According to the National Emergency Number Association, an estimated 240 million calls are made to 9-1-1 in the U.S. each year, and the medics in San Diego know these numbers all too well. Under the leadership of James Dunford, MD, FACEP, the San Diego Fire-Rescue Department and Rural/Metro Ambulance decided it was time to address the issue of “frequent flyers.”
Identifying the Problem
The result is the implementation of the San Diego Resource Access Program (RAP) and the electronic Resource Access Program (eRAP), an EMSbased surveillance technology and case management system. RAP is designed to help people find appropriate avenues of care other than calling 9-1-1 to be transported to the emergency department. The system uses advanced health information technology (HIT) to track, prioritize and even alert case managers of individuals in real-time.
“Every city in America has this problem; there is no urban community that doesn’t have this problem,” says Dunford, San Diego’s EMS medical director and professor emeritus of emergency medicine at the UC San Diego School of Medicine. “We have identified at least 1,000 people who call an ambulance six or more times a year. We had 130 people who called more than 20 times last year, generating more than 2,000 transports.”
The eRAP system harnesses the resources of a federal Beacon Community Health Information Exchange grant, as well as the expertise of San Diego-based First Watch and InfoTech Systems Management. The system was able to pinpoint one patient who called 9-1-1 96 times over a threemonth period. “This
man wasn’t on anyone’s radar because he was all over the city,” Dunford says. “Any one of our 30 ambulances probably transported him four times; that would have turned into 120 transports without the tools to finally spot the problem. these callers will show up everywhere in the city, but aren’t enough of a thorn in anyone’s side to be flagged. eRAP has the ability to analyze the entire system minute-by-minute.”
The eRAP system also allows EMS to map where frequent callers are encountered and identify hotspots impacting the 9-1-1 system. The system examines current and past EMS medical records with “vulnerability filters,” searching for terms that reflect such issues as substance abuse, psychiatric/behavioral emergencies and unaddressed in-home social needs. “As a part of a Centers for Medicare and Medicaid Innovation (CMMI) grant, we are helping one medical group to identify and case manage 200 dual eligible beneficiaries to reduce their rates of readmission,” says Dunford. “The RAP program concentrates on bringing resources to individuals and communities. We can hotspot communities by ZIP code to identify vulnerable individuals and potentially link them to valuable programs.”
Dunford believes EMS systems are ideally suited for this role because they are on the front lines. “We know who is in trouble,” he says. “We are trying to leverage our omnipresence, if you will, to identify and prioritize ‘vulnerability.’ When people call 9-1-1 a lot, their conditions are very symptomatic and that’s a bad sign.”
Dunford says the system also recently used hot spotting techniques to identify communities where cardiac arrest victims were rarely receiving bystander CPR, then overlaid them with census track data. “These are communities that are clearly not being reached by current training methods,” he says. “We have begun to target these neighborhoods with the American Heart Association and
others to provide more contextual training. It’s a more focused approach to an important public health intervention.”
The program currently works with a coordinator who is an experienced paramedic. She is equipped with novel software on an iPad that notifies her whenever one of her pre-identified clients is in the system. She also works with clients in the field, sometimes in coordination with the San Diego Police Department’s Homeless Outreach Team (HOT).
“The RAP coordinator will attach to the HOT team, which consists of a police officer, a psychiatric emergency response team specialist and an eligibility worker,” Dunford says. “With this complement of resources she can target the most high-need homeless individuals to link them to resources and move them out of the 9-1-1 system.”
Changing the Impact
A recent study published in Prehospital Emergency Care on 51 clients indicated that the program works, reducing transports, hours of service for engines and ambulances and charges. Because the system continually mines more than 100,000 EMS run records per year, eRAP can identify the most frequent callers by week, month or even year, providing a measure of chronicity. The system also
tracks why any individual repeatedly calls. For example, it lists the individual’s
most frequent chief complaints, such as psychiatric, ETOH, shortness of breath or diabetes.
“We can stratify the EMS high-user community by need, including the homeless,” says Dunford. “The eRAP system helps us target the most difficult people with particular conditions and begin to link them with the resources they need. We are health navigators, not case managers.”
What’s more, the system tracks dollars and cents, aggregating the fixed costs of sending fire engines and ambulances to various areas of the city. “This is not the doctor or ambulance bill, but instead what it actually costs per hour to have a fire engine and ambulance respond,” Dunford says.
Two-and-a-half years ago, San Diego was awarded more than $16 million as one of 16 U.S. “beacon communities” poised to demonstrate the value of electronically exchanging health information. “San Diego wanted to show the value of exchange of health information between hospitals and EMS, as well,” says Dunford. “The system we are building is meant to inform hospitals of what is happening before the patient arrives, and to take advantage of this new technology.”
More than just a piece of sophisticated technology, Dunford believes the eRAP program is a new instrument to put on the dashboard of public health, one that can more accurately track chronic disease and assist it its management. “We feel it provides an opportunity to alert case managers and doctors before the person goes to the emergency room,” he says. “For chronic conditions, it would be very beneficial to be able to contact the patient’s case manager before the decision is made to take him to the emergency department.”
The eRAP system will also notify the patient’s care team by the time he or she arrives in the emergency department, facilitating direct communication with the treating doctor—and possibly avoiding an unnecessary admission. Quickly bringing the emergency room doctor into the care team provides the ability to efficiently determine the best treatment plan.
Dunford has hopes of quickly expanding the system regionally and nationally. “As the health information system grows, and as this technology can be replicated in other parts of the region, we can show that we can do the whole thing on far larger scale,” he says.
The initial development and launch of the system has taken many people working together to bring the idea to fruition. Still, it has been the vision and drive of James Dunford that has put RAP on the map. In 1997 he saw the problem of people using 9-1-1 and emergency departments inappropriately—as so many do—and made it his personal mission to do something about it.
“As the city EMS medical director, and an emergency physician enduser, I felt that if I didn’t do something about the problem, who would?” he says. “This is in my wheel house of responsibility. I’m pretty passionate about the importance of lowering healthcare costs and improving the value of the care we deliver. I feel this is an important new role for EMS.”
That passion, says Dunford, begins with understanding where disease starts and how to effectively address it, particularly in more vulnerable populations. “You need to understand the ecosystem from which people come,” he says. “We have to focus first on those people if we are going to do anything about reforming the quality and value of healthcare care in this country.”
Dunford’s passion and vision also come from a place of deep personal caring and a belief that if given the right tools, people can—and will—work together toward common objectives. “Believe it or not, when I was in sixth grade, my hero was Dag Hammarskjold, then secretary-general of the United Nations,” says Dunford. “I believe in the power of people working together. And I’m excited to be in a place right now where I can try to make a difference and do something for the common good.”