Innovative pilot program addresses needs of fire service & low-income communities
Alex Briscoe, the director of the Alameda County (Calif.) Health Care Services Agency (HCSA) began eyeing fire stations when he started looking for an innovative way to provide timely access to healthcare. His concept, he says, will improve the county’s healthcare safety net and cut costs by reducing unnecessary emergency department (ED) visits and EMS calls. As an added bonus, Briscoe says, the additional revenue can help fund an additional firefighter per station.
Still in the planning stages, the pilot program will select five fire stations in medically under-served areas of Alameda County to operate as limited-scope, non-emergent, walk-in clinics—called “fire health portals.” These portals will serve as an alternative for chronically underserved patients in need of immediate primary care, offering walk-in medical care within an integrated EMS system. Each portal clinic will be staffed by a paramedic, nurse practitioner and administrative care coordinator.
Briscoe says the idea was born of two experiences. During the H1N1 outbreak, Alameda was the first county in the state to apply for an emergency scope of practice extension for paramedics. “That whetted our appetite for using the prehospital system more broadly in meeting the pressing needs of our community,” he says.
Then, during a demonstration for Oscar Grant, the young man who was shot by a Bay Area Rapid Transit police officer New Years Day 2009, Briscoe witnessed an angry mob turn in unison and wave happily to a passing fire engine and its crew. In that moment, Briscoe had an epiphany. “Even in the toughest community, firefighters retain a trust and allegiance,” he says.
Using fire stations as health portals has a number of advantages. First, as Briscoe witnessed, firefighters are trusted in a way most public servants are not. Second, fire stations are well-distributed within the communities they serve. This includes the low-income communities that typically have limited access to the medical system. Finally, people already know they can get help at a fire station and, for the most part, know where to find one.
Briscoe took his idea to Alameda County Fire Chief Sheldon Gilbert, Oakland Fire Department Fire Chief Mark Hoffmann and EMS Division Chief Bill Sugiyama. All agreed to participate in the pilot project and are actively involved in the planning process. Oakland is the largest city in Alameda County and, according to Sugiyama, has a poverty rate of greater than 30%. The high concentrations of poverty correspond with an equally high use of emergency medical care, both prehospital and at the ED. What Sugiyama likes about the plan is that by improving healthcare, other aspects of people’s lives develop. “Their outcomes in life improve,” he says.
Such an innovative partnership has no existing model for comparison and many issues to consider. Fortunately, the HCSA has experience in establishing community-based healthcare portals. It already provides direct healthcare services to county residents through contracts with the Federally Qualified Community Health Centers (FQHC), School-Based Health Centers and the county’s public hospital system. Even so, there remains a growing demand for healthcare services, especially for those who are publicly insured or uninsured.
Sugiyama says he and others have pored over reports that correlated poverty levels with life span and access to healthcare. Map overlays graphically illustrated that those who struggle with poverty were the most likely to use the ED for their primary care.
The next step was to identify the optimal hours to help relieve some of the burden on the hospitals. By reviewing hospital diversion by day of the week and time of day, it was determined that having the fire portals open Monday to Friday from 2 to 10 p.m. would be most convenient for patients and mitigate the ED burden. “This is well thought out,” Sugiyama says. “We don’t know if this will work, but we are fairly certain it can.”
In addition to walk-ins, the portals would be a destination for non-emergent, “Omega” 9-1-1 calls. The fire departments estimate that 8–12% of their emergency calls require a lower-level response. In order for the portals to respond to 9-1-1 Omega calls, they will need to fully implement the Medical Priority Dispatch System.
There are other important issues to consider. Ambulances can’t be used to bring patients to the portals since they can’t legally transport patients to non-ED destinations. Even if they could, using an ambulance would devastate any cost savings the portals provide. One option is to use portal cars or vans for these types of calls. But that solution raises new concerns about insurance coverage and staffing to transport patients.
