Multistakeholder perspectives of a managed care-funded community paramedicine programme

Abstract

Background

Community paramedicine (CP) programmes extend traditional paramedic care by delivering scheduled healthcare and social services to high-risk individuals. Research is needed on the perspectives of patients, families, and providers, and their relational dynamics in managed care CP programmes.

Methods

This qualitative study evaluated a CP programme funded by Molina Healthcare of Texas, a managed care organisation. We conducted interviews with 21 programme members and four significant others and held a focus group with paramedic providers. Data were analysed using reflexive thematic analysis, interpreting across three stakeholder groups.

Results

Four themes described members’ journey through the programme: (1) Opening the Door and Accepting Help; (2) Building Trust through Support and Navigation; (3) Finding Connection and Belonging through Human-Centred Care; and (4) Reaching the Limits of Support. These themes form a Wheel of Relational Care, illustrating how consistent, personalised work helps open the door to care, build trust, foster connection, and illuminate the practical limits of support across the programme journey.

Conclusion

CP programmes, under managed care, can meaningfully support high-risk members with their personal needs and improve access to needed services. However, these programmes require substantial staffing and resources for long-term scalability.

Keywords

community paramedicine managed care high-risk patients relational care reflexive thematic analysis

Introduction

There is growing interest in deployable, community-based healthcare programmes that can improve access and care of adults who are frequent users of acute care services, such as emergency departments, homeless services, and inpatient hospitals.^1–3 One relatively new model of such programmes that has received international interest is community paramedicine (CP).⁴ CP extends traditional paramedic care by having trained paramedics also deliver other healthcare and social services to communities, such as assisting with disease management, conducting home assessments, and making linkages to other community services.⁵ CP providers can address non-medical drivers of health beyond the capacity and reach of traditional medicine models of care.⁶ The role of a community paramedic is often a combination of four aspects: assessment, referral, education, and communication.⁷ Through scheduled or arranged visits, paramedics provide these community services during downtime between emergency calls or after triggering events such as an emergency department visit or hospital encounter, leading to more effective use of paramedic resources.⁸

A 2019 systematic review found that CP programmes are diverse and address a spectrum of population health and social needs.⁹ But the review concluded there has been little empirical study of the impact of these programmes on the members served or the communities in which they operate. A subsequent 2021 systematic review, which included more recent studies, reported evidence that CP programmes can improve patient health outcomes, such as diabetes risk, blood pressure, and levels of care and personal health.⁷ Improvements were also observed in the wider healthcare system where CP programmes were operating, such as reductions in emergency calls, urgent care visits, and hospital admission rates. However, there were few studies on patient experiences, or little examination of what aspects of CP programmes could be improved. Further study is needed, along with the development of a consistent training curriculum for CP and their integration with healthcare systems.^5,7 A 2022 restricted review identified a growing body of qualitative research in CP, including studies on patient experiences, provider role development, and interprofessional collaboration.⁵ However, much of this work has examined single stakeholder groups, typically CP providers or patients alone, and not how perspectives intersect across patients, families, and providers or their relational dynamics. The review also noted that qualitative studies from the United States remain limited, particularly in fire-based CP models, where paramedics work within municipal fire departments and programme structures differ from those in countries where paramedicine is a standalone profession. There has also been nearly no study of CP programmes in the context of managed care, which is an important part of the healthcare landscape in the United States.

To address this knowledge gap, we conducted a qualitative study of a CP programme funded by a large managed care organisation in San Antonio, Texas. Three stakeholder groups were interviewed: programme members, their significant others, and the paramedic providers who provided services. The aims of the study were to (1) examine the experiences of people in the programme and relational dynamics between stakeholders; (2) understand any impacts on programme members’ health and quality of life; and (3) identify programme challenges and areas for improvement.

