1. Home visits in Fort Worth
When John Farris, a paramedic in Fort Worth, Texas, pulled up to Anita’s home, he wasn’t using his lights or sirens, and he wasn’t in a rush. If anything, he moved slowly to give her more time to wake up — often when he calls to remind her that he’s on the way for their scheduled appointment, she is still in bed.
Anita (not her real name) didn’t call 911 today, but she has many times in the past. So many times, in fact, that MedStar, the EMS provider in Fort Worth, flagged her as a high user. They also enrolled her in the Community Health Program and Farris, one of MedStar’s community health paramedics, began visiting her.
Today, Anita is awake, and lets Farris into her small, dark apartment. They sit at the kitchen table and talk for more than 15 minutes before he even checks her vital signs and listens to her lungs. She is a diabetic and suffers from depression and chronic pain.
Farris isn’t there to start an IV or take her to the hospital; instead, he is trying to work with Anita to take control of her own care. Farris is blunt and not afraid to challenge his patients.
“I can give you a shovel. I can sharpen your shovel,” he told her. “But I’m not going to do the shoveling for you.”
MedStar hopes that helping Anita manage her medical and psychiatric issues will not only improve her health, but also reduce the likelihood that she will call 911.
MedStar is just one of hundreds of EMS agencies around the world that have initiated programs to decrease the use of 911 by what many call “frequent flyers.” Most agencies have tried to find terms that are less demeaning: MedStar’s is the “EMS Loyalty” program. In Winnipeg, Canada, they’re referred to as “common callers.”
2. Winnipeg connects patients to health services
Situated in the mostly rural central Canadian province of Manitoba, Winnipeg has a population of more than 700,000 and growing. Like other cities, its EMS providers were dealing with frequent calls for low-acuity problems, often from the same people.
In this case, many of them were also at the same location: the Main Street Project, which provides emergency shelter, detox, transitional housing and other services.
Winnipeg Fire Paramedic Service ambulances were responding to the Main Street Project more than once each day, and were usually transporting patients to the hospital even for low-acuity complaints. Not only did that seem inefficient, but it wasn’t producing much revenue. Manitoba Health, which provides insurance coverage to citizens of the province, does not pay for emergent ambulance transports, said Ryan Sneath, a Winnipeg paramedic and nurse.
A program is born
Initially, in 2009, Sneath was assigned to the Main Street Project following the death of a “regular” at the detox facility the previous year.
Through a joint venture between the Winnipeg Regional Health Authority and the Fire Paramedic Service, Sneath began working at the Main Street Project and evaluating individuals brought to detox to ensure that they did not need more urgent medical attention or hospitalization.
What he and his colleagues discovered is that simply by being on site at Main Street Project, they could avoid many unnecessary ambulance responses and transports. In 2010, a second paramedic was added. Later, the program expanded to include paramedics at the Main Street Project 24 hours each day.
The paramedics provide medical clearance, primary care referral, and emergency response at the facility; they also conduct health promotion and prevention programs. In October, they began HIV screening.
Once paramedics began working in the facility, the need for ambulance responses dropped significantly. So Winnipeg decided that if the program succeeded at the Main Street Project, it could work with other common callers.
Last year, they launched EPIC — Emergency Paramedics in the Community. EPIC medics have several roles, but one is to try to curb the use of emergency ambulance services by those who call the most often; they started by identifying individuals who had called more than 10 times in a six-month period.
“That was quite a long list, unfortunately,” Sneath said. “We narrowed it down.”
So EPIC started with the top 40 callers. The program was staffed by medics who received additional training that focused on the social determinants of health, illness prevention, health promotion, advanced wound care, and other topics. They spent time doing clinical rotations in primary care settings.
Initially staffed with one paramedic during day-time hours, seven days a week, the EPIC program focused on creating profiles of these common callers that would identify why they were calling 911, what their needs were, and what resources were available to help address those issues.
Helping patients access resources
It began as “intensive case management,” Sneath said, that “tapered off as other agencies started getting involved in their care.”
The goal of EPIC was not to become these patients’ medical home, but to find them one, and to link them to other resources that could help address social, psychological, and medical issues. Three months into the pilot program, ambulance transports for the group had decreased by about 60 percent.
While EPIC is staffed by paramedics who have experience treating medical emergencies and training in some primary care areas, much of the work they do is less medical and more social. Sneath estimates that of those first 40 patients, about 10 were calling 911 due to serious chronic medical problems. The remaining three-quarters of the group had mental health or social issues that led to their reliance on EMS and the emergency room.
