How many times do EMS providers witness patients in need of social services? As EMS providers, we are dedicated to helping every patient we encounter no matter the medical complaint. For most, our primary focus is to assess and treat the acute medical or traumatic complaint. In some of these same situations though, providers witness other issues that could be contributing to the decline in the patients’ health. For example, a dirty house, minimal to no food in the house, no heat, a broken-down car, no insurance, no money, homelessness or signs of substance abuse. The result of these challenging social situations can cause a person’s health to be affected.
Throughout the U.S., EMTs and paramedics experience these types of situations every day. These patients often end up calling 9-1-1 because they have no other option for medical treatment. At Albuquerque Ambulance Service (AAS) in Albuquerque, New Mexico, “it is estimated that 27% of our 100,000 annual calls for service have a variety of unfavorable social situations and that these patients’ health could benefit from social services assistance,” according to AAS executive director Kurt Krumperman. Krumperman also says that many of these 27% of calls are frequent users of the 9-1-1 system, EMS treatment and ambulance transport, which results in an over-use of resources.
To help improve the overall health and wellbeing of patients while also reducing frequent users of the 9-1-1 system, AAS set out to create a social services referral program that EMS providers could utilize to help patients beyond their current acute complaints. In this article I will discuss how AAS partnered with local social workers to create a referral program in an effort to improve unfavorable social situations, improve patient outcomes, reduce frequent users of 9-1-1 and provide an improved job satisfaction for the provider. Lastly and very importantly, I’ll review how this was all done with a zero dollar budget.
Partnering with an established social services program
A common time for a patient to be referred to social services is during their hospital stay. Unfortunately, due to a number of factors, some patients are not given this referral. The patients may not mention the need for assistance to their doctor. Other patients continually refuse transport to the hospital all together. This is where EMS is in a unique position, as they get to see first-hand the social issues burdening the patient.
Reaching this population means that EMS would need a resource to be able to refer a patient. AAS didn’t want to reinvent the wheel, so it set out to partner with an organization that was already established and had the infrastructure in place to accept referrals. In Albuquerque, this organization is Pathways to a Healthy Bernalillo County, or Pathways for short. This organization is part of the University of New Mexico Health and Science Center and was modeled after the Community Health Access Project (CHAP) in Richland County, Ohio. This model has been replicated in more than 16 other geographic areas across the U.S., according to the Pathways website. Pathways has an established list of social services agencies as part of its program.
AAS met with a representative from Pathways and discussed how EMS could begin referring patients. Since Pathways is an established community based program that is looking for referrals, they were excited to partner with AAS and accept referrals from EMS. This partnership was mutually beneficial for both organizations and, because Pathways was a community program, the partnership came at no cost to either group. Pathways did advise AAS that there was an important step missing. For the process to work, AAS would need to work with a social worker who could take the EMS referrals and then move them through the Pathways program. Pathways had social workers, but they were already overwhelmed.
Introducing MSW students into the process
There are a variety of options for introducing social workers into this program. For AAS, the goal was to keep this program cost neutral, so hiring a social worker was not an option. To do this, AAS set out to partner with a graduate social work education program with the idea of having students work with EMS on the referrals. In Albuquerque, there are two master of social work (MSW) programs: New Mexico State University and Highlands University. The idea was to utilize MSW students during their internships to be the point of contact between the EMS referral and the process through Pathways. In essence, the students would be the navigators to the Pathways program.
This step was great for the program but had two significant barriers. First, the idea for AAS and the education institutes to partner was solid, but the process to complete legal agreements between each was very involved. “For EMS agencies looking to create a similar program, my only advice is starting this process early,” Krumperman says. Because the MSW student is affiliated with a couple of different universities in New Mexico, AAS needed to set up legal agreements with each university, as well as with Pathways. In total, the agreement process took four months to complete.
Second, because the MSW students are working for the program during their internship phase, the program required a properly licensed social worker to supervise the students. AAS met with the University of New Mexico Community Health Workers Initiative (CHWI), which in turn worked with Pathways to overcome this barrier. The result was that a CHWI licensed social worker agreed to supervise the MSW students during their internships. Since CHWI works in connection with Pathways and is dedicated to improving the health of Bernalillo County, this was a partnership that was mutually beneficial and was completed at no cost to either group.
Approval of other EMS agencies & medical control–protocol vs. SOG
The next step was to gain approval from our partnering EMS agencies, i.e., fire departments and the Medical Control Board (MCB), which is a group of physicians who govern the protocols for EMS in Bernalillo County. The big decision was whether to make this new program a protocol or a standard operating guideline (SOG).