Methodology

Setting

In much of the United States, paramedics are employed by municipal fire departments (known in the UK as fire and rescue services) rather than hospitals or private ambulance services.⁵ As a result, there are many firefighter-paramedics who respond to both medical emergencies and fire calls, wearing fire department uniforms and operating out of fire stations. Emergency medical calls are often answered using fire department vehicles, including fire engines. CP programmes vary widely across the country, and paramedicine providers serve these roles within fire-based, hospital-based, private, or third-service models. The San Antonio programme reflects a fire-integrated model in which paramedics are embedded within the city's fire department rather than operating independently. This structure is common in Texas and parts of the US South and West, but differs from international systems where paramedicine is a standalone profession separate from fire services.^10,11

Programme description

Molina Healthcare was started in 1980 and has grown into one of Texas’ largest managed care organisations.¹² Molina Healthcare has created a mobile integrated health programme in partnership with the Southwest Texas Regional Advisory Council (STRAC) to deploy a CP programme in San Antonio.¹³ The focus of the current study is the Molina Community Paramedicine programme. Eligibility for the programme was Molina Healthcare members who had Medicaid, Medicare-Medicaid Plan, or marketplace health insurance, and members who had five or more emergency department and/or inpatient admissions within the past 6 months before enrolment. The programme's stated purpose was to identify and address members’ needs and barriers contributing to potentially preventable emergency department visits and hospital admissions. These needs and barriers included assistance with primary/speciality care; prescription refills; transportation; financial, housing, and food insecurity; untreated mental health issues or non-adherence with treatment; social isolation; and health literacy.

Research paradigm

This study was grounded in a relativist ontology, which assumes that multiple realities exist and are constructed through individuals’ subjective experiences and social interactions. This ontological position aligns with an interpretivist epistemology, which holds that reality is co-constructed and best understood through the perspectives of those who live it.^14,15 Interpretivist research prioritises understanding the meaning participants assign to their experiences, acknowledging that these meanings are shaped by specific social, cultural, and relational contexts.¹⁶ In contrast to positivist paradigms that seek generalisable findings, interpretivism values the existence of multiple subjective realities and the depth of individual perspectives. This approach is well-suited to study CP, where the perceived value and impact of care or care programmes can vary widely across individuals and situations.¹⁷

Accordingly, this study aimed to explore how participants, including programme members, family members or partners, and healthcare providers, experienced and made meaning of their involvement in the programme. This interpretivist approach supports reflexive thematic analysis (RTA) to examine how meaning is produced, interpreted, and situated within specific personal and social contexts.¹⁸ Interpretivist inquiry views participants as the best source of insight into their own lives and emphasises the co-creation of knowledge between researchers and participants.¹⁹

Ethics

We were a research team at the University of Texas Health Science Centre at Houston (UTHealth) School of Public Health who served as independent evaluators of the programme with funding support from the Episcopal Health Foundation and administrative support from Molina Healthcare, including co-author NA. Participants were explicitly told their responses would remain confidential from Molina Healthcare, but we cannot entirely rule out impression management or other sorts of response biases. The study procedures, including risks, ethics, and safeguards, were reviewed and approved by the UTHealth Institutional Review Board (project approval #HSC-SPH-24-0198).

Researcher characteristics and reflexivity

None of the team members had direct experience as CP patients or paramedics, although one author has served as a volunteer state-certified firefighter. We approached this work primarily as outsiders to the emergency medical services field, which allowed us to ask open, clarifying questions; however, we also recognise that this outsider perspective may have limited our understanding of certain clinical or operational nuances. To support well-informed interpretations, we met with programme leadership to review our study protocol, data generation plan, and interview approach, and later provided an evaluation report to the programme. These engagements strengthened our understanding of the programme's workflows, roles, and operational context. We relied on reflexive awareness of how our experiences and perspectives informed the analytic process¹⁸ and recognised that our position as neither full insiders nor outsiders placed us in a productive ‘space between’ these roles.²⁰

Our social identities, cultural backgrounds, and professional experiences also shaped how we engaged with participants, our analytic focus, and the meanings we constructed from the data. The research team included White, Hispanic, and Taiwanese members with training in behavioural science, public health, and qualitative inquiry, ranging from graduate student researchers to senior faculty. Several members brought lived experience shaped by bilingual or bicultural identities, working extensively in low-income and medically underserved communities, and growing up in immigrant families. These perspectives sensitised us to issues of access, trust, and system barriers that occurred across participant narratives. Throughout the analysis, we reflected on how our assumptions and backgrounds shaped our engagement with participants and the meanings we drew from their accounts.