“We assign a social worker to every patient,” Sneath said. They also brought respiratory therapists, physical therapists, occupational therapists and other specialists into the field to see these patients at home. Many of these services are supported by the regional health authority.
“They saw the benefit of seeing these patients where they are,” Sneath said. “We were in a bit of a unique situation compared to places in the United States; it’s a little easier to get government money [in Canada].”
Fire department involvement leads to success
Sneath credits some of the success of EPIC to the participation of the entire Winnipeg Fire Paramedic Service, not just the EPIC paramedics. If paramedics respond to a 911 call for a patient not in the program, they can check a box on their electronic patient care report identifying the patient as at-risk.
Through the use of FirstWatch, a real-time surveillance and monitoring software system, those referrals trigger an alert that immediately sends an email to Sneath. So even if the patient is not a common caller yet, EPIC paramedics can address their medical, social, and psychiatric needs early on.
These referrals allow the paramedics in the field as well as EPIC paramedics to feel that they’re actually helping patients, and not simply taxiing them to the ED without addressing the problem.
If you really want to make a difference in somebody’s life, this is what we need to be doing as an organization, one of the EPIC medics told Sneath recently. He added, These types of programs make a long-term meaningful impact.
3. Digging through data in San Diego
“We are not really in the business of trying to help hospitals save money. Our focus is trying to help fire and EMS save resources. I’m sure that all the other value will be seen by the hospitals … and there will be shared savings programs that are going to come.”
Like Winnipeg, San Diego is a large city with a significant homeless population and a busy EMS system. The San Diego Fire-Rescue Department, in conjunction with Rural/Metro San Diego (the contracted ambulance service), responds to more than 100,000 medical calls each year.
As far back as 20 years ago, San Diego medical director James Dunford, M.D. realized that many of those callers would be better served by an alternative to ambulance transports and emergency room visits.
“It was so absurd,” said Dunford, who is an emergency physician at the UC San Diego Medical Center. “I saw it day in and day out as just this incredible waste of resources and I started talking to police officers. I had a whole file of people who were driving paramedics and firefighters out of their minds [with frequent calls].”
Nearly 15 years ago, Dunford worked with the San Diego Police Department on a Serial Inebriate Program, which places people who are frequently intoxicated in public into a treatment program rather than jail. That treatment program, which serves as a medical home, resulted in decreased use of ambulances and emergency rooms.
Those early successes evolved into the Resource Access Program (RAP), which is now led by Rural/Metro San Diego paramedic Anne Jensen. For the last three years, Jensen has combined her background as a San Diego paramedic and her passion for technology to address frequent 911 callers — or as she calls them, mega users, super users, and frequent users, based on how many times they called EMS in one year. For example, the mega users are a very small group but have used EMS more than 50 times in a 12-month period.
Using software to sift through patients
As the RAP coordinator, Jensen helped develop a software platform called Street Sense , which uses algorithms to sift through EMS patient care reports and identify frequent callers. The program gets past some issues that plague other agencies trying to conduct similar searches with PCR software by using tools that look for different spellings of names, combinations of birthdates and other identifying information, along with other methods of linking incident-based reports to create patient-centric data.
In addition to surveillance of EMS reports, the RAP program relies on referrals built into the PCR used by providers in the field.
What makes Street Sense different from similar attempts at finding frequent users is its ability to use algorithms to look at all the patient care reports for a particular patient and try to determine whether the frequent use of 911 is due to psychiatric issues, substance abuse issues, specific chronic conditions or other categories.
As the only dedicated staff member for RAP, Jensen initially found herself trying to contact many of the patients by phone; it didn’t take long for her to change her approach.
“I [started] visiting them mostly because phone calls tended not to be that effective,” she said. “I thought, ‘Why am I making these phone calls?’ When you’re dealing with social vulnerability, the only thing that’s going to make a difference is changing their social environment.”
Even before the implementation of Street Sense, the RAP program showed some success — as evidenced by a significant drop in transports among the most frequent EMS users. After Street Sense was added to the program, coordinators estimated that the 20 most frequent EMS users in 2011 made 1,200 fewer calls the following year.
Four medics with a focus
With the growth of the program, San Diego recently added four more community medics. In January 2015, they will become part of an expansion of RAP that will include having those paramedics respond to 911 calls from patients who have been flagged as frequent users, instead of simply following up with them at a later time.
