Community paramedicine · Mobile Integrated Healthcare · Treatment in Place · Transport to Alternate Destination · Value-based payment
Care models that meet patients where they are
Community paramedicine and treat-in-place programs let paramedics deliver the right care in the right setting: at home, in the community, or at a destination other than an emergency department. The clinical case is established. What decides whether a program survives is the payment structure and the governance around it. The Paramedic Foundation designs the program, builds the measurement, and works the policy and payment pathway that keeps it running after the start-up money is gone.
The terms are not interchangeable
Community paramedicine and mobile integrated healthcare are routinely used as synonyms in solicitations, statutes, and board presentations. They are not synonyms, and the conflation has consequences: it produces program designs that cannot be evaluated, scope-of-practice language that does not match the workforce actually delivering the service, and payment arrangements that name the wrong contracting party. TPF maintains a controlled vocabulary for these terms and applies it in every deliverable.
Community paramedicine is a model of care in which paramedics apply their training and skills in community-based settings outside the conventional emergency response and transport model. A community paramedic practices within an expanded scope, applying specialized skills and protocols beyond base paramedic training, and in an expanded role, applying existing skills in non-traditional functions. This is the reference definition proposed by the International Roundtable on Community Paramedicine, as reported by the Institute of Health Economics (Guo et al., 2017).
Mobile integrated healthcare is the provision of healthcare using patient-centered, mobile resources in the out-of-hospital environment. The distinction TPF draws between the two is directional. Mobile integrated healthcare is delivered by a range of healthcare entities and practitioners that are administratively or clinically integrated with EMS agencies. Community paramedicine refers to services provided by EMS agencies and practitioners that are administratively or clinically integrated with other healthcare entities (National Association of Emergency Medical Technicians, n.d.). The current authoritative synthesis 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).
One point TPF states plainly rather than glossing: no formal consensus definition of community paramedicine exists in the literature. The Institute of Health Economics review found no consensus and reported that the Roundtable definition above is the one most widely cited (Guo et al., 2017). TPF adopts it as a reference standard and discloses the absence of consensus wherever the point is material to a finding or a recommendation.
Other frameworks draw the line differently. The Rural Health Information Hub, for instance, distinguishes the two by workforce composition, treating mobile integrated healthcare as the term for programs staffed by a mix of paramedics, EMTs, nurses, and social workers, and community paramedicine as the term 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 case is established. The barrier is structural.
A national analysis estimated that 13.7 to 27.1 percent of all emergency department visits in the United States could take place at an urgent care center or retail clinic instead (Weinick et al., 2010). Community paramedics are positioned to close part of that gap. They are members of the communities they serve, they carry built-in trust, they operate at all hours, and they can provide assessment, care coordination, and referral outside hospital settings.
The evidence supporting community paramedicine includes reduced hospital readmission rates, lower emergency department utilization, improved chronic disease management, and documented cost savings. The structural barrier is separate from the evidence. Medicare’s ambulance fee schedule has historically required transport to a covered destination for reimbursement to occur. No transport, no payment, regardless of the clinical outcome. That single rule shaped how EMS systems were built, trained, staffed, and financed for four decades.
Changing it takes jurisdiction-specific work, which commonly includes state legislation, a Medicaid State Plan Amendment or waiver, medical oversight frameworks that satisfy the state medical board and the local medical director, and a payment arrangement with whichever party actually captures the savings. TPF’s EMS policy and legislative work addresses the reimbursement barrier at the state and federal level. The practitioners and advisors who do that work have run these systems rather than studied them from outside. They can say which statutory language has held up in practice, which payer strategies are realistic in a given state, and which clinical governance structures regulators and medical directors will accept.
Extending paramedic expertise into everyday health
Community paramedicine sends paramedics to patients outside emergency contexts for chronic disease management, post-discharge follow-up, behavioral health navigation, medication reconciliation, and screening for the social conditions that drive utilization. The model does the most work in communities where primary care is limited or inaccessible, where the emergency department has become the default for conditions that do not require it, and where high-frequency 911 use is consuming system capacity.