It’s not just the uninsured who use the ED for primary care. Difficulty in accessing primary care services drives insured Californians to use the ED for basic care, and that number is expected to increase. According to a 2006 California HealthCare Foundation study, nearly half of emergency department users believed that their medical problem could’ve been treated in a primary care setting.
The HCSA anticipates that the five fire health portals could help reduce the strain on the EDs by seeing 675–900 patients per year per portal—a total of more than 2,000 visits annually per portal during the three-year pilot period.
The most typical types of conditions the practitioners expect to see at the portals include upper respiratory infections, urinary tract infections and other urgent but non-life-threatening concerns—conditions that are often considered avoidable ED visits and would be more appropriately treated in a primary care setting if the patients could be seen within 24 hours. Unfortunately, most of these Medi-Cal and uninsured patients currently wait up to three months to get assigned a physician and often end up in the hospital instead.
The cost to build each portal is estimated at $400,000. Although it would be housed at the fire station, it would be a separate or adjacent structure on the property, with a separate entrance. The rest of the station would be secured. No staff would be allowed in the crew’s break room or sleeping area. “We fully recognize that this is the firefighter’s home away from home,” Briscoe says. The idea is to make certain that the program doesn’t disrupt the core mission of the fire service.
The operating cost of each portal will likely run between $502,500 and $562,500 annually. Although firefighter/paramedics have significantly more medical training than a medical assistant, both paramedics and EMTs receive much higher salaries, adding to the overall cost of the program.
Sugiyama is hopeful that reimbursements could make the program self-sustaining, but the HCSA is less optimistic. Cost savings will definitely be realized by diverting care from higher-priced alternatives, but they anticipate it will be difficult to cover the costs strictly on reimbursements. Long-term success of the portals will depend on maximizing third-party reimbursement.
During the initial three-year pilot period, the five portals will be funded through a combination of state and county coffers. Although the portals will likely receive some third-party reimbursement for services provided to patients, HCSA says it’s committed to fully covering the costs to give portals time to create and refine a successful model during the pilot period.
Firefighters as primary care providers
Paramedics and EMTs are trained and licensed to provide critical medical care to ill or injured patients in the prehospital setting. They currently aren’t trained to operate within a primary healthcare system. A Scope of Practice Waiver must be granted from the state to allow them to perform any medical services in the portal because it’s a non-emergent setting. Because the firefighter working in the portal could be either a paramedic or an EMT, depending on the paramedic/EMT staffing ratio at a given station, the scope of practice will have to be developed to accommodate both certification levels.
Although the fire department paramedic/EMTs will also provide medical assistance and perhaps independent medical services while on duty at the portal, the nurse practitioner or physician’s assistant will provide the majority of medical service. This could be an adjustment for those who come from the EMS system where the paramedic is the lead provider.
The firefighters will rotate through the portal in two eight-hour increments during their 48-hour shifts and must also be available for emergency calls. This particular logistical challenge makes it important to strategize how best to ensure proper integration of the firefighter in portal operations. A back-up plan must allow for times when the firefighter is away on calls.
Then there’s the issue of culture. In 2009, the Oakland Fire Department reported 62,353 incident responses. Of those, 4% were fire-related. The vast majority of 9-1-1 calls (80%) were medical in nature. Even though firefighters already serve as first responders in the EMS system, it may be a challenge to convince some firefighters to accept a new mission as first responder in the county’s public healthcare system. This shift in thinking on the part of firefighters is necessary for the portals to function as an effective alternative to the ED for patients in need of urgent, one-time, one-issue medical care.
Briscoe says these concerns are “important, understandable and easily surmountable.” In part because the portals represent one large carrot—an opportunity to help fire stations reach four-person staffing by providing access to a new and long-term revenue stream. “We think we have the incentives right,” he says. “We’re learning together. The truth is in the unfolding.”
In October, the Alameda County Board of Supervisors approved $750,000 to fund the fire health portal project. Currently, seven municipalities are vying for the five locations provided for in the three-year pilot program. An announcement on the final decision will be made in January. The program is expected to launch in the fall of 2013.