Recruitment

Molina Healthcare provided a contact information list of all 105 members who had graduated (i.e. completed the programme) or were currently enrolled in the CP programme in San Antonio, Texas, from 2022 to 2024 to the research team. Molina initiated contact by first sending a mass email to all members, letting them know a recruitment email from the research team would be forthcoming to legitimise the request and to state that participation was completely optional and would not affect their services. The research team then began recruiting members for participation in the study. The research team used a random number generator to sort the member list to ensure a fair order of outreach and to avoid systematic patterns in programme records (e.g. alphabetical or chronological), determining who was contacted first. All members were contacted, at least three times by phone, to invite them to participate in an interview. All members were told that participation was completely voluntary, confidential, and would not affect their services in any way.

A semi-structured qualitative interview script was constructed with feedback from Molina Healthcare programme administrators. The interview script consisted of questions regarding the experiences and effects of the Molina CP programme among multiple stakeholders – members, their significant others, and paramedicine service providers. Members were asked about programme enrolment, what the programme offered them, level of satisfaction, their perceived impact of the programme, specific aspects that helped them, and suggestions to improve the programme (see Appendix).

After the interview, members were asked to identify a significant other, who could be a family member, caregiver, or friend, who was knowledgeable about their experiences with the programme, so that they could be invited for a qualitative interview. Significant others were invited to participate in interviews using a similar set of questions and procedures to collect information to supplement the members’ interviews.

Interview procedures

Data generation included one-on-one interviews with programme members and significant others, and an in-person focus group with programme providers. Interviews were conducted virtually in English or Spanish using semi-structured guides tailored to each participant group. All interviews and the focus group were audio-recorded and transcribed using Microsoft Teams’ automated transcription. A research team member reviewed each transcript against the original audio to verify accuracy prior to analysis. Informed consent was obtained verbally from all participants before beginning interviews or the focus group, given the low-risk, conversational nature of these procedures, which were approved by the institutional review board. For Spanish-language interviews, a bilingual team member reviewed the transcript for accuracy and fidelity to the original meaning, and any interpretive ambiguities were resolved through discussion with the broader team.

Focus group

We conducted an in-person focus group with six providers in the Molina Community Paramedicine Programme to explore their experiences with the programme, their perspectives on its impact, and areas for improvement. The session took place at the providers’ fire station, and all participants were San Antonio Fire Department paramedics. The focus group lasted approximately 60 minutes.

The discussion began with a brief brainstorming activity, in which participants wrote post-it notes and used coloured stickers to identify programme strengths, areas for growth, and perceived impacts on members’ health or well-being. This activity served as a generative warm-up to prompt conversation. We photographed the brainstorming materials to preserve contextual information and used them during the familiarisation phase of analysis, but we did not analyse them as standalone data sources.

Consistent with reflexive thematic analysis, we analysed the full focus group transcript using the same iterative coding and theme-development process as the individual interviews, integrating provider perspectives across all analytic phases rather than treating them as a separate dataset.

Data analysis

We conducted a reflexive thematic analysis following the six-phase process outlined by Braun and Clarke.^21,22 These phases include becoming familiar with the data, generating initial codes, constructing themes, reviewing themes, defining and naming themes, and producing the final report. The process was recursive rather than linear, meaning we moved fluidly between phases as our understanding of the data evolved. We chose this analysis over framework analysis because our primary aim was to generate rich, interpretive insights into participants’ experiences and relational dynamics of the programme rather than to map data against a pre-existing framework. Transcripts were coded by three team members (PPW, MC, GF). Our coding approach was primarily inductive, with codes developed directly from participants’ language and experiences. The analysis was guided by the study's research questions and sensitising concepts, including communication, care coordination, and programme impact. Consistent with reflexive thematic analysis, coding and theme development were iterative, interpretive, and team-based. Data were managed using ATLAS.ti version 25.0.1. Team members used reflexive memos to document analytic insights and support theme development. For example, we initially coded descriptions of frequent check-ins and emotional reassurance as ‘programme support’. On reflection, this felt too broad and did not fully capture the relational work participants were describing. Through team discussion, we refined the code boundaries, which contributed to the development and naming of the theme ‘Building Trust’.

