Documentation & Patient Care Reporting, Exclusives, Patient Care

Impact of Implementing an Out-of-hospital Social Work Program on a High-volume Emergency Medical Services System

DeSoto Fire Rescue Assistant Chief Bryan Southard and EMS Chief Bryan Whitacre explain the fire department's new process requesting social work follow up while on scene with patient. (Photo/Michelle Henrise)

Introduction

The Univerity of Texas Southwestern/Parkland BioTel EMS System provides centralized prehospital medical direction to 12 North Texas cities via their fire-department based EMS agencies.

These agencies serve a population of 2.4 million people and respond to more than 260,000 911 medical calls each year. Since its inception in 1974, BioTel has continued to evolve to meet the needs of its EMS agencies, their EMS providers and the patients that they serve.

In 2015, after identifying an increasing number of 911 calls that involved an increasing number of psychosocial-driven complaints, BioTel launched a new innovative program. This program utilized a dedicated senior emergency department Licensed Clinical Social Worker (LCSW) to assist EMS Providers in meeting the needs of patients with complex psychosocial issues.

Initially conceived to be just a part-time position, the demand for services quickly escalated beyond the budgeted hours and prompted the expansion of the social work role to a full-time position in 2016.

In this article, we highlight the experience of two BioTel EMS agencies whose leadership assisted with the development of a prehospital social work program, and embraced core social work values, theories and models in their departments.

Program Development

Katherine Herrian completes a roundtable discussion with Garland Fire Department Station One to gather additional information about referrals and provide follow up. (Photo/Casey Lindsay)

BioTel leadership and its EMS chiefs identified that a significant amount of crews and resources were being expended for a subset of patients with low acuity medical needs or with medical needs exacerbated by social stressors. Together, they developed an out-of-hospital social work program which had two strategic goals:

  1. Improve the patient’s overall health and well-being.
  2. Decrease the over-utilization of scarce EMS resources for lower acuity or non-medical needs.

Prior to developing a formal social work program, there was an obvious gap between the needs of some patients and the ability of traditional 911 EMS response to fulfill them. The identification of this gap within the system led BioTel and its EMS chiefs to actively seek out a tangible solution to increase the “goodness of fit” between their citizens and the environment.1

Despite having no formal social work background, the EMS leadership, and providers involved in the program’s development, shared many of the fundamental social work values and goals and gravitated to a “person in the environment” systems approach.

Even prior to the social work program being implemented, the philosophy of utilizing fire service personnel as experts in their community had been recognized and used for outreach and education activities.

As EMS leadership attempted to respond to the ever-increasing challenge of meeting patient needs that were not within their scope of practice, a solution was developed to expand their agency’s capabilities to address those needs through the addition of social work.

This concept is systems theory at its core, and it opened the door for a social worker to address the day-to-day needs of some of the most complex, at-risk, and neediest patients that EMS responds to.

It also provided an opportunity for EMS personnel to be exposed to a more holistic, person-centered approach for their most challenging patients.

In addition, the involvement of a social worker in the field provided the opportunity to share insights and offer advice with regards to departmental practices and policies that affect patient care.

Fire Department Support

The fire department’s EMS leadership was crucial to the creation and execution of the social work program. It was through extensive dialogue and cooperation that each department was able to tailor the program to meet its own specifications based on the fire department’s knowledge of their community.

This information, coupled with a LCSW’s understanding of practice perspective, theories, models and mechanism for change is ultimately what led to a successful relationship for both parties and a positive outcome for many of our patients.

City of DeSoto, Texas

DeSoto is a southern suburb of Dallas with approximately 55,000 residents living in 22 square miles. The Desoto Fire Rescue employs 68 uniformed personnel who operate out of three fire stations and provides EMS, fire prevention and protection. In 2018, the department responded to 6,413 EMS and 2,236 fire requests for service.

The first patient was referred to the social work program in December 2015 and, to date, more than 50 patients have now been referred.

From the outset, the department’s Assistant Chief Bryan Southard took an active role in the program. Under his leadership, DeSoto quickly became a top referral source and a model for the implementation of a social work program in a fire department setting.

This early buy-in and open-minded collaboration from DeSoto Fire Rescue resulted in enthusiastic referrals from field providers, and a doubling in the number of referrals from 2017 to 2018.

On-duty paramedics were also given the opportunity to take an active role in social work home visits. Paramedics who were normally assigned to an ambulance brought new perspectives and community information to the LCSW.

