Community paramedicine programs help address health and social needs outside of emergency situations. They expand the role of paramedics and emergency medical technicians (EMTs) beyond emergency response to provide post-discharge follow-up, chronic disease management, care coordination, and connection to community resources. Community paramedicine programs may also support underserved individuals who frequently rely on emergency services to address unmet medical, behavioral health, or social challenges. Some programs use a mobile integrated health care-community paramedicine (MIH-CP) model, in which community paramedics work alongside physicians, nurses, social workers, and peer support specialists (peers) to provide coordinated support for individuals with complex needs.

Behavioral health needs are frequently identified during paramedic home visits and follow-up encounters. In response, many community paramedicine programs have expanded to include mental health and substance use disorder services. Some, particularly in rural areas facing workforce shortages and geographic barriers, have integrated peers with lived experience of recovery into their care teams to help connect individuals with behavioral health needs to appropriate resources and support.

This profile describes how McDowell County, in rural western North Carolina, uses MIH-CP to support residents with complex medical, behavioral health, and social needs. This profile explores the program’s behavioral health services, its staffing and funding model, and highlights implementation lessons for other rural communities interested in developing or expanding community paramedicine.

Implementation Approach

North Carolina, like the nation as a whole, faces persistent behavioral health challenges, with workforce shortages and transportation barriers particularly acute in rural communities. Overdose-related emergency department (ED) visits and fatal overdose rates in rural areas of the state exceed those in urban areas. In western North Carolina, where McDowell County is located, more than 46 percent of residents report that substance use has negatively impacted their lives, and poor mental health among residents increased 39 percent between 2012 and 2024.

McDowell County Community Care Paramedics was established in 2013 after leadership at the county’s emergency services agency documented frequent 911 use and ED visits. The agency identified several underlying drivers, including lack of primary care, challenges managing multiple chronic conditions or new diagnoses, substance use, loneliness, social isolation, and fall-related injuries among older adults. The agency subsequently secured a grant from the Kate B. Reynolds Charitable Trust, which focuses on improving health in rural North Carolina, to launch a program to address these challenges.

The community paramedic team responds seven days a week to urgent calls and referrals from local EMS crews, law enforcement, and health care providers for situations that do not require ambulance transport. By collaborating across agencies and systems, including local mental health providers, social service agencies, law enforcement, and homeless shelters, the team addresses challenges with resourcefulness and creativity. Peer support professionals are a core component of the program, using their own recovery experience to engage individuals, connect them to behavioral health services, and support those who recently experienced an overdose.

Programs and Services

McDowell County Community Care Paramedics provides in-home assessments, care coordination, and connections to community resources. Some of these services are delivered in partnership with local health care providers, behavioral health organizations, social service agencies, and community organizations. Key services include:

• System navigation and care coordination: Coordinates prescription delivery and collaborates with primary care and home health providers to ensure care continuity.

• Post-overdose follow-up and medications for opioid use disorder (MOUD): Initiates buprenorphine treatment for individuals who meet assessment criteria and refers them to a local nurse practitioner, who typically assumes their care within 24 hours. If needed, community paramedics can provide a bridge dose.

• Social determinants of health support: Connects individuals to housing resources and addresses food insecurity.

• Application assistance: Guides eligible individuals through the application process for Medicaid and the Supplemental Nutrition Assistance Program.

• Medical services for individuals experiencing homelessness: Collaborates with local homeless shelters and cooling centers to provide medical services, including wound care.

• Mental health diversion to alternative destinations: Responds to mental health crises alongside local law enforcement, deescalating and determining the appropriate course of action, often diverting individuals from unnecessary hospitalization to mental health providers or mobile crisis centers.

• Home safety assessments: Assesses older adults’ homes for potential fall risks and identifies opportunities for home modifications and durable medical equipment.

Staffing Model

McDowell’s community paramedicine program functions as an interdisciplinary team, working together to support community members (see the table below for staff roles).

McDowell County Community Care Paramedics Staff Roles and Responsibilities

Role	Primary Function
Community Paramedic	Provides community-based assessment, care coordination, and crisis response for individuals with complex health, behavioral health, or substance use needs. Determines whether individuals are medically stable or if further care is needed, may initiate buprenorphine1 before connecting individuals to ongoing care, and co-responds to mental health crises with law enforcement. One community paramedic on the team also serves as the coordinator, managing the program’s day-to-day operations. Training: Licensed paramedic with additional training in community paramedicine, care coordination, behavioral health, and crisis response. May receive Crisis Intervention Team training and other specialized training based on local program needs.
Peer Support Specialist	Uses their own recovery experience to support individuals with behavioral health needs, connect them to resources and supports, and plays a critical role in addressing mental health, SUD, and post-overdose response. Training: North Carolina Certified Peer Support Specialist (NCCPSS) certification. EMT-Basic certification is also required to support participation on multidisciplinary response teams.
Social Worker or Care Navigator	Connects individuals to community resources, assists with applications for public benefits, and provides non-clinical interventions related to social determinants of health. Training: Master of Social Work degree or relevant knowledge and experience of community resources. EMT-basic certification is also required to support participation on multidisciplinary response teams.