The full team participated in key phases: reading transcripts, sharing impressions during familiarisation, and reviewing developing themes. The coding team of three members met regularly to discuss coding decisions, explore different interpretations and refine code definitions. These discussions were intended to deepen analytic engagement with the data rather than to establish agreement or reliability.

This collaborative process encouraged multiple interpretations, challenged assumptions, and deepened our collective understanding of the data. Themes were developed through ongoing team discussion and reflection on the data. We moved from codes to themes when patterns of shared meaning felt conceptually coherent and meaningful in relation to the research questions, rather than simply because they appeared frequently across participants.

Reporting followed the Big Qualitative Quality and Rigour Guidelines (BQQRG), emphasising reflexivity, relational accountability, and interpretive rigour.²¹

Analysis

Of the 105 programme members initially contacted, 24 had phone numbers that were out of service or wrong, and 15 verbally declined participation. A total of 21 members were interviewed. A total of 10 participating members identified significant others, and 4 significant others responded and consented to participate in virtual qualitative interviews.

Programme members’ experiences in the Molina CP Programme reflected a health journey that moved from initial uncertainty to growing trust and connection, and, for some, unmet needs and programme limitations. Table 1 displays the background characteristics of the 21 members interviewed; notably, many members were missing data on race. We organised the qualitative findings as a thematic journey, tracing how individuals encountered, engaged with, and reflected on the programme over time.

Table 1.

Background information of participants of the Molina community paramedicine programme (n = 21).

	n	%
Age
40–44	3	14%
45–49	4	19%
50–54	4	19%
55–59	4	19%
60–64	2	10%
65–69	1	5%
70–74	2	10%
75–79	1	5%
Sex
Female	15	71%
Male	6	29%
Race
Black or African American	2	10%
White	5	24%
Unknown/Not reported	14	67%
Ethnicity
Hispanic or Latino	17	81%
Unknown/Not reported	4	19%
Member status
Graduated	17	81%
Engaged	4	19%

Note. Graduated members were those who had completed the Molina Paramedicine programme.

We constructed four main themes that reflect shared meanings in participants’ accounts. Theme 1, Opening the Door and Accepting Help, describes how members entered the programme through self-recognition of need or external outreach. Theme 2, Building Trust Through Support and Navigation, highlights how the programme's responsive care and communication built confidence in managing health. Theme 3, Finding Connection and Belonging Through Human-Centred Care, reflects feeling seen, respected, and less alone. Theme 4, Reaching the Limits of Support, identifies where programme communication broke down or members’ needs were unaddressed.

Due to our small sample and to humanise participants while preserving confidentiality, all quoted individuals were identified using pseudonyms and their role in the programme (Name, role). Pseudonyms do not reflect actual identities and were not selected to represent race, ethnicity, or cultural background.

Theme 1: Opening the door and accepting help

Members described enrolling in the programme as a pivotal moment, driven by internal and external motivations. ‘Opening of the door’ reflected their readiness to accept support. Other eligible members were influenced by external forces such as a provider's recommendation, persistent programme staff outreach, or family members’ encouragement.

Subtheme 1: Internal motivations to enrol

Members joined the programme because they recognised a need for change. Frequent emergency room visits, unmanaged health conditions, access barriers, or isolation created a readiness to accept programme support.

Go to a walk-in clinic and sometimes you’re there for five hours … it's difficult to get the care you need and it's like, is it worth it to go and sit somewhere, or should I just wait it out?…. Sometimes it's better to have somebody come see you than to have to deal with going out (Gina, programme member).

Another member reflected on the crisis point that led them to connect with the programme, ‘I had a lot of things wrong with me. So, I will call the ambulance a lot, and that's how I got in that programme’ (Cathy, programme member). Dealing with systemic barriers and deteriorating health issues were some of the participants’ motivators to enrol in the programme.