The program is one of a small number of pilot programs being used by the state of California to evaluate the feasibility and effectiveness of community paramedics.
According to Dunford, the four medics will take part in the state’s community paramedic training, but then each will also have a focus area within RAP, such as homelessness or mental health issues. The funding for the program currently comes from Rural/Metro, not from agreements with area hospitals or payers (which is how Fort Worth’s MedStar is funding many of its programs).
“We are not really in the business of trying to help hospitals save money,” Dunford said. “Our focus is trying to help fire and EMS save resources … I’m sure that all the other value will be seen by the hospitals ... and there will be shared savings programs that are going to come.”
4. When Texas doctors get involved
McKinney, Texas, is much smaller than Winnipeg or San Diego, with a population of about 150,000 in a 60-square-mile area just northeast of Dallas. But McKinney was one of the fastest growing cities in the U.S. in the last decade and it has had its own problems with frequent 911 users.
“Here in McKinney, we’re not in crisis mode, [but] now is the perfect opportunity,” said McKinney Fire Chief Danny Kistner. “Number one, it’s the right thing to do. Second, [we can] improve the quality of life. And the tangible benefit is the associated cost reductions.”
Partly inspired by their neighbors in Fort Worth, the McKinney Fire Department brought together stakeholders a few years ago to discuss the possibility of creating an advanced practice paramedic program. They quickly realized that while they could learn some valuable lessons from MedStar and others who had gone down this road already, not every aspect of the other programs would be relevant in McKinney.
“Chief Kistner told me, about two years ago now, about the vision he had for the program,” said Elizabeth Fagan, M.D., medical director of the emergency department at Baylor Medical Center at McKinney. “MedStar didn’t fit our demographics at all, and we didn’t have their resources.”
What McKinney found was that most of their frequent users were older and had chronic diseases — they were not homeless and, for the most part, they did not have problems with alcohol or drug abuse.
“We did not find 911 abusers,” Fagan said. “What we found were chronically ill people who just simply got lost in the system.”
“A lot of our patients, it’s just honestly health care is so complicated, especially if you’re older and you have five specialists,” she said. “Patients are a little reticent sometimes to give full disclosure to the hospital or the ER or even home health. People will always open the door to the firemen. They’re always seen in a good light.”
In conjunction with a local community college, McKinney put several paramedics through a community paramedic course and then put them on the street. Initially, they had two paramedics in a non-transport response vehicle during day-time hours, focusing on visiting members of the high-utilization group, as McKinney Fire Department termed its frequently seen patients.
Since then, the department has expanded to 24-hour coverage. The advanced practice paramedics make scheduled visits with patients during the day; at night they can respond to 911 calls made by patients who have been enrolled in the community healthcare program, while also responding to critical calls to relieve some of the burden on heavy fire apparatus.
They implemented the program using existing personnel and some donated resources, and soon after the department received some additional funding for two paramedic positions.
“We’re very fortunate: we have a supportive city council,” Kistner said.
The tipping point
In McKinney, a high-utilizer is defined as someone who uses EMS more than four times in a six-month period. This number didn’t come from a sophisticated analysis so much as the paramedics’ impression of what defined a frequent caller.
“What they told me was that [four times in six months] seemed to be the tipping point for them,” said Fagan, who helped develop the program and continues to oversee it.
In addition to Fagan, McKinney also has a medical director for its community health care program, and a different medical director for its emergency response system. The department is currently developing medical protocols for its advanced practice paramedics to provide in-home care on scheduled visits — those protocols will include guidance on when to switch to the emergency treatment protocols already in place.
Initially, Fagan said, she and the medical director were frequently talking to patients’ primary care providers or specialists. But it didn’t take long for the physicians to see the benefit of the program and start interacting with the advanced practice paramedics directly.
“Once the physicians realized what an amazing program it was, many of them have actually given their cell phone numbers to the paramedics,” she said.
McKinney only recently completed its pilot program and is in the process of analyzing the results and preparing to present the findings. Both Fagan and Kistner, however, are confident that the program has made a difference.
“I can think of several callers — people that were high utilizers to the [department] — who, since inclusion in our program, have gone from multiple calls to in some cases zero [or] one or two,” Kistner said. He calls community health programs the “new normal” for EMS and thinks every EMS agency can find innovative ways to provide more effective service.
“Pick something small,” he said. “But don’t be afraid to start it.”