Interdisciplinary collaboration among program staff is critical to providing effective support. When an individual’s needs are unclear, community paramedics and peers respond together to ensure the right support is available, whether medical care, behavioral health support, or both.

Community paramedics assess medical needs, determine whether additional care is required, and arrange transportation or treatment when appropriate. Peers focus on building trust, discussing substance use and recovery goals, and ensuring access to overdose reversal medication, food assistance, and hygiene supplies. The peer may also work with family members and conduct follow-up visits to maintain engagement and address ongoing recovery and support needs.

Funding Strategy

Securing sustainable funding for the program required demonstrating measurable impact and cost savings. To do so, program leadership first identified the primary drivers of high 911 utilization in the county, namely substance use and older adult falls. They then measured the frequency of these calls and calculated the costs associated with EMS responses, including ambulance services and ED care, to estimate program-related savings from cost avoidance. These savings were particularly important because the county bears the cost of many emergency responses involving uninsured residents. By demonstrating the costs avoided through community paramedicine interventions, McDowell secured support from county government. After the initial Kate B. Reynolds Charitable Trust grant ended, the program was funded through the county EMS budget. Additional funding from North Carolina’s Opioid Settlement Fund covers the peer support specialist’s salary.

Impact

The paramedic team reported serving 825 patients during its first three years. Among patients with complex care needs and frequent 911 use, 83 percent had fewer 911 calls within 90 days of receiving services compared with the 90 days prior to receiving services. By the following year, the program had contributed to 1,575 fewer 911 calls, 76 fewer behavioral health-related ED visits, 79 fewer hospital readmissions, and an estimated $1.6 million in avoided costs compared to four years before the program as reported by program leadership.

Implementation Lessons

McDowell County’s experience offers several lessons for rural communities seeking to implement or expand community paramedicine programs that address behavioral health and social needs.

• Partner with community organizations. McDowell emphasized the importance of partnerships across health care, behavioral health, criminal-legal, and social service systems. In rural areas, where services are often fragmented and difficult to navigate, the community paramedicine team serves as a bridge between individuals and available supports. For example, McDowell’s partnership with a local MOUD provider enables warm handoffs to ongoing care after initiating buprenorphine in the field.

• Integrate peers into rural community paramedicine teams. Adding a peer support specialist after the pandemic enabled the team to better support individuals with resource navigation and enhanced their ability to conduct follow‑up visits with individuals post-overdose. More broadly, embedding peers in additional settings, including hospitals or correctional settings (see below for an example from Caldwell County) can further help expand access to care in resource-constrained environments.

• Plan for the unique professional boundary and confidentiality challenges of rural communities. In rural communities, smaller populations and close-knit social networks increase the likelihood that peers will have pre-existing relationships or shared connections with the individuals they serve. While these connections can strengthen engagement, clear training and expectations for boundaries and confidentiality are important tohelp peers navigate potential challenges.

• Develop a sustainability strategy from the outset. McDowell’s Emergency Services agency used its initial grant period to demonstrate the value of the community paramedicine program. Other rural areas can consider a similar approach by collecting program data to document outcomes and cost savings. Programs can also seek Medicaid reimbursement for community paramedicine, as several states have done, including Arizona, Georgia, Minnesota, Nevada, and Wyoming. Other federal opportunities, such as the Rural Health Transformation Program (RHTP), may help communities launch or expand community paramedicine programs — 20 states are using funds from the initial round of RHTP funding to develop or expand community paramedicine/mobile-integrated health approaches like McDowell’s.

Looking Ahead

McDowell County’s experience demonstrates how community paramedicine programs can expand access to behavioral health care in rural communities by meeting people where they are and leveraging deep knowledge of local services, providers, and community resources to connect individuals with the care and assistance they need. The program also offers a model for integrating peers into teams alongside community paramedics, pairing lived experience from a trusted community member alongside clinical training to better address the complex medical, behavioral health, and social needs that often underlie frequent use of emergency services.

By connecting residents with appropriate community services, these programs can also reduce costs associated with ambulance transport and ED visits for non-emergency situations. Community paramedicine offers a promising approach for states seeking to improve behavioral health care access in rural areas, particularly given the RHTP funding opportunities available to support program development and expansion.

Acknowledgements

Thank you to Lt. Cailan Calloway, Community Paramedic Coordinator, McDowell County EMS; and Tara Swanson, Community Paramedic Captain/PORT Coordinator, Caldwell County Emergency Services who helped inform this profile.

1. For more information on buprenorphine initiation by paramedics see: Building bridges to outpatient treatment services for post-overdose care via paramedic buprenorphine field initiation. For more information on buprenorphine initiation by paramedics in North Carolina see: From revival to recovery: Some paramedics are changing the front line of addiction care.