Melissa, a frequent 9-1-1 user, was the worst she’d ever been. She’d been transported 16 times in a week and first responders from San Diego Fire-Rescue Department and Rural/Metro Ambulance (SDEMS) were again en route to assess her in a belligerent, intoxicated state.
On this day she was laying down in the middle of a business lobby complaining she wasn’t feeling well. To bystanders who called 9-1-1, Melissa appeared to be just “a drunk homeless person,” but responders knew her situation was more complicated than this. Her excessive drinking and 9-1-1 use were merely symptoms of a severe vulnerability.
More than ten years ago, while in her late 20s, Melissa sustained a traumatic brain injury in a traffic collision. Unable to control her impulses, she soon developed a substance abuse disorder and became homeless. The violent street life she experienced while homeless worsened her situation, as frequent assaults resulted in compounded brain injuries and even greater cognitive disability. She became a frequent 9-1-1 user and remained so for nearly a decade.
SDEMS and law enforcement consistently advocated for her over the years but community services were already overwhelmed by their current workload and unable to take such a difficult case. The responders had resigned to simply keeping her from getting worse, but this week, things were different with Melissa. Not only were her 9-1-1 calls occurring more closely together, an increasing portion of these calls were a result of being assaulted. She was no longer taking measures for her personal safety. Her behavior was becoming more erratic and it appeared poor nutrition was taking effect.
Intervention was nearly impossible, as she often eloped from the hospital in search of more alcohol, sometimes just minutes after her arrival.
SDEMS and the San Diego Police Department (SDPD) felt a sense of urgency. The situation was critical: other chronic alcoholics had died while engaging in this type of binge behavior.
Melissa is representative of some of the most difficult of clients for the award-winning SDEMS Resource Access Program (RAP). She has a cognitive disability with a co-occurring substance abuse disorder.
Interestingly, most of San Diego’s top 9-1-1 callers have some kind of cognitive disability (e.g., mental illness, developmental disability, traumatic brain injury, dementia or stroke) in combination with either a substance abuse disorder, a chronic respiratory disease or chronic chest pain.
Melissa’s barriers to resources reflect why this is so often the case:
1. She had no access to primary care because she has no insurance. SDEMS and SDPD attempted to obtain Social Security disability benefits for her; however, her multiple applications were denied on the basis that she wasn’t disabled, but that the underlying cause of her situation was alcoholism. Tests to prove her cognitive disability would cost anywhere between $1,500 to $2,000, and neither agency was successful in finding a funder.
2. Her cognitive impairment isn’t related to a psychiatric diagnosis. Certain laws allowing stronger case management methods only pertain to cognitive disability related to a psychiatric diagnosis.
3. She was frequently incarcerated. Not only was coordination of care difficult, jail sometimes led to a degradation of Melissa’s life skills.
4. Many services available in the community are intolerant of the often aberrant behaviors that come with cognitively impaired individuals (including unpredictably violent behavior). Upon successful referral to a program, Melissa would “fail out” and become ineligible to return because of her behavior. Even when her behavior was calm and appropriate, she was unable to comply with the strict rules and requirements of the programs, making her again ineligible.
5. She was habitually aggressive toward care providers, and care providers were no longer willing to assist her past what was minimally required. Care provider burnout set in and undoubtedly affected potential care, as even the most compassionate of providers felt intimidated or overextended, or failed to recognize what was really going on with Melissa.
A Repetitive Process
These issues surface repeatedly across multiple 9-1-1 callers, specifically those who call more than 100 times per year. As a result, these clients are often the most vulnerable of community members, yet they have fewer resources than anyone else. They’re inclined to use the 9-1-1 system because acute care services may very well be one of the only services that doesn’t turn the individual away. As EMS systems and EDs are faced with this unique problem, the skill of effectively caring for these individuals is extremely valuable.
It’s important to acknowledge that cognitive impairment is most often permanent. Without intervention, the individual’s situation is likely to worsen, until he or she eventually dies from self-destructive behavior, exposure to the elements or violence.
As an individual’s situation worsens, the response community (EMS, fire and law enforcement) is positioned to have a more comprehensive perspective of vulnerability than any other discipline. Not only does the response community understand system-wide service use (e.g., hospitals, jail, mental health facilities) along with the client’s behavior in public through non-9-1-1 street encounters, responders are also able to view the vulnerability in the context of its environment.
Ironically, RAP often worries more when a known vulnerable individual stops using the 9-1-1 system. 9-1-1 calls rarely cease without a person’s enrollment in a program or incarceration. If they cease before RAP is able to make a successful referral, RAP often contacts the coroner’s office to see if the patient has died.
Repeated 9-1-1 encounters allow RAP to understand the client’s situation as they plan intervention. It also allows for multiple attempts to obtain a successful intervention in cases where law requires that stringent conditions be in place prior to the intervention.
