Every day, EMS providers in communities around the U.S. respond to thousands of 9-1-1 medical calls. Most of these calls are, indeed, emergencies, which require the expertise and aid of paramedics. There are, however, a small percentage of calls made to 9-1-1 by people who could be better served through alternate means of support.
In the community of Fort Worth, Texas, Matt Zavadsky, associate director for operations at MedStar Emergency Medical Services, decided to analyze the problem and see if he could come up with some solutions to lift some of the burden off 9-1-1 dispatch.
He wanted to create a program that would target the top two-dozen users of the MedStar EMS system and find ways to help them outside of calling 9-1-1.
Diagnosing the Problem
Being response time compliant has been challenging for MedStar, Zavadsky says. “One of the reasons we have trouble meeting those response times is because we are responding to a bunch of calls we shouldn’t be going on.”
Convinced there had to be a better way, Zavadsky started analyzing data, trying to pinpoint trends.
“We as an EMS industry need to stop responding to calls that we can prevent,” he says. “There is a fair amount of our population that we service, and a fair amount of calls that we respond to, that are preventable. They would be unnecessary if the people who we were serving were better medically managed in a more appropriate setting.”
Lessening MedStar’s burden was important. The regional, high-performance EMS agency provides exclusive emergency and non-emergency ambulance service for the city of Fort Worth and 14 surrounding suburban cities. It covers 421 miles and a population of 860,000, which generates more than 100,000 ambulance service requests every year.
“We have folks in our community who fall into two categories,” Zavadsky says. “A lot of people call 9-1-1 because they have no other health care or primary care outlet, and we as an industry have become the primary care provider. Ask any paramedic in EMS today, and they will tell you that half or more of the patients that they respond to really didn’t need an ambulance.”
Next, Zavadsky identified frequent 9-1-1 callers who had no other social interaction or means of support. “Their health-care issues weren’t being managed well at home, or they had social issues that they needed addressed,” he says.
As Zavadsky closely scrutinized the patient care reports of some frequent 9-1-1 callers, he realized the need for a program that would deliver the right care to the right person at the right time. “If we know that there are a handful of patients who are frequently using EMS and emergency rooms, let’s identify those folks, look at how many times we have responded to them, and what we are responding to them for,” he says. “We needed to go and talk to them, and see if we could proactively manage their health care, or teach them a better way to get health care, rather than calling 9-1-1.”
Assembling the Team
A team of paramedics was picked to participated in an advanced practice paramedic program, which added an additional eight weeks of training to their existing EMS training.
The program “not only certified them for critical care transport, but gave them the advanced practices that they needed to treat community health patients,” Zavadsky says. “They spent clinical rotations with the local mental health agency, which taught them how to do crisis intervention.” They were also familiarized with social and medical resources available in the community.
With the team in place, community care plans were developed for the targeted 9-1-1 callers, the majority of whom needed assistance with such things as recurrent hypoglycemia, seizure disorders, and mental health disorders. The goal was to offer short-term aid, which would result, hopefully, in long-term decreased EMS utilization.
“We wanted to see if we could get them to stop calling 9-1-1 by bringing them needed resources on a pre-scheduled or episodic basis,” he says.
The program has had an impact. Zavadsky offers a dramatic example of a man who was calling 9-1-1 multiple times a day for more than 20 years. “He was bored and lonely and wanted someone to talk to, and we had no recourse but to take him to the hospital,” Zavadsky says. “So we developed a care plan that got someone to visit daily to check his vital signs and make sure he was taking his medication.” The paramedic assigned to the patient also went over the myriad community options available. “The guy had no idea there were resources in the community that could get him medical coverage and a primary care physician.”
The paramedic also secured bus passes and taught the patient how to ride the bus. “One of our community care paramedics went to his house, walked him to the bus stop, rode on the bus with him to his doctor’s appointment, waited in the doctor’s office with him, and at the end of the doctor’s visit, escorted him back home on the bus, so that he knew how to do that,” Zavadsky says.
Return on Investment
Initially, addressing these frequent 9-1-1 callers can be time- and labor-intensive, but Zavadsky believes the initial price in the short term is more than justified in the long term. “We can either take a $20-an-hour paramedic once or twice to teach someone how to seek his own medical care on a proactive basis, or we can keep sending ambulances three or four times a day at $106 an hour,” Zavadsky says.
The program is actively managing 11 patients. An additional six patients have graduated from the program, having sufficiently learned how to manage their own medical and psychiatric needs. “We are still monitoring them, and they still have the ability to call us for a home visit, but we don’t actively go out and see them every day because they are doing great,” Zavadsky says.
To make the program successful, Zavadsky linked area hospitals and other resource agencies. “We’ve gone to the homeless shelters and taught the staff that if they have a patient who meets the criteria for non-emergency response, they should call us on a non-emergency number and we will send a community health paramedic out to assess the patient,” Zavadsky says.
In fact, a large local-area hospital has asked to use the advanced practice paramedic program to follow up with high-risk patients who have been discharged from the hospital after a cardiac procedure. This avoids having the patient bounce back to the emergency department. “We can pay X amount of dollars each time one of these paramedics goes out and sees one of these patients, or we can pay X amount of dollars to the fourth power when that patient comes back to the emergency room seven days later,” says Zavadsky.
The county mental health authority is also on board. Rather than sending a suspected psych patient directly to the emergency department (ED) and tying up a bed waiting for a psychiatric placement, the advanced practice paramedic can do a preliminary assessment and speed up the placement, sometimes avoiding the ED altogether.
“Our paramedics have spent time in the field with the crisis-intervention folks,” Zavadsky says. “We can make a couple of phone calls and ask to either have the mobile crisis team meet us on scene or bring a patient to the [facility] for a psychological evaluation and then bring them right there.”
In addition, Zavadsky has worked tirelessly to promote bystander CPR in his community. “We took all of our cardiac arrest calls, and did latitude and longitude plotting on a [Geospatial Information System map] of our service area. We found the clusters where we had a lack of bystander CPR,” he says. They’re now asking the local community influencers in those areas to arrange for MedStar to provide free CPR training for community members.
“We may find that the biggest influencer in a community is a local church, so we will go to the church and ask them to help us sponsor a free CPR class, so that we can get more people certified in CPR,” he says.
Zavadsky is also asking the city council and county commission to host community CPR training programs. “We want to take that cluster of no-bystander CPR and change it to a cluster of high-incidence bystander CPR,” he says. “That’s how we are going to impact survivability.”
With a combination of better managing frequent 9-1-1 callers and training community bystanders in CPR, Zavadsky hopes to impact community health on a wider basis.
“We as a profession need to figure out a way to make our communities healthier,” he says. “The patients that we are managing in our community health program have reduced their 9-1-1 use by 57.2 percent. Imagine now that we could do that for the general population.”
He adds, “This is going to reduce unnecessary 9-1-1 use exponentially and save the system a ton of money. We’re doing it, and it’s working well.”