Subtheme 2: External motivations to enrol

Other members were drawn into the programme by external sources, such as trusted providers, family members, or active outreach from the Molina team. For some, the first point of contact was unexpected and memorable. Members recalled the fire department's arrival at their door, not for an emergency, but to introduce a new kind of help:

The firefighters came over here and introduced themselves. I said, ‘Did we call them? Where's the fire?’ And he goes, ‘No, no, there's no fire.’ He said he was with the fire department and with Molina, and they were going around the community because they were starting a new programme that they were going to help people. (Tonya, significant other)

The fire department's involvement particularly caught members’ attention and lent credibility to the programme. Molina providers noted the built-in trust associated with firefighters. Members and providers viewed them as credible, dependable, and approachable because of their uniforms, emergency response background, and longstanding community presence.

Everybody grows up understanding that the fire department is there to help you. So, when you show up in uniform, with the patch on, it's like—oh yeah, positive association. (Randall, paramedic provider)

Programme members were also introduced through providers or family members. ‘The doctor told me about it and said it might help, so I agreed’ (Thomas, programme member). External outreach was often an important first step in initiating care. The invitation to participate often arrived unexpectedly, yet for some members, it came at exactly the right time. External motivation, especially face-to-face encounters with respected figures, helped connect participants to care they may not have actively sought on their own.

Theme 2: Building trust through support and navigation

Once enrolled, members frequently discussed the importance of trusting relationships with programme staff. They credited the CP providers with helping them navigate complex healthcare systems, including scheduling appointments and accessing needed services. Through consistent check-ins, health education, and reassurance, members reported feeling more empowered and in control of their care.

Subtheme 1: Reaching care through coordination

Members described how the programme helped them overcome barriers to care by bringing essential services such as medical appointments, equipment, medications, and diagnostics directly into the home. ‘With my asthma and my immobility… instead of having to go find it, go sit in the lobby, be in pain in the lobby, being in pain having an X-ray, I got to do [X-rays] in the comfort of my own home’ (Deborah, programme member).

Members valued support with prescriptions, supplies, and in-home services: ‘They pick up my medications for me … and they helped me find a way to have them to get delivered’, and ‘I needed a new [bedside commode] because I gained a lot of weight, and I needed a heavy duty one and they got it for me’ (Marilyn, programme member). The programme's in-home care reduced logistical barriers and physical discomfort that might have caused members to delay or avoid care until they require emergency services.

The fire department's involvement was surprising and reassuring to members. The involvement of these providers shifted expectations, helping to build trust in the programme's approach to care.

Being the fire department, I thought they did one thing—they go and rescue people from fires. But these are medical people as well … it was really encouraging that they’ll come to your home and check on somebody who's been sick. I thought that was very different. (Donna, significant other)

Coordinated, accessible, in-home support helped members overcome barriers to care and receive timely services in ways that felt accessible and personalised.

Subtheme 2: Empowerment through education

Hands-on education helped members manage chronic conditions, monitor vital signs, and use home equipment. One member reflected on how much she learned through her interactions with programme staff, ‘Everything was learning, I really didn’t know too much … she explained what she was doing … what I need to do … and basically how to take care of myself better’ (Greer, programme member).

Education also extended to family members and caregivers. One significant other described learning how to manage her mother's blood pressure, ‘When her blood pressure is low, have her sit down … I didn’t even know, and I’m my mom's caregiver … so it's really good for me to learn these things’ (Mary, significant other). In-home, personalised education helped build members’ and caregivers’ confidence in managing health more independently, improving daily care, and potentially reducing unnecessary emergency room visits.

Subtheme 3: Advocacy and translation across systems

CP providers played a key role in helping members navigate fragmented healthcare systems. They not only coordinated care but also acted as advocates, translating information across clinical and real-world contexts. Providers described their role as intermediaries, ensuring members were heard and understood,

A lot of these patients won’t speak up for themselves—and that's what we do. It's like, ‘Alright, tell them why you’re not taking these meds.’ They don’t always understand what the doctor's telling them … the level at which doctors speak isn’t always clear enough for the average person to understand. (George, paramedic provider)

Providers also observed that members often mask their needs when interacting with clinicians, making it harder for physicians to grasp the full picture.