In Renfrew County, Ontario, the County of Renfrew Paramedic Service’s Virtual Triage and Assessment Centre combines virtual physician assessment with in-person paramedic care. A population-based study comparing the two years before its March 2020 launch with the first year after it found a 34.4 percent decline in emergency department visits among county residents, larger than the declines in comparable rural regions over the same period, which coincided with the first year of the COVID-19 pandemic (Fitzsimon et al., 2023). The study measured the hybrid model as a whole and does not attribute the decline to paramedic care alone. The Ontario government announced permanent funding for the centre in 2023, with $3.2 million for 2023-24 (County of Renfrew, 2023).
TPF designs community paramedicine programs, develops the outcomes measurement framework, and builds the legislative and payment strategy that makes them financially durable. Training and education sit alongside that work at CommunityParamedic.org, TPF’s training and education resource site and the route by which colleges, universities, and other bona fide educational institutions request the Community Paramedic curriculum from TPF. The curriculum itself is a matter of custody rather than authorship: copyright is held by The Paramedic Network, and TPF’s role is to ensure it reaches those institutions.
The right response to the right situation
Treatment in Place means a paramedic assesses and treats a patient at the scene without transport, where clinical judgment and the applicable protocol support that decision. Transport to Alternate Destination means routing a patient to the appropriate destination, such as an urgent care center, a behavioral health facility, or a sobering center, rather than defaulting to the nearest emergency department.
CMS ran the Emergency Triage, Treat, and Transport (ET3) model from January 2021 until it ended early on December 31, 2023, citing lower than expected participation and interventions; 147 ambulance participants remained at the end. The final evaluation, published in January 2025, found that mortality after treatment in place did not differ significantly from comparable low-acuity emergency department episodes and that Medicare spending was moderately lower. It also reported that ET3 interventions were fewer than 1 percent of participating agencies’ Medicare transports, that follow-up emergency department visits and hospitalizations were higher after treatment in place, and that its design calls for caution in interpreting the results (CMS, 2025).
TPF produces model statutory language, medical director guidance, Medicaid State Plan Amendment strategy, and coding frameworks for these programs. The work is jurisdiction-specific from the first meeting, because the binding constraint is almost never clinical.
The legislative window
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) are before the 119th Congress. New York, California, and Illinois have enacted structural state-level changes. TPF tracks these measures and analyzes how they intersect with state strategy for the agencies it advises. TPF is not a lobbying organization and takes no position on any of them. Current status for each bill is maintained on the policy page.
Paying for care that does not involve a transport
Most community paramedicine and mobile integrated healthcare programs that fail do not fail clinically. They fail when the grant ends, because nothing in the ordinary payment system pays for the thing the program does. Grant funding, hospital in-kind support, and local subsidy are the three sources the field has leaned on, and none of them is a business model (Rural Health Information Hub, 2026).
The parties who capture the savings are the ones with a reason to pay: hospitals carrying readmission penalties, health systems and accountable care organizations holding total-cost-of-care risk, Medicaid managed care plans, and increasingly commercial payers. Getting money from those parties to an EMS agency is where the difficulty lies, because a payment from a hospital to an entity that influences where patients are taken raises the physician self-referral law and the federal Anti-Kickback Statute immediately.
The value-based enterprise is the structure most often used to make that payment defensible. A value-based enterprise is not a new legal entity by default. 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 requires four things: at least two participants collaborating toward at least one value-based purpose, participation in a value-based arrangement, an accountable body or person responsible for financial and operational oversight, and a governing document describing the enterprise and how its participants intend to achieve its value-based purposes (Frier, DiGuglielmo, & DeWitt, 2022; 42 C.F.R. § 411.351).
What makes the structure useful for this field is the risk continuum built into it. The physician self-referral regulations set out three value-based exceptions at 42 C.F.R. § 411.357(aa): paragraph (aa)(1) for full financial risk, paragraph (aa)(2) for value-based arrangements with meaningful downside financial risk to the physician, and paragraph (aa)(3) for value-based arrangements generally. The Office of Inspector General established corresponding Anti-Kickback Statute safe harbors at 42 C.F.R. § 1001.952(ee) for care coordination arrangements to improve quality, health outcomes, and efficiency, § 1001.952(ff) for value-based arrangements with substantial downside financial risk, and § 1001.952(gg) for value-based arrangements with full financial risk. Both sets of rules were published in the Federal Register on December 2, 2020.