This insight was more applicable to direct practice social work versus the macro-level input provided by leadership. Field paramedics provided indepth knowledge about smaller aspects of their community.

They shared challenges that were specific to their district, certain neighborhoods, and various streets or individual patients.

They also provided valuable history on family dynamics of particular addresses where they frequently responded. This collaboration not only added additional depth to the social worker’s understanding of the community, it also reinforced the department’s internal support for the program and their desire to make an overarching change in the options their EMS providers had in caring for patients.

This commitment by DeSoto Fire Rescue has remained consistent through department officer transitions and promotions. While the level of contact has fluctuated through these changes, regardless of the officer assigned to oversee the daily operations of the social work program, it has continued to gain momentum and popularity with frontline paramedics.

The ability of this paramedic-social work partnership to sustain growth and engagement regardless of transitions in leadership is evidence that this is not just a temporary change but a true shift from the top down of incorporating social work practice into their EMS delivery model. Desoto’s EMS providers have been able to witness the benefits to the citizens, who are ultimately reaping the benefits of this commitment.

City of Garland, Texas

The City of Garland is a northeastern suburb of Dallas and is significantly larger than the City of DeSoto. Garland Fire Department serves a population of approximately 240,000 people with 11 fire stations. They responded to a total of 25, 330 calls in in 2019, of which 18,332 were EMS.

Like Desoto, Garland incorporated the social worker into key components of the department’s response and practices.

For a department of this size, implementation of the social work program required a different approach. The Garland model aligned the social worker closely with its EMS shift supervisors. The EMS supervisors, located at one of the centralized fire stations, serve as the primary 24/7 contact for EMS field providers.

For this larger department, the availability of a shift captain to serve as a resource for field providers and to accompany the social worker on home visits proved essential to both the referral process and the success of the program.

Through their participation during home visits and acting as liaisons between the social worker and the referring paramedics, the EMS captains developed a greater knowledge of social work theory.

Using this knowledge, captains often were able to provide effective preliminary suggestions to EMS crews at time of referral, and also identify patients not initially recognized by crews as either requiring or potentially benefiting from referral to the social work program. Finally, EMS captains were often able to apply these concepts to EMS patients during times when the social worker was not available.

The common denominator among the DeSoto and Garland Fire Departments related to a departmental cultural shift and a fundamental desire to empower paramedics to utilize this new tool to improve the health and lives of their citizens.

Social Work Program Data

Katherine Herrian meets with Chief Bryan Southard and Chief Greg Chase to discuss social work patient care plans. (Photo/Bryan Whitacre)

Data was collected from both agencies for patients enrolled in the BioTel social work program. Only internal fire department referrals were enrolled to ensure the integrity of the EMS-based program was maintained.

To remain consistent with the core ethical principle of patient autonomy, enrollment and program participation was completely voluntary for patients and their families.

A total of 94 patients were enrolled in the program, with 43 patients enrolled in Desoto over a three-and-a-half year period, and 51 patients enrolled in Garland over a four-year period.

Average age of referrals for both agencies was 68 years of age, with generally an equal split between genders. In both agencies, the majority of enrolled patients had some funding source.

Primary funding source for Desoto referrals was 74% Medicare, 33% Medicaid, and 14% commercial insurance providers, with one third of referrals having more than one funding source. A similar predominance of Medicare and Medicaid as the primary funding source was observed for Garland referrals as well.

Social work evaluation and intervention resulted in 65% of Desoto and 35% of Garland referrals being placed in an alternate environment including assisted or independent living, skilled or long-term care nursing facilities or acute rehabilitation centers.

Placements included temporary rehabilitation stays to increase the ability to safely complete activities of daily living, as well as permanent transitions to a more appropriate setting dependent on a patient’s baseline level of functioning.

An average of 23% of enrolled patients required referral to Adult Protective Services (APS). However, when circumstances mandated APS involvement, the social work program provided support and served as a liaison between the paramedics and protective services workers. We believe that the early referral of high risk and vulnerable patients to the social work program by EMS providers allowed prompt social work interventions to prevent deterioration and need for notification and involvement of a protective services agency.

Patients with mental health disorders or behavioral health needs comprised around 25% of referred patients. An additional 20-25% of referred patients had been diagnosed with some form of dementia.

Given the large prevalence of behavioral health needs and the limited training of most EMS personnel in this area, a LCSW with additional exposure to mental health disorders and their treatment is uniquely suited to provide the complex psychoeducation and support that is needed for patients and families.

