier, J., Wallace, N., Bigler, K., O’Connor, M., Farris, P., & Shannon, J. (2023). Community paramedicine in Central Oregon: A promising model to reduce non-urgent emergency department utilization among medically complex Medicaid beneficiaries. Journal of the American College of Emergency Physicians Open, 4(3), e12988. https://doi.org/10.1002/emp2.12988
Fitzsimon, J. P., Belanger, C., Glazier, R. H., Green, M., Peixoto, C., Mahdavi, R., Plumptre, L., & Bjerre, L. M. (2023). Clinical and economic impact of a community-based, hybrid model of in-person and virtual care in a Canadian rural setting: A cross-sectional population-based comparative study. BMJ Open, 13(5), e069699. https://bmjopen.bmj.com/content/13/5/e069699
Frier, D. B., DiGuglielmo, T. M., & DeWitt, N. M. (2022, August 29). Understanding the value-based enterprise. Medical Economics. medicaleconomics.com
Guo, B., Corabian, P., Yan, C., & Tjosvold, L. (2017). Community paramedicine: Program characteristics and evaluation. Institute of Health Economics. ncbi.nlm.nih.gov
National Association of Emergency Medical Technicians. (n.d.). Mobile integrated healthcare and community paramedicine (MIH-CP). naemt.org
Rural Health Information Hub. (2026, July 30). Rural mobile healthcare toolkit. ruralhealthinfo.org
Weinick, R. M., Burns, R. M., & Mehrotra, A. (2010). Many emergency department visits could be managed at urgent care centers and retail clinics. Health Affairs, 29(9), 1630–1636. https://doi.org/10.1377/hlthaff.2009.0748
Plan a community paramedicine or treatment in place program that lasts
TPF can show what is feasible under the rules where you work. It can use your data to find where an alternative response would help most. TPF can also name the party that captures the savings and define what it takes to build a program that holds up after the start-up funding ends.