The care coordination pathway does not require the EMS agency to take downside risk, which matters for a rural service that has no balance sheet to absorb it.
Two constraints deserve stating directly. First, the parties must hold a good-faith belief that the value-based activities will achieve the stated purposes, and ongoing monitoring must substantiate that they do; a structure assembled mainly to reach the exception, without genuine commitment to the activity, loses protection (Frier, DiGuglielmo, & DeWitt, 2022). Second, this is legal work. Practitioner guidance for health system executives is explicit that qualified healthcare counsel should be closely involved from the design stage (Biernat, 2025).
TPF’s contribution sits on the program side of that line. TPF identifies which party captures the avoided cost and quantifies it, defines the target patient population using criteria that can be verified and set in advance, designs the value-based activities and the clinical governance around them, builds the performance measures the arrangement will be judged on, and models the financial case for both sides. TPF does not provide legal advice and does not draft the governing document. Legal opinions and instruments rest with TPF’s counsel and with the client’s healthcare counsel. Nothing on this page is legal advice.
Designing a program that does not duplicate what already exists
The most common design error in a rural program is not clinical overreach. It is building a service that a home health agency, a home visiting program, or a community health worker program is already delivering in the same county. That fragments a small workforce and invites a turf dispute at the exact moment the program needs local partners. The Rural Health Information Hub’s Rural Mobile Healthcare Toolkit, published July 30, 2026, treats this as a threshold question: assess overlap first, then tailor the service to the gap that is actually open. It is a sound public starting point for a community at the beginning of this work, and TPF points communities to it rather than duplicating it.
The second threshold question is statutory. Some states still limit paramedic practice by statute to emergency calls, which forecloses the model before design begins. Minnesota and Wisconsin both broadened paramedic scope of practice through legislation in order to make community paramedicine possible (Rural Health Information Hub, 2026). Establishing where a state sits on that question is the first item in a TPF feasibility assessment. It determines whether the engagement is a program design or a legislative one.
The toolkit’s program examples show what the work produces at small scale. The Kanawha County Ambulance Authority program in West Virginia reported decreased readmissions and increased 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).
These are program-reported figures rather than independent evaluations, and TPF says so when citing them. The gap between program-reported metrics and evaluation-grade evidence is precisely what a measurement framework is for. It is one reason TPF builds the framework before the program launches rather than after a funder asks for outcomes.
What TPF builds for clients
An engagement begins with the client’s own call data and regulatory environment, and with the specific access gaps in the community rather than a generic model. The first deliverable is usually a feasibility assessment grounded in local call volume, payer mix, and utilization patterns, paired with a scope-of-practice and regulatory review for the jurisdiction.
From there a typical engagement produces a program design document covering scope of practice, referral pathways, inclusion and exclusion criteria, and partner integration; a clinical governance framework that a medical director will sign; a payment strategy, which may be a Medicaid State Plan Amendment or waiver route, a value-based arrangement with a health system or payer, or a combination; a workforce and training plan; an outcomes measurement framework specified before launch; and a phased implementation roadmap with the decision points named. Every deliverable is documented to APA 7 standard, and TPF designs for durable local ownership rather than continuing dependence 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 transition from a distant delivering hospital back to a county with no obstetric provider is where time-critical warning signs go unseen. TPF designs prenatal and postpartum in-home visit pathways for community paramedicine networks, with hospital-to-home transition protocols authored alongside obstetric clinical leadership and measures that report postpartum contact within a stated interval of discharge.
That design draws on a bench that pairs maternal health policy work, including a 2025 national webinar on emergency medical services collaboration in obstetric readiness for the Alliance for Innovation on Maternal Health and a 2026 Colorado Perinatal Care Quality Collaborative presentation on rural problem solving, with 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 bench behind community paramedicine and MIH engagements
Community paramedicine and mobile integrated healthcare is one of the knowledge domains TPF maintains a standing bench in. Engagements in this pillar are staffed from the disciplines below and scoped to the work rather than to a fixed roster.