A Successful Intervention
Melissa’s successful intervention occurred on her 17th 9-1-1 call for the week. Her situation was deteriorating and EMS and law enforcement felt their opportunities to intervene were limited. In a legal sense, the conditions of this call were ideal, so in a combined decision by San Diego’s EMS medical director, SDPD, and SDEMS, law enforcement officers placed her in custody on the grounds that she was a danger to herself. They assumed custody of her and accompanied EMS to the hospital. Once medically cleared, she was taken by law enforcement to the only place able to keep her safe: jail. The response team had weighed other options, but the few programs without waiting lists, who might be able to offer immediate crisis placement, were not equipped to handle her behavior.
She spent two weeks in custody, during which time RAP, the city medical director and the SDPD Serial Inebriate Program (SIP) petitioned with local programs and court judges in an attempt to help find a stable living situation for Melissa.
One organization RAP approached was a local homeless services provider, St. Vincent de Paul Village, which was operating a program called Project 25 (P25). P25 was a pilot initiative funded by the United Way of San Diego to address homeless frequent 9-1-1 users.
The program uses a housing-first model and provides permanent housing, intensive wraparound case management services, and primary and psychiatric care through the medical home at the St. Vincent de Paul Village Family Health Center.
A representative from P25 agreed to meet with SDEMS and SDPD to discuss Melissa’s situation. P25 had already taken the responsibility of caring for the city’s top 25 most vulnerable individuals. They’d expertly provided case management to clients similar to Melissa, who’d temporarily moved to another region when P25 was initiated and missed the initial opportunity.
RAP felt the chances of getting Melissa into P25 were slim. They had been full for months and had already extended the program to 35 individuals. However, P25 recognized the severity of Melissa’s situation and agreed to take her as a client under the condition that SDEMS and SDPD be willing to assist when needed. After years of advocacy work on her behalf, Melissa might finally be able to achieve a better quality of life.
P25 obtained a Department of Housing and Urban Development housing voucher through the San Diego Housing Commission and began the application process for disability benefits. St. Vincent de Paul Village had spearheaded a new local program along with the Corporation for Supportive Housing called Homeless Outreach Programs for Entitlement (HOPE) San Diego, to expedite approval of disability benefits for homeless individuals. They knew how to handle Melissa’s situation.
To support the application approval, the city EMS medical director, James Dunford, MD, who had been advocating for her prior to even the implementation of RAP, wrote to the Social Security Administration:
“In my 32 years practicing emergency medicine, I know of no individual who is more in need of social security disability assistance. [She] has been my patient dozens of times since at least 1992. She suffers from a combination of serious brain conditions including tumor resection and trauma that have rendered her incapable of reaching consistent, logical thoughts. She has required numerous brain surgeries involving her frontal lobes, such that her CT scans demonstrate loss of brain matter in areas required for executive thought processes. … As such, her circumstance is much like a veteran after a serious head injury; she no longer possesses the intellectual capacity to care for herself. … By authorizing these benefits, you are providing a life-saving opportunity to a woman who frankly cannot help herself.”
Just weeks later, P25 notified the city that Melissa’s disability assistance had been approved.
In the meantime, the SDPD SIP officer had presented the program in front of the court judge overseeing her case. The judge agreed, and ordered treatment by P25 in lieu of jail time. Melissa was released into the care of the P25 team. At this time, EMS and law enforcement transitioned to secondary support to P25, who assumed primary case management responsibilities.
Melissa’s first year in P25 was indeed successful. In the year prior to P25, she received 136 ambulance rides and spent 210 days in jail. After one year of enrollment, she reduced her ambulance rides to 49, and reduced her days in jail to 33. Public costs decreased dramatically. (See Table 1.) The integrated, multiagency care coordination team was able to eliminate 87 dual ALS first response engine and ALS ambulance dispatches for a savings of $52,259. Overall, the cost savings to the city of San Diego and associated agencies with the reduction of system use by this one patient was $163,533 (68% savings in one year).
As the numbers indicate, Melissa was still using EMS and public resources disproportionately. She was working hard to change her life, but this type of dramatic life change requires adjustment.
Melissa would backslide from time to time and generate multiple calls in a day. Sometimes she disappeared for days. P25, SDPD and SDFD EMS would often work together to bring Melissa back into the program, sometimes by court order. P25 had the resources to provided in-home detoxification services to Melissa. Each time she returned, P25 welcomed her back and continued helping her to achieve her goals.
Slowly, the time intervals between relapses became longer. She used to relapse every few months, then every six months. It’s now been nearly a year since her last relapse. Though unofficial, reports for her nearly complete second year indicate she may not even be considered a frequent user (at the time of publication, she’s used EMS less than six times in a year).
More importantly, Melissa’s quality of life has improved. She’s no longer in constant danger and is participating in positive activities. Recently, she organized a barbeque for her fellow P25 participants and has since reconnected with her family.