In both agencies, the social work program was successful in reducing 911 utilization including among the highest utilizers. Social work program patients with two or more 911 calls prior to enrollment had an average of 6.4 calls in the six months pre-enrollment, and 2.3 in the six months post-enrollment.

Calls to 911 were reduced on average by 58%. In the eight enrolled patients with over 10 calls in the six months pre-intervention, five had a greater than 70% reduction in utilization, and two had a 50% reduction in utilization.

Discussion

One of the most significant benefits for social workers in forming a relationship with a Fire Department is the tacit endorsement of the Social Worker and the services they provide. Social Workers need the support of community leaders and decision-makers in order to get community buy-in on the micro, mezzo and macro level.2

The endorsement of a uniformed member of the local fire service who responds along with a social worker on a home visit and who takes an active role in the assessment, treatment and planning is critical to the success of the program.

The benefit of a social worker and paramedic team approach is twofold. It sends the message that the community supports and embraces the utilization of social services delivery through a licensed clinical social worker.

It also sends the message to citizens that while the fire department’s primary concern and function is to ensure rapid and appropriate fire suppression, rescue and emergency medical services response to the community, they also have a vested interest in their patient’s long-term health and welfare.

This partnership offers the opportunity to reframe social services intervention as strength-based and supportive in nature, rather than the punitive or even intrusive historical connotation sometimes associated with social service intervention. A collaborative and trusting relationship between client and clinician is at the root of most Social Work theories and paramedics have the opportunity to better the lives of the citizens in their community in a proactive way through in-house social work referrals.1

Most first responders can relate countless stories of 911 responses for individuals with complaints that do not fall under the umbrella of an emergent medical, public health or safety need. It can be argued that the predictable, timely and reliable response from the fire department makes them often the first point of contact for most non-law enforcement emergencies regardless if they are fire, medical or social in nature.

In addition to the cost to the system for both unnecessary and low acuity 911 calls, there is an impact on the providers who frequently and repeatedly respond to the same patients only to see their psychosocial needs remain unmet. Partnering a social worker with fire and EMS personnel has the potential to identify and address social welfare needs on multiple levels while simultaneously strengthening a patient’s attachment to their community and decreasing their reliance on scarce and overburdened emergency medical services systems.

Social Workers attempting to establish services in a community, especially one that previously had very few formal social service resources, will undoubtedly face challenges.2

For social workers, this means a potentially significant learning curve. Social workers need to educate themselves on the community and local customs, work to gain acceptance with key community members and combat the stigma that sometimes accompanies the concept of social work referrals.2

Members of the fire service are an invaluable resource to assist social workers as they are often experts on their communities. The longevity of firefighter’s careers uniquely situates them to serve as ambassadors for new social workers within the community and to sustain an established program.

Most importantly, they can provide observations about community interventions that will be beneficial for social workers as they work towards identifying potential areas for growth and service development.

Conclusion

The addition of an out-of-hospital social work program to an EMS System can have significant benefits for patients, EMS providers, EMS agencies and the communities that we serve.

An experienced, EMS-savvy social worker supporting fire service chiefs, officers, and their operational firefighter/paramedics introduces a novel level of service to the provision of out-of-hospital emergency medical care.

The relationship between social workers and EMS providers capitalizes on both professions’ strengths, relies upon the innate trust already established in the community by the fire department, and can fill gaps in patient needs previously unable to be fulfilled by traditional 911 response ultimately setting patients up for short-and long-term success.

We describe our early experience with two EMS agencies who have enthusiastically embraced a social work program. The lessons learned from this initial collaboration may be generalized to other urban, suburban and rural EMS systems throughout the country.

We enthusiastically support the development of a rigorous evaluation of the benefit of a social work program in supporting and augmenting EMS system development and operations.

References

1. Langer, C. L., & Lietz, C. A. (2015). Applying theory to generalist social work practice: A case study approach. Hoboken, NJ: John Wiley & Sons.

2. Daley, M. R. (2016). Rural social work in the 21st century. New York, NY: Oxford University Press.

Acknowledgement

The authors wish to recognize and thank the men and women of DeSoto Fire Rescue and the Garland Fire Department along with their department leadership for their commitment to the application of a EMS-based social sork program. Their support and dedication to this program and their citizens have made this program possible. We are grateful for the daily operational resources that these departments have committed to our collaborative work and acknowledge that this could not have been done without their contributions.