They clean up, they get dressed, they sit under control, they look their best…. And the doctor says, ‘Okay, how are you feeling?’ [and the patient says] ‘I feel great.’ It's like, ‘No, doctor, this is what's going on … this is how many times they’ve called 911.’

(Max, paramedic provider)

The CP programme built trust through advocacy and translation, improving care coordination and communication. Programme members described the team as reliable allies who helped them navigate the system, better understand their health, and feel more confident managing it.

Theme 3: Finding connection and belonging through human-centred care

Members spoke powerfully about the emotional impact of feeling respected, heard, and cared for. The programme stood out for what it provided and how it was delivered.

Subtheme 1: Being seen, heard, and respected

Small moments of personal attention made members feel valued and visible. ‘One of them [provider] saw that I like a lot of arts and crafts and stuff like that. On the next visit, he brought me some clay pots, so I could paint them’ (Susan, programme member). Respect also meant providers helped members navigate barriers and regain control of their care.

They helped me feel back on track, keeping up with my appointments and seeing the right doctors because I was battling getting … and going to my appointment. It's gotten way better. Now I’m stable, I’m good, and my life is good. I’ve got health issues, but I’m keeping up with them. (Heather, programme member)

Providers also noted how meaningful their presence was for members: ‘A lot of them were lonely, and they looked forward to our visits. Just us showing up’ (Caspar, paramedic provider).

Subtheme 2: No longer alone

The programme provided consistent contact and a sense of connection for members. Regular check-ins reassured members that someone cared, helping ease feelings of isolation and build programme trust. Providers described how even small gestures made a difference: ‘We tell them, “We’ll be checking on you again next week.” They like that—just knowing someone's checking up on them’ (Daniel, paramedic provider).

Members emphasised that these interactions were meaningful beyond medical tasks. They felt supported and more confident staying active and engaged with care. ‘They just treat me like a human being, you know, they care’ (Ella, programme member). Another recalled, ‘They’re taking the time to listen; they don’t seem to be in a hurry to get out’ (Aubrey, programme member).

The programme's ongoing interactions helped members feel recognised and more connected, reducing the isolation some had previously experienced. Experiences of trust and belonging suggested that a part of members’ programme journeys were relational, a pattern we later synthesised in a conceptual ‘Wheel of Relational Care’.

Theme 4: Reaching the limits of support

Despite overall positive experiences, some members reached a point in their journey where the programme's support fell short. Miscommunication about visit timing and follow-ups caused confusion and uncertainty. These members felt unprepared for the programme's end and needed more guidance during that process.

Subtheme 1: When communication breaks down

Members described moments when programme communication became inconsistent with missed visits, unclear timelines, or a lack of follow-through. ‘The biggest bad aspect for me was that they wouldn’t come when they said they were … and it's like, okay, I don’t know how to explain it, but I was really actually invisible to them’ (Lara, programme member).

Along with feeling overlooked, some members were frustrated when providers assumed they were available because they were sick or homebound.

They’ll call and say, ‘hey, we’re in your area. We’ll be there in 15 minutes.’ That doesn’t cut it. Just because I'm sick or I may be classified as a homebody or whatever, it doesn’t mean that my time is any less valuable than anybody else's time. (Kathleen, programme member)

Significant others also reported confusion around the end of the programme, why visits stopped, and disappointment that the support was gone. ‘It was fairly often, but then it was stopped—I don’t know why it stopped’ (Lucia, significant other).

. Members described feeling unacknowledged and uncertain about the programme when communication gaps and unclear endings left them without closure. These communication challenges were not unnoticed by CP providers. CP providers described the difficulty of maintaining personalised care with staffing shortages and overlapping responsibilities across multiple programmes, ‘We have at least 10 programmes and everyone here works across all of them…. Molina is just one of those ten programmes’ (Gerald, paramedic provider).

CP providers noted that increasing staff capacity would significantly strengthen the programme's ability to deliver consistent, patient-centred care. They recognised that communication challenges were sometimes compounded by barriers on the members’ side, including transportation issues, missed appointments, or difficulty reaching members at the time of visits.

I think some of the difficulty is the patient, too…. We go to see them and they’re not home. I even set up their transportation, and they still miss it. I’m like, ‘They’re outside your house right now. Go out the door. Answer your phone.’ That's the big one—answer your phone (Jenn, paramedic provider).