This case example illustrates four important concepts in mobile integrated healthcare:
1. When clients don’t respond productively to care coordination attempts by EMS, consider referring to a service with more intense case management. Effective management of some clients may require partnerships with a multitude of agencies working across disciplines, including law enforcement, courts, behavioral and homeless outreach teams, social workers, case managers, housing providers, medical partners, etc.
2. Even after partnerships are formed, EMS must continue to maintain these relationships and agreements for the benefit of the clients. In cases where EMS, hospitals and insurance policies are in conflict with primary care or the client’s interest, it’s important to articulate these interests and begin discussion around these issues.
3. Once a client has achieved relatively stable behavior, don’t consider it a failure if the client occasionally backslides. EMS should expect relapses and expect to participate with case management on a long-term basis to help reinforce the teachings of the current program, or at least notify the program of the situation.
4. Alternative sentencing programs (e.g., drug courts, behavioral courts or other programs that promote mandated treatment over incarceration) may be an important component in helping a vulnerable individual. Incarceration alone does not usually stop an individual’s perpetual crisis. Identifying and offering a treatment alternative has shown to be more effective in stabilizing a client. Though privacy laws can be intimidating, begin dialogue with your agency’s attorney. Alternative sentencing has saved many lives in the city of San Diego.
SDEMS RAP chose to highlight this story because it represents a realistic case, with a realistic success, in one of the most complicated frequent 9-1-1 user types. In programs that deal primarily with the most vulnerable or most disruptive individuals, meaningful results almost always require persistent, hard work.
Working with this population often requires expertise unique to the response community. EMS and law enforcement outreach teams often engage individuals in hard-to-reach areas, which have included climbing chain link fences, hiking into ravines and even coaxing clients from under freeway bridges to take the individual to rehab or to an appointment.
Law enforcement officers are able to handle potentially dangerous situations as needed, while paramedics are well equipped to extricate a client or deal with an unexpected medical situation. At the end of this effort, success would not come without diligent, intuitive and tolerant case management provided by programs like P25. (Figure 1 shows the massive impact P25 has had on service utilization for the original 35 participants.)
Figure 1: Service utilization for 35 original P25 clients
Like most efforts in implementing mobile integrated healthcare, Melissa’s case was challenging, but it also illustrates that through EMS’ willingness to participate in hard work and with our openness to engage with other like-minded organizations, we can successfully tackle difficult issues that have been abandoned by other disciplines, to address clients whose needs have remained unaddressed, and to insist that patient advocacy is at the core of our efforts. jems
San Diego Resources Used in this Case
San Diego Serial Inebriate Program (SIP) is a treatment strategy that offers court-ordered therapeutic alternatives to individuals repeatedly arrested due to unlawful behavior associated with chronic alcoholism. The client is offered an opportunity to participate in a recovery program rather than serve jail time. SIP was pioneered by two police officers who began attending community meetings in an attempt to find a treatment program willing to take a chance on their idea. Thirteen years later, it’s now a formal collaboration between law enforcement, EMS, the San Diego Superior Courts, the Office of the Public Defender, the Office of the City Attorney, Mental Health Systems Inc., and St. Vincent de Paul Village Family Health Center. SIP has served as a model for other major cities across the country. For more information on this treatment model, go to www.sandiego.gov/sip/index.htm.
Housing First is a model that offers immediate placement into permanent housing for individuals and families experiencing homelessness as a first step, with no required conditions or participation in treatment. Once in housing, voluntary wrap-around supportive services are provided to the individual or family based on their needs, with the goal of maintaining housing, addressing barriers and working on personal goals. Supportive services vary in intensity and time, depending on the household.
Those requiring more intense services and time may need a Permanent Supportive Housing model, while others with fewer barriers can benefit from the Rapid Re-Housing model, which combines limited rental assistance and brief supportive services. Learn more about Housing First initiatives at www.usich.gov/usich_resources/solutions/explore/housing_first/.
Homeless Outreach Programs for Entitlements San Diego (HOPE SD) is a local initiative based on the national best practice Supplemental Security Income/ Social Security Disability Insurance (SSI/SSDI) Outreach, Access, and Recovery (SOAR) model. SOAR aims to increase access to disability benefits for eligible adults who are homeless or at risk of homelessness, and who also have a mental illness and/or a co-occurring substance abuse disorder. The model is supported by the Substance Abuse and Mental Health Services Administration (SAMHSA) and is currently implemented in all 50 states. Communities across the country using the SOAR model are demonstrating that, on average, 65% of applications are approved on the initial decision in 100 days or less, whereas the traditional process may take upwards of several years, affecting care coordination efforts. Go to http://soarworks.prainc.com for more information and to learn how to start a SOAR initiative in your community.
To read more about the San Diego Fire-Rescue Department’s Resource Access Program, go to www.sandiego.gov/fire/services/ems/rap.shtml. For details on Project 25, go to www.svdpv.org/permanenthousing.html.