Administration and Leadership, Documentation & Patient Care Reporting, Mobile Integrated Healthcare

How San Diego EMS Integrated System-Wide Conditional Social Referrals in ePCRs

Issue 2 and Volume 41.

EMS providers encounter patients in difficult social situations on a day-to-day basis—sometimes as the primary cause of a 9-1-1 incident, or sometimes in the background of an incident. In fact, EMS providers are often the first to recognize a social difficulty in a person’s life, but with few tools to assist in a non-emergency capacity, these vulnerable patients don’t always get the kind of help they actually need, leaving providers feeling helpless.

In San Diego, community paramedics address the needs of these vulnerable EMS patients, who are most often recognized through frequent encounters with EMS as part of the Resource Access Program (RAP), which operates as the strategic social arm of the San Diego Fire-Rescue Department and Rural/Metro Ambulance (SDEMS).


In 2010, SDEMS implemented an effortless, one-touch RAP electronic referral button on all SDEMS providers’ iPads that allowed them to refer patients they identified as vulnerable, but hadn’t yet been identified as frequent 9-1-1 callers or been flagged through RAP’s system-wide monitoring.

Upon implementation, roughly 6% of the city’s daily EMS call volume resulted in a RAP electronic referral for social assistance. This daily influx of 15–25 referrals proved too hefty for the small team of five community paramedics, who were already operating near capacity handling frequent 9-1-1 callers. So San Diego EMS (SDEMS) teamed up with a close community partner, 2-1-1 San Diego, to find a solution.


The 2-1-1 and RAP collaboration resulted in an improved electronic referral system, called a “2-1-1 referral” (and known as a “reverse 2-1-1” to the general public). It uses conditional routing, or a decision algorithm, to direct vulnerable patients to either 2-1-1’s team of health navigators or RAP’s community paramedics.

The referral system was integrated into Street Sense—the monitoring and case management program used by the RAP paramedics and developed by World Advancement of Technology for EMS and Rescue Inc. Street Sense monitors 9-1-1 and computer-aided dispatch data in real-time, creating profiles for each patient and analyzing system use. By integrating the decision algorithm into Street Sense, referrals could be distributed with the perspective of total EMS use, not just the current 9-1-1 call.

The issues and complexities of building this system-wide referral system included: Privacy and consent; impact on workforce; collaboration procedures; and case management.


Nonmedical referrals to help address a patient’s social issues (such as burial assistance, housing, food assistance or utility assistance) require authorization from the patient in order to meet HIPAA requirements under the San Diego governance structure. Rather than limit referrals to healthcare or collect paper authorizations needing human filtering that could introduce discrepancies, an electronic consent process was developed.

SDEMS used the existing RAP authorization form to create an electronic version that fits into the current electronic patient care report (ePCR) platform of the 9-1-1 responders. Using the existing authorization form provided two unplanned benefits: 1) not only did it allow SDEMS to share information with 2-1-1, it also allowed SDEMS to share information with hundreds of other medical and social providers through traditional care coordination if RAP sees the need; and 2) the small, five-member RAP team now had hundreds of 9-1-1 responders obtaining consent within the system and supporting care coordination for the community because authorization forms have already been completed before RAP meets the client or begins care coordination, whether or not intervention is initiated through a referral or system surveillance.




The first-generation one-touch RAP electronic referral button was effortless; it was activated with a tap of the finger and didn’t require additional data entry. This low-barrier referral system assured maximum referrals to RAP, but ePCR narratives often lacked additional information regarding why the referral was made, causing many referrals to remain unaddressed.

Additionally, it became an emotional outlet for frustrated responders. Though RAP didn’t mind providing some emotional relief from patients who most likely required social assistance anyway, it was clear that the emotional impact on providers should be handled differently, and that the referral mechanism needed a better balance between data validation and accessibility.

Instead of a one-touch solution, the new 2-1-1 electronic referral system requires responders to provide three pieces of additional information:

Referral category: Responders assign a category/concern to the patient, including 9-1-1 dependency, caregiver services, food assistance, general medical care, health supportive services, homeless outreach team, mental health support, social insurance and substance abuse support.

Social narrative: Separate from the medical narrative, the social narrative describes the situation and reason for referral. Without a narrative, the system won’t allow the provider to submit the referral.

Signature-based authorization: Responders assess the patient’s capacity to consent according to current medical protocol, explain the referral, and obtain a signature from the patient. If the patient is unable to consent but is in need of assistance, the provider is still able to submit the referral, but the system routes the referral directly to RAP for follow up from community paramedics.

The updated electronic referral system has, as expected, led to a decrease in the overall number of referrals because the information gathering requirements are now placed on first responders. SDEMS estimates that referrals have decreased from 6% of total call volume to just under 3%.

This 3% is a combination of referrals sent to RAP, estimated at 2.6% of total call volume, and referrals sent to 2-1-1, estimated 0.4% of total call volume. Though the new medium-barrier referral results in fewer referrals overall, the referrals are of better quality and are more actionable.


RAP community paramedics and 2-1-1 health navigators agreed upon a collaboration plan that led to the decision algorithm incorporated into the updated electronic referral process.

 Referrals related to patients who are alert, oriented and have capacity to follow up with over-the-phone coaching—and who have appropriate contact information—are routed to 2-1-1.

 Referrals related to patients with limited cognitive ability, excessive 9-1-1 calls or limited contact details are routed to RAP.

 Subsequent referrals for the same patient route to the same organization as before, to maintain continuity in care coordination.

 The RAP and 2-1-1 teams are able to “push” referrals back and forth to each other with accompanying comments if the recipient feels the other organization is better suited to address that patient’s needs, or if the two teams are working together for a patient.


After receiving a referral, each agency initiates case management—often the most difficult aspect of the referral. RAP’s case management methods haven’t changed significantly. Though community paramedics still struggle with insufficient information from some referrals, there have been fewer to sort through and the RAP team is able to follow up or investigate each one.

For 2-1-1 health navigators, the proactive approach to following up on referrals from EMS was a new process. Navigators attempt to contact patients after they’re expected to return from the hospital, a goal that’s been challenging for a number of reasons. Some patients don’t answer the phone and others refuse assistance despite prior authorization. Other times, a patient’s contact information was entered incorrectly. Despite these difficulties, 2-1-1 San Diego has been able to work through these issues and effectively connect EMS patients with resources, the most common being for senior supportive services and community health centers.


Since 9-1-1 activation is a reflection of a person’s coping skills and available resources, RAP hopes that connecting coachable patients to 2-1-1 will allow them to develop new coping skills so that they become less reliant on the 9-1-1 system. This will allow community paramedics to focus on the more vulnerable EMS patients.

In addition to teaching coping skills, 2-1-1 health navigators are able to connect patients with resources related to basic needs, like getting food on the table, securing shelter, filling prescriptions, etc. Once their basic needs are met, patients may have a better chance of rationalizing and managing personal afflictions like chronic medical diseases, substance abuse disorders, or mental illness.


The partnership between 2-1-1 and 9-1-1 represents an important component in SDEMS’s overarching goal of caring for vulnerable EMS patients and reducing 9-1-1 utilization. By combining the unique skills from each agency, 9-1-1 and 2-1-1 can address the diverse needs of EMS patients while providing relief to first responders.