Subtheme 2: Unanswered needs

Even with programme support, some members described significant gaps in care. For example, delays in receiving supplies and difficulty accessing appointments created challenges. ‘I mean I still need more supplies for myself because I have a hard time getting all that and getting to the diabetes doctor appointments once a while’ (Eric, programme member).

Emotional and mental health needs were also not easily addressed by CP providers. At times, members dealing with personal stressors or emotional lows viewed well-intended outreach as poorly timed or difficult to receive.

Sometimes when people wanna help, it happens at the wrong time, you’re not looking for it … and if at that time you have somebody trying to cheer you up, sort of in a pep rally mode, it seems inconsequential and more of an inconvenience. (Kevin, programme member)

Summary of themes

These four themes describe CP programme members’ evolving journey through the programme, from initial outreach to building trust, forming connections, and confronting the limits of support. The ‘Wheel of Relational Care’ (Figure 1) visually represents this dynamic process, with relational care at the centre. However, the wheel also illustrates boundary conditions: the relational benefits were most pronounced during active engagement but often diminished when organisational constraints (e.g. staffing shortages, competing programme demands) disrupted continuity.

Figure 1.

Wheel of relational care capturing participants’ experience with the Molina community paramedicine programme.

Discussion

This study explored how programme members and significant others experienced the Molina CP programme, their impacts, and opportunities for improvement. Members described their CP care as a journey shaped by trust, connection, occasional disappointment, and overall reported positive impacts. Starting with programme enrolment, which was pivotal and often prompted by members’ internal motivations (declining health, isolation) or external influences (provider referrals, outreach, family encouragement). These early activation points highlight the importance of targeted outreach and relational engagement in initiating CP, and are consistent with prior literature.^23,24 These findings may also reflect the benefits of a managed care programme in which a healthcare entity can help determine eligibility and facilitate enrolment in a CP programme.

Members described a distinctive feature of the programme's outreach as firefighter involvement. They were surprised and reassured when uniformed personnel arrived not for an emergency but to introduce the programme. Community trust in firefighters encouraged enrolment among people who might not have otherwise engaged with the programme. Other US-based CP programmes have reported similar benefits, with fire department integration lending visibility and credibility.^25,26 Leveraging the trusted identity of firefighters may represent a unique strength of CP programmes and could be particularly effective in engaging hard-to-reach populations.

Once enrolled in the programme, members valued care coordination, including appointment scheduling, assistance in obtaining supplies, and navigating fragmented healthcare systems. Logistical support was important, however, and trust was built through the consistency and attentiveness of CP providers. Reliable provider presence helped members feel more in control of their health and more confident in managing their care. These findings suggest that relational continuity was central to how care is experienced.^27,28 Notably, however, not all members experienced this relational continuity equally: those who described missed visits, abrupt programme endings, or poorly timed check-ins reported a breakdown in trust that contrasts with the predominantly positive relational accounts. This divergence suggests that relational care can be a dynamic and fragile achievement rather than a guaranteed programme feature, and that programme conditions, such as staffing levels and multi-programme workload, function as key moderators of whether relational goals are realised in practice.

Members also highlighted being treated with respect and heard in ways that contrast with prior healthcare experiences. Examples of simple interactions, such as arriving as promised and engaging in casual conversation, helped members feel respected and recognised. These experiences reflect principles of patient-centred care, emphasising empathy, dignity, and attention to the whole person rather than focusing solely on clinical needs.^29–32 Training CP providers on how to form therapeutic alliances may be important, especially since paramedics and firefighters often serve individuals in time-limited capacities instead of in long-term provider relationships.

Our findings suggest that members experienced CP as relationally grounded. Relational care places a purposeful focus on relationships, depending on trust, consistency, and authentic engagement between providers and patients.^33,34 Themes such as ‘Opening the Door’, ‘Building Trust’, and ‘Finding Connection and Belonging’ highlight relational care as central to CP from the perspectives of members and significant others. These themes form the basis of our Wheel of Relational Care, illustrating how engagement and trust shape the members’ experience across their programme journey.

