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Aging population, payment and liability issues drive increasing calls to long term care facilities

Firefighters at Station 7 in Columbia rushed to the same nursing home three times during two recent 24-hour shifts. Only one of those 911 calls – for a patient in “respiratory distress” – was a true emergency, crew members said, but firefighters still took all three residents to a hospital by ambulance.

“Sometimes we’re more of a transportation service [for these facilities] than an emergency service,” paramedic firefighter Jeffrey King said.

As the population ages, fire departments across the region are faced with a growing demand for ambulance services from long-term care facilities.

Unnecessary 911 calls from such facilities not only waste money but also divert resources away from true emergencies, said Dr. Robert R. Bass, director of the Maryland Institute for Emergency Medical Services Systems.

“For volunteer [ambulance crews], it’s going to take a lot more of their time. Charles County is still heavily volunteer, and they’ve been struggling down there because of the growing number of assisted-living facilities,” he said.

His agency, which oversees the statewide emergency medical and trauma network, plans to launch a pilot program this year to try to cut down on non-emergency 911 calls from nursing homes.

Precise data on the phenomenon are hard to come by because no department separates ambulance trips to long-term care facilities from the others.

However, a Sun analysis of the 911 calls for one county – Howard – during the first four months of the year found that firefighters were responding to 10 nursing homes and assisted-living facilities in the county an average of 4.35 times a day. Those calls accounted for one in 10 of all medical emergency calls in the county.

Although privacy laws make it impossible to tell which of those 911 calls were true emergencies, anecdotal evidence from firefighters and state emergency officials indicates that long-term care facilities are relying on the public ambulance system when it’s not medically necessary.

At Station 7, for instance, the other two recent 911 calls were for a “low” heart rate of 80 beats per minute, which is considered normal, and a patient with dementia whose “mental status” had changed. Some Howard firefighters informally call three of the county’s long-term care facilities “the Bermuda Triangle.”

Local officials stress that their main concern its to ensure that an ambulance is available when residents need it.

“People who occupy nursing homes are citizens of Howard County,” Fire Chief Joseph A. Herr said. “We don’t pick and choose who we serve. What we do is focus on the outcome of the patient and quality of patient care.”

But many firefighters entered the profession to rescue people from danger, not to transport the chronically ill.

“These surely aren’t glory calls,” said Joseph L. Brown Jr., Baltimore County’s director of emergency medical services. “They’re not your gunshot wounds. They’re not automobile accidents, but they still need help.”

State health and emergency officials are drafting a new set of guidelines to help workers at long-term care facilities decide when to call 911 and to make it easier for medical staff to rely on private ambulances.

The program will be tested in Howard County this year, said Dr. Richard L. Alcorta, medical director of the Maryland Institute for Emergency Medical Services Systems.

“The reason we’re focusing on these facilities is that it’s hard to do something about someone calling from their home,” Bass said. “But when you have a trained health care professional on site, you can educate them on when to call a commercial ambulance or a 911 ambulance.”

Long-term care facilities argue that they lack an adequate alternative to the 911 system. Private ambulances often take hours to arrive, require too much paperwork and open facilities to potential lawsuits, facility owners and the industry’s association say.

“Nobody is ever going to get sued for sending your mom to the emergency room when she didn’t need to go,” said Lou Grimmel, CEO of Lorien Health Systems, which runs a half-dozen long-term care facilities in Maryland. “But you will get sued if the mom should have gone to the ER and you didn’t send her.”

Once the pilot program begins, participating facilities will be asked to follow guidelines that say they should call 911 only if the patient needs attention within 30 minutes or if a private ambulance can’t arrive within four hours, Alcorta said.

“It’s very challenging and stressful to transport a long-term care patient out of their environment, particularly if they’re confused or suffering from dementia,” said Debbie Fleischmann, administrative director of emergency services for Howard County General Hospital. “From that perspective, to be able to better determine who needs to go now and who doesn’t need to go stands to benefit the patient.”

The change would likely eliminate one frustrating call for firefighters: “abnormal lab values.”

“Blood is drawn two to three days earlier, and they call us when the results come in,” King said. “What’s three more hours? And a lot of patients aren’t exhibiting any complications.”

The state Department of Health and Mental Hygiene also has proposed regulations that would increase nursing requirements at assisted-living facilities.

Hiring higher-skilled nurses, however, won’t reduce needless 911 calls on its own. Training must be repeated because of “constant turnover” among nursing staff, Brown said.

But the most critical issue is reimbursement. In fiscal year 2003, Medicaid paid for 62 percent of all nursing home stays. State and federal regulations determine when taxpayer dollars can be spent on private ambulance transports for those residents.

Under state rules, Medicaid won’t pay for after-hours private ambulance transports without prior authorization from the county health department, a restriction Alcorta is trying to lift.

“If a nursing home has a contract with a commercial ambulance service, then the nursing home is solely responsible for any charges,” said Ethan Moore, director of policy for Health Facilities of Maryland, an association of nursing home and assisted-living facilities, which is supporting the state’s pilot program in Howard County. “If the nursing home can get reimbursement from the patient or Medicare for the transport, they’ll do it. But otherwise, they’re stuck with the bill.”

A few larger facilities have avoided this problem by creating their own private ambulance service.

At Oak Crest, a retirement community with more than 2,400 residents in the Parkville area of Baltimore County, a paramedic and an emergency medical technician are on duty at all times and conduct more than 1,000 hospital transports a year.

Oak Crest’s ambulance service also has easy access to “do not resuscitate” orders and medical history. Nothing can be more frustrating, firefighters say, than responding to a call, beginning to treat a patient and then being informed that, legally, they can’t continue.

“Baltimore County is very happy we have these two ambulances here,” said Eric Trautman, Oak Crest’s business operations manager and a paramedic, who supervises the emergency medical staff. “Otherwise, we would have 911 in here all of the time.”

Oak Crest bills Medicare and Medicaid for the transport but absorbs any uncovered costs, Trautman said.

Volunteer fire departments in Carroll County also bill Medicare and Medicaid for regular 911 medical emergencies and then charge residents or their health insurance for leftover expenses. Under state law, if a resident refuses to pay, the volunteer fire companies can’t hire collection agencies to go after them.

Alcorta said that most jurisdictions in Maryland bill for ambulance services. Baltimore City charges a flat fee of $410 for an ambulance transport, said Chief Kevin Cartwright, a spokesman for the department. But Howard, Anne Arundel and Baltimore counties do not.

The Baltimore County Fire Department also has an “adopt a nursing home” program, which assigns an EMS lieutenant to each facility, Brown said. When inappropriate 911 calls are made, the lieutenant will meet with facility staff to fix the problem.

When told of the statistics showing that a small number of residents were using a comparatively large portion of emergency medical services, Howard County Executive Ken Ulman said he was surprised the rate wasn’t higher.

“We have a small senior population, but it’s also the fastest growing” in the state, Ulman said. “Our hospital is expanding, and we have a need for 55-and-over housing. So these are good questions for the future.”

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