Community paramedicine governance and program architecture. Clinical protocol development and service bundle design. Physician medical direction for treat-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.
Named profiles, credentials, and current roles for the full bench are on the team page. TPF names the individuals proposed for an engagement in the proposal for that engagement, where the names can be matched to the scope.
RHTP connection
Community paramedicine and Mobile Integrated Healthcare under RHTP
The Rural Health Transformation Program’s permitted uses of funds include payments to health care providers, right-sizing rural delivery systems across pre-hospital and emergency service lines, and innovative care models. CMS’s award announcement names treat-in-place options among the activities states will fund. Whether a community paramedicine or mobile integrated healthcare program is funded depends on each state’s approved plan and the terms of its solicitation.
Where a state’s solicitation permits, TPF supports RHTP-funded initiatives under contract with the state or 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, and that designation governs its treatment under 2 CFR Part 200. The Foundation carries the program design experience, the clinical credibility, and the federal compliance infrastructure, including 2 CFR Part 200 frameworks and subrecipient monitoring design, that state agencies and the organizations they fund need from proposal development through delivery and federal reporting.
States funding these programs through RHTP subawards and looking for an implementation or technical assistance partner can start a direct conversation.
About community paramedicine, MIH, and TIP/TAD
Common questions
What is community paramedicine?
Community paramedicine is a model of care in which paramedics apply their training and skills in community-based settings outside the conventional emergency response and transport model. A community paramedic practices within an expanded scope, applying specialized skills and protocols beyond base paramedic training, and in an expanded role, applying existing skills in non-traditional functions. This is the reference definition proposed by the International Roundtable on Community Paramedicine, as reported by the Institute of Health Economics (Guo et al., 2017). No formal consensus definition exists in the literature, and TPF states that plainly wherever the point is material.
What is the difference between mobile integrated healthcare and community paramedicine?
The distinction TPF draws is directional. Mobile integrated healthcare is delivered by a range of healthcare entities and practitioners that are administratively or clinically integrated with EMS agencies. Community paramedicine refers to services provided by EMS agencies and practitioners that are administratively or clinically integrated with other healthcare entities (National Association of Emergency Medical Technicians, n.d.). The current authoritative synthesis 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 workforce composition instead. A program should pick one framework and use it consistently 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 allows paramedics to assess and treat patients on scene without transporting them to an emergency department, when clinically appropriate and with proper medical oversight. Standard EMS is typically reimbursed only when it transports. 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, and that treatment in place was followed by more follow-up emergency department visits and hospitalizations.
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 generally has to come from a party that benefits from avoided utilization: a hospital, a health system, an accountable care organization, or a payer. The value-based enterprise is the contractual and regulatory structure most often used to make that payment defensible under the physician self-referral law and the federal Anti-Kickback Statute. It requires at least two participants collaborating toward a value-based purpose, a value-based arrangement, an accountable body or person responsible 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.
Formation is legal work: TPF designs the program, the target population definition, the measures, and the financial case, and does not provide 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, right-sizing rural delivery systems across pre-hospital and emergency service lines, and innovative care models. Whether a particular 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 engagement options.
Where should a rural community start?
With a needs and readiness assessment that establishes which gap the program fills, and with a screen for duplication against home health, home visiting, and community health worker programs already operating 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 engagement?
A needs and feasibility assessment, a program design document covering scope of practice and referral pathways, a reimbursement and payment strategy, a workforce and training plan, an outcomes measurement framework, and a phased implementation roadmap. All deliverables are documented to APA 7 standard. The South Carolina community paramedicine impact survey (Nudell et al., 2023) is an example of the evaluation methodology TPF applies.
Does TPF own the Community Paramedic curriculum?
No. Copyright in the international Community Paramedic curriculum is held by The Paramedic Network. TPF’s role is custodial: it ensures the curriculum reaches bona fide educational institutions. Institutions request it from TPF through CommunityParamedic.org, which is TPF’s training and education resource site.
Exploring a community paramedicine, MIH, or TIP/TAD 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
Exploring a community paramedicine, MIH, or TIP/TAD program?
TPF can establish what is feasible in a given regulatory environment, identify from the data where alternative response would have the highest impact, 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.