In late 2004, firefighters at Houston Fire Department (HFD) Station 6 had a casual conversation that providers across the country would likely recognize: "If only Ms. Johnson had someone to look in on her once in a while, she wouldn't need to go to the hospital every other day."
If you've ever had a patient like Ms. Johnson -- you've seen them so many times you could recite their address, birth date and medical history from memory -- you've experienced the problem of frequent callers.
Frequent callers can lead to issues with availability of EMS apparatus in large, high-volume-call cities. Even in communities with smaller or limited EMS response capability, frequent responses to non-emergent patients can affect response time or unit availability.
Further, the repeated response to these individuals can lead to morale issues within the workforce and complacency -- the repeat patient with a complaint of chest pain over several calls without priority symptoms can cause providers to overlook the one call that's truly a myocardial infarction in progress.
HFD has its share of frequent callers, but it has a different way of addressing them.
Started in February 2005 as a pilot program, CareHouston identifies and tracks frequent 9-1-1 callers. Once identified by HFD EMS, they're referred to the Houston Department of Health and Human Services (HDHHS). Members from HDHHS contact the individuals and attempt to identify underlying problems, such as lack of education about their health condition or transportation or social issues. HDHHS members then address that need, seeking to redirect the patient's calls for EMS services and keep them out of overcrowded emergency departments (EDs).
The Houston Emergency Center, HFD's dispatch center, provides records to the CareHouston team each month for the prior 90 days. Patients who've called eight times within the report period (which translates to a call about every 10 days) are included. Of the 60,000 total calls this process returns, some are filtered due to the transient nature of the patients or the severity of the incident (e.g., motor vehicle collisions to pedestrian accidents). Calls from public locations are also omitted. The goal is to identify addresses that are primarily residential and can be reasonably analyzed for single or multiple patients at that location.
CareHouston members are encouraged to report callers within their primary response areas with emergent or immediate social services needs. This helps locate frequent callers without a permanent address or those who move between multiple addresses.
The HDHHS team makes initial contact by sending a letter, followed by phone calls to set an appointment to visit the patient and discuss their situation. If no contact is made, they attempt a "cold call" visit. Once the HDHHS team, made up of community resource specialists and nurse case managers, meets with the patient, a needs assessment is completed.
The goal of the HDHHS team is to provide the callers with information about alternative resources or offer case management assistance to eliminate their dependence on HFD EMS as a health-care safety net. This information will allow the department to focus resources on addressing true patient needs. This information might include referrals to social service agencies, such as Meals on Wheels, or elderly support services, help registering with a local hospital for free or reduced cost health care, or enrollment with Medicaid or Medicare. A management plan is then agreed upon between the team members and the caller.
Follow-up is done on a continuing basis until the caller drops below the call criteria for 60 90 days. At that time, they "graduate" from the program, and their case is placed in periodic review status. The success of the program is measured by the reduction rate in the frequency of 9-1-1 calls made by these patients.
The Sunnyside area, which is located in a high-call-volume region in southeast Houston, was initially selected to pilot the project. The area is also underserved by health-care facilities and transportation services. There's one HFD fire station, housing first responder companies and an ALS transport unit, but the closest medical facilities are 15 20 minutes away by car. Public transportation is limited to stops along each of two major streets in the area.
Some 18 patients were identified in the Sunnyside area between April 1, 2006, and June 30, 2006. These patients accounted for 113 9-1-1 calls during this period. These patients were referred to HDHHS and contacted in early July. These same patients were re-evaluated for 9-1-1 service requests at the end of September. They accounted for only 33 responses, representing a 70% decrease. Eight of the patients (approximately 40% of the identified patient population) made no 9-1-1 calls. As of December 2006, the 70% reduction was maintained.
In August 2007, the CareHouston program was expanded to the entire city. The first citywide data collection began in September 2007 for frequent callers for the June-to-August period. Some 55 patients were identified across Houston. These patients accounted for 574 responses during the data collection peroid. The first evaluation in December showed a reduction to 140 responses (a 76% reduction), and a second evaluation in March showed a reduction to 65 responses (an additional 13% reduction for a total of 89% from the initial response total).
The second phase achieved a 85% call reduction from the targeted patient population, and the third achieved a 73% decrease.
The final set of patients was selected in spring of 2008. Some 98 patients (with 1,117 calls among them during the data collection period) met the criteria for inclusion. At the first evaluation in September, this call volume had decreased to just 313 calls, representing a 72% reduction. The second evaluation showed only 117 calls had been made (an additional reduction of 18% for a total of 90% from the initial response total).
Overall, during the September 2007 September 2008 period, the total number of patients seen out of the high-call-volume population was 215, and the diverted responses compared to prior usage was 2,692 responses.
HFD uses a statistical amount of $1,700 for the cost of EMS transports. This call reduction allowed the department to redirect $4,576,400 in resources to other areas. In practical terms, this savings is the equivalent of adding four medic units to the HFD fleet budget, (HFD medic units are budgeted at approximately $1,000,000 per year).
The HDHHS team found that they frequently spend the majority of their time educating patients about their medical conditions and what social services were available to them.
Previous attempts to educate the patients about their disease and/or condition through literature and brief discussion in the ED did not reduce repeated calls for 9-1-1 service. By contrast, face-to-face, in-home discussions, at a time other than an emergent situation, were readily received. It was also found that the patients were simply unaware of what types of social assistance was available or they were unable to "navigate" the application process alone.
In summary, CareHouston is an example of a concept born from field personnel experience and developed into a systematic method to obtain information on frequent callers, intervene and address their underlying needs. By focusing on and providing resources to correct the underlying problem, the result is a general improvement in the patient's living condition and health. As a byproduct, the caller's need for 9-1-1 services is reduced and the EMS call volume related to these callers drops.
The tools and methods used by HFD are available to any department or agency regardless of size. The primary source of data was our own dispatch records, and although not every agency has a stand-alone health department to work with, almost every agency has ties to the social services network in their area, such as faith-based groups, senior citizen organizations and other types of non-profit social agencies.
Captain Byron A. Harrison, Sr., LP, BMEd, EMS-C,is the education coordinator for Houston Fire Department EMS Administration. Harrison received a bachelor's in education from Texas A&M-Commerce in 1984 and holds a lifetime teaching certificate in Texas.
David E. Persse, MD, FACEP,is the physician director of EMS and the public health authority for the City of Houston. He s also an associate professor of surgery at Baylor College of Medicine, an associate professor of emergency medicine at the University of Texas Medical School -- Houston and a member of theJEMSeditorial board.
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