In the end, our decision was to make it an SOG. While discussing this program with the other agencies, they agreed it was a necessary program and approved of it. But due to a variety of factors, the agencies were unable to dedicate the time to train all of their providers. This immediately withdrew the program from being a system protocol, as all protocols must be trained to personnel within all agencies. The decision then was to make this an internal SOG for AAS, which means AAS providers would receive the training for making referrals. Making this program an SOG and not a protocol meant AAS only needed to notify the MCB. This decision resulted in a much faster turnaround for this step. In most cases, SOGs are approved faster than protocols, as SOGs are internal to only one organization.
Creating a name, referral process, paperwork, brochure, & training
With the first three steps of the process complete, AAS was ready to design the process, create the referral paperwork and begin training materials. But first, the program needed a name. AAS, CHWI, and Pathways considered a variety of options, but settled on the name Connections. Simply stated, this program was created to connect patients from 9-1-1 calls to social services that, prior to this program, had never existed in Bernalillo County.
Next, the group needed to design the referral process from AAS to Pathways. The key to the success of the process was making it easy and efficient for the EMS providers. AAS completed this by creating an online referral form with a link placed directly in the laptop charting program. It is also important to note that, in this program, the patient must provide consent to be referred to a social worker. To capture consent, we created a signature form within our electronic patient care report that the patient can sign immediately. I have included copies of the process flowchart and referral form in this article so that other agencies looking to create a similar program may reference our process and form.
The Connections team also created a brochure to pass out to EMS providers to help educate them on the process. A copy of the brochure is available in the document repository on emsinsider.com. Lastly, the Connections group put together a training video that is published on YouTube and was emailed to the AAS EMS providers. To prevent expenses for filming, Colton Dean, a Paramedic with AAS who has a background in videography, filmed the training video. The video is at youtu.be/SCsQNJH1nNw.
Onboarding MSW students
To get the program started, CHWI licensed social worker supervisor Ivette Cuzmar, LISW, LADAC, who was charged with supervising the MSW students, brought on three students. Their training process had three steps. First, they completed the same training as the EMS providers with the SOG, referral form and training video. Second, they were trained in the Pathways program. Third, the Connections group felt it was important that the MSW students gain some understanding and experience of what the EMS providers do in the field. To accomplish this, the MSW students went on a ride-along for a day with an EMS crew.
Once their training was complete, the students worked part-time under Cuzmar’s direction. When a referral from EMS is received, the “MSW students reach out to the patient via telephone to set up an initial meeting face-to-face. The goal for the first meeting is to identify what help is needed and to complete a comprehensive assessment,” Cuzmar says. From there, the patient is referred to a social services agency that will help them with their identified needs.
“The goal is empowerment” Cuzmar says. Social workers are not looking to work for the patient to help fix their social challenges. Their job is to help remove barriers, educate and empower the patient so that they may thrive and overcome these challenges on their own. For example, if a patient is lacking money for food, the MSW student would meet with the patient and then go with them to the income support division office to help them start a food stamp application.
Implementation, results, & other programs throughout the nation
The time from the initial meeting between AAS and Pathways, to implementation on Oct. 6, 2014, was six months. This time frame will obviously differ for other organizations depending on available resources and partnership opportunities. After one month of implementation, AAS providers have referred 13 patients into the Connections program. So far, the majority of patients are elderly and lack certain things such as home care support, a primary care physician (PCP), money for medications and transportation.
“One of the first referrals was an elderly male with chronic back pain who wanted longterm help to relieve the pain,” says Cheryl Birmingham, an MSW student in the Connections program. In this instance, the patient’s barriers were no PCP, not understanding how to get a PCP, and lack of transportation. The patient was referred to the Connections program by an AAS EMS provider. From there, Birmingham met with him to complete his comprehensive assessment. From the assessment, Birmingham educated and assisted the patient on how to find a PCP, how to set up appointments and, lastly, assisted the patient in getting his car fixed so that he could make it to his appointments.
Going forward, this patient will be monitored for progress, but to-date he has successfully been empowered to reduce his social barriers. The result to the 9-1-1 system is that this patient will now utilize what he learned from the Connections program to work with his PCP on chronic complaints and leave 9-1-1 for acute emergencies.
Even in its early stages, this program has been a success for AAS. “We have needed a program like this in place for a long time,” says Paige Diamond, a part-time paramedic with AAS and a licensed social worker in Albuquerque. But this is not the only program of its kind in the nation. During the process of creating Connections, AAS referenced EMS systems in San Diego, Calif., Syracuse, N.Y., and Boise, Idaho for lessons learned and best practices in their referral programs.
For those looking to create a similar program, I invite you to contact us and other organizations for tips and reference materials. From start to finish, AAS successfully created this program with a zero dollar budget that could be mirrored in other communities. This program is definitely a way to help improve patient health and outcomes, increase resources for the EMS provider and reduce the number of frequent users of the 9-1-1 system.