Other home-based CP models point in the same direction. A systematic review of ten programmes in Canada, the United States, and the United Kingdom found consistently high member satisfaction.⁷ Members described paramedics as caring and trustworthy, and valued their advocacy and reassurance. In Ontario, Canada, the EPIC programme showed how a strong relationship with providers became the backbone of support in the home. In the United States, Houston's CP programme tells a similar story, with paramedics explaining that ‘building trust’ can be as important as any clinical intervention. Together, these examples suggest that relational care is not an add-on but central to the effectiveness of CP.

Despite positive experiences, a number of members described programme shortcomings with missed visits, unclear communication, and abrupt endings that left them feeling disappointed or forgotten. These challenges mirror broader concerns about sustainability and operational limits in other CP programmes^9,35 and the need to manage expectations, ensure continuity, and clearly communicate scope and duration. Emotional distress also shaped how support was received; at times, stressed members perceived assistance from CP providers as poorly timed. Prior studies note CPs often encounter unmet behavioural health needs but lack resources, underscoring the value of integrating behavioural health support and referral capacity.^23,28

CP providers also described difficulties meeting some members’ needs due to limited staffing and competing programme demands. These constraints affected their ability to deliver consistent, personalised care, which may contribute to breakdowns in communication or follow-up. We do not know whether these constraints were due to the Molina's managed care model, but similar issues have been reported in many other CP programmes, where there are few resources and community paramedics have to manage traditional emergency and CP roles, leading to role strain and operational tension.^24,36 Sustaining relational care requires supportive organisational conditions and workforce capacity.^33,34 Programme success has been shown to rely on collaborative partnerships, adequate staffing, and sustained system-level investment. Supporting provider capacity through dedicated staffing, realistic caseloads, and investment in workforce retention may be essential to programme success and sustainability.

Limitations

This study explores one community paramedicine programme within a specific regional and organisational context, and the findings are shaped by that setting. The analysis reflects the accounts of those who chose to participate and does not capture the perspectives of members who declined or disengaged from the programme. The sample of members was predominantly Hispanic and female, which reflects the demographics of the member population in San Antonio but may limit transferability to CP programmes serving different demographic groups or operating in different managed care or geographic contexts. The sample was small, and data on race were missing for many members, which constrained our ability to examine dimensions of programme experiences across demographic groups. Additionally, this programme operates within a fire-integrated model that is common in the southern and western US, but differs from international systems and from hospital-based or third-service CP models, so findings may not translate to other settings. Finally, the managed care funding structure introduced organisational dynamics, including eligibility criteria, enrolment workflows, and resource constraints that are specific to this context and should be considered when interpreting the findings.

Conclusion

In conclusion, this managed care-funded CP programme was found to support members’ health and social needs. Recognising care as a journey within the programme reflected the need for continuity of care, support for emotional and behavioural health needs, and clear expectations between members and providers. CP programmes that seek to reduce system strain should prioritise trust, consistency, and human connection to maximise impact and improve patient experience.

Footnotes

Acknowledgements

Special thanks to members, loved ones, providers, and leadership at Molina Healthcare and Episcopal Health Foundation (Shao-Chee Sim and Amy Willa).

ORCID iD

Jack Tsai

Ethical considerations

All study procedures were approved by the institutional review board at UTHealth.

Consent to participate

All participants provided informed consent.

Author contribution(s)

Jack Tsai: Conceptualization; Formal analysis; Supervision; Writing – original draft; Writing – review & editing.

Paige P. Wermuth: Formal analysis; Methodology; Supervision; Validation; Writing – original draft.

Mia S. Chan: Data curation; Formal analysis.

Gloria Flores: Data curation; Validation.

Naomi Alvarez: Formal analysis; Resources.

Vanessa Schick: Data curation; Visualization; Writing – review & editing.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the Episcopal Health Foundation.

Declaration of conflicting interests

Dr. Naomi Alvarez serves as Associate Vice President at Molina Healthcare of Texas, but was not involved in the data collection or analysis of the study. All other authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data availability statement

Data are available upon request from the corresponding author with proper institutional approvals.

Appendix: Members interview script

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