New Mnemonics for Community Paramedics

Behind every EMS administrator who preaches the novelty and success of community paramedicine is a community paramedic sorting through tangled mazes of social and medical issues for each patient to make it work. Community paramedics know community paramedicine isn’t easy! For both new and experienced CPs, working without a defined structure to your assessment can feel like navigating a maze in darkness.

Assessing and addressing these determinants of health is vital to the success of community paramedicine but can be an overwhelming task, especially for CPs new to the role. Unlike our traditional work, where we rely on time-tested memory triggers such as the ABCs, SAMPLE, and OPQRST, community paramedicine has not, until now, had a way to ensure we systematically evaluate and triage the problems facing our patients. We’ve developed a new assessment model to capture the relevant determinants of health. The model includes a mnemonic device and a triage rating scale to help CPs prioritize their time.

The Mnemonic: CP’S MERITS 

The mnemonic CP’S MERITS was designed to help the community paramedic remember the primary dimensions that influence health outcomes. 

C = Clinical—The CP assessment starts with the medical issues familiar to traditional EMS providers. The C dimension of the assessment tool looks at the clinical aspect of the individual’s wellness, such as medical status, history, medications, and healthcare utilization history. We also recommend assessing the patient’s understanding of their disease(s) to determine whether they are appropriately following their providers’ recommendations.

P = Psychological—The P dimension addresses mental health comorbidities. Like the clinical review, this component of the assessment considers the patient’s past mental health history, medications, substance use disorders, and utilization of mental health and substance use care services. 

S = Social—The S dimension asks about the perceived support of friends, family, or more formal organizational support systems. Social isolation or loneliness scales may provide a way to quantify and compare the relative support (or lack thereof) of CP patients. 

To note, the first part of the mnemonic (CP’S) can be compared to the clinical-psychological-social combination taught as a “biopsychosocial assessment” in existing community paramedic programs.

M = Meals—The M dimension looks for hunger, the quality of nutrition, eating disorders, and food hygiene, all of which impact a person’s ability to maintain good physical and mental health. Hunger is more prevalent in the U.S. than most people realize and correlates to hospital stays and emergency department utilization. Poor food hygiene, such as eating from garbage bins or not refrigerating food, can also cause illnesses. Dietary restrictions, such as those found with many chronic illnesses, are hard to follow but also influence health status. 

E = Environment—The E dimension looks at a multitude of environmental factors that influence health. Traditional EMS providers are trained to manage acute emergencies due to extreme exposure to the environment. Community paramedics take this further, managing even more chronic environmental factors ranging from housing conditions to mitigating broader geographical or community infrastructure hazards. 

R = Records—The R dimension looks at the broad range of patient records that help or deter access to services. Access to social support services usually requires one or more forms of identification. Even with proper identification, some patients (such as registered sex offenders, convicted arsonists, or meth manufacturers) have criminal records that prevent them from receiving certain services or housing. Challenging delays in service may occur due to nonexistent or existing records, and the community paramedic may need to begin working on these issues quickly. 

I = Income—The I dimension looks at the cash and noncash income of the patient. Patients who lack enough income to manage their monthly expenses often find themselves sacrificing essentials such as food, medicine, and utilities. Navigating through the application process for state and federal income subsidy programs or filing for permanent disability status is complex and time-consuming, and often requires specialty expertise. Given the complexity involved in filing these applications, if other support systems already exist, we recommend CP teams partner with agencies in their area that already specialize in this work.

T = Transportation—The T dimension looks at the transportation resources of the patient in relation to their needs. Patients who lack reliable transportation or have physical or mental challenges navigating public transit often resort to calling 9-1-1 for their transportation needs.

Seasoned CPs also recognize that transportation needs don’t just refer to the process of moving between facilities but also require some forethought as to how those patients will navigate within those facilities. Every step of the patient’s movement, from within their apartment to the curb, to the vehicle, to the curb and inside the destination facility, may present an insurmountable obstacle if not addressed by the community paramedic before the transport occurs.

S = Skills—The S dimension is different because it applies to all the above dimensions. The patient’s literacy and competence in each domain plays a vital role in their ability to resolve problems on their own. Community paramedic interventions are designed to provide temporary assistance and ultimately empower the patient to resolve future problems independently. However, if the patient does not have or cannot reasonably obtain skills in these domains, they should be referred to longer-term services in the respective systems of care.  

TUSI Triage

Within each of the CP’S MERITS fields, the authors suggest rating each dimension as threatening, unsustainable, sustainable, or ideal. TUSI is the second mnemonic in the assessment tool and helps the community paramedic prioritize efforts. 

T = Threatening—Problems that pose an immediate threat to life of the patient or others need to be addressed immediately.

U = Unsustainable—Unsustainable problems are not considered an immediate threat but will pose a risk to the patient soon. These problems typically include the patient’s use of temporary resources that will not be available in the future. 

S = Sustainable—Sustainable situations are not considered an immediate threat and will generally be OK for the patient in the foreseeable future, provided circumstances don’t change. For example, a patient who has been homeless for 15 years and understands how to be homeless may be able to navigate the streets relatively safely. 

There may be times when the patient’s way of coping includes behaviors that are difficult for the CP to endorse. Some coping mechanisms involve behaviors that are morally or legally questionable. These situations may put the CP in a position to evaluate whether to take action, consult with leadership, or examine whether the issue involves a difference in values. 

I = Ideal—Ideal situations serve as a protective factor for the patient and should be investigated further to determine if the resources available for that area could help address needs in other areas. For example, ideal social, environmental, or income situations may help the patient cope with threatening or unsustainable medical or psychological problems. 

Customizing CP’S MERITS

Each CP program will reflect the unique patient population served and resources available in its community. The priority you assign to the problems in each dimension will depend largely on your subjective assessment of the patient’s situation; however, adding additional screening tools such as clinical lab values, mental health screening tools, hunger vital signs, or other, more objective measures may help determine the need for more timely interventions in your specific program.  

Getting Started

Traditional assessment mnemonics like SAMPLE and OPQRST use prescribed questions to elicit information from the patient. CP’S MERITS relies more on conversational skills such as motivational interviewing to assess the patient’s status in each of its dimensions. For new CPs or those unfamiliar with motivational interviewing techniques, the following questions may help you determine the patient’s current status in each dimension. 

1. What’s working?
2. What’s not working?
3. What resources do you have?
4. What do you want to see happen?
5. What did we miss? 

The CP’S MERITS and TUSI triage models may help CP programs ensure they’re conducting a comprehensive assessment of their patients and addressing the most salient issues first. Based on our experience and the feedback of experienced CPs, we believe this memory device may not only help CPs assess their patients but may help those managing CP programs determine the types of community partnerships they need to consider when designing their interventions. We encourage CP programs and vendors of electronic health records to adopt this or similar tools in their documentation systems. 

Anne M. Jensen, BS, EMT-P, is  special projects manager at San Diego Fire-Rescue Department, EMS Division, and a member of the EMS World editorial advisory board.

Dan Swayze, DrPH, MBA, MEMS,  is vice president of the Center for Emergency Medicine, Pittsburgh, Pa., and a member of the EMS World editorial advisory board.