Salt Lake City (UT) Fire Department Finds Success in Deploying Social Workers

A group of people stand around an SUV in front of a fire station.
Licensed Clinical Social Worker and Program Manager Natasha Thomas, EMT Aalec Shields, Social Services Worker Sarah Bohe, EMT Brock Smedley and Clinical Social Worker Shannon Luckart. (Photo/Salt Lake City Fire)

The Salt Lake City Fire Department (SLCFD) is an “all hazards” fire department. There are 14 stations and a two-tiered system of EMS with ALS and BLS engines.

The fire department contracts with Gold Cross ambulance to provide BLS medical transportation, with the fire department paramedics riding in the ambulance when needed on ALS calls. The fire department runs approximately 35,000 calls for service each year.

Recognizing a Need

For many years, the fire department has seen a rise in calls of psycho-social issues from drug abuse, psychiatric issues, domestic violence, homelessness, and grief from trauma, violence or death.

While department paramedics and EMTs have training in each of these subjects, it is very basic compared to what specialists in the mental health field are trained to handle.

Approximately one year ago, the fire department and city management team met and discussed if there was a need for a more specialized approach to these issues facing the fire department. The idea of creating a social work team was brought up and received support from the fire chief, mayor and city council.

Creating a Program

SLCFD designed a pilot program that included social workers running calls, embedded with the fire department. Due to the limited budget of a pilot program, three full-time employees were hired for the program. One licensed clinical social worker (LCSW), one clinical social worker (CSW), and one social services worker (SSW).

The LCSW was hired as the team manager with the rest of the team reporting to and working for her. The LCSW reports directly to the Medical Division chief. The team was named Community Health Access Team, or CHAT. These employees belong to the fire department.

JEMS

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

Mobile Integrated Healthcare Program Changing How EMS Responds to Behavioral Health Crises

Our department currently runs three two-person Mobile Response Teams (MRT) in sport utility vehicles during the daytime, Monday through Saturday, for 12 hours a day.

They are currently staffed with two EMTs but have also run with one EMT and one paramedic depending on staffing availability.

They are designed to run lower acuity calls in the core of the city. We decided to staff one of the MRTs as a CHAT/MRT combination by placing a social worker on the vehicle from Monday through Friday between 7 a.m. and 8:30 p.m.

Additionally, when not on the MRT, the other CHAT members can pair up with each other or a paramedic or EMT assigned to our medical division office and operate as a second out team from the Public Safety Building as staffing allows on Tuesday and Wednesday.

We created a list of calls that would be best for CHAT to respond to, like suicidal ideation, drug overdose, domestic violence, homeless issues, fatalities, and cardiac arrest when requested by on-scene captains.

We were able to designate a response area for the MRT/CHAT team and have them automatically dispatched on these types of calls. Other districts could request a CHAT response if needed.

Data Points

We recognized that we were very limited in the area we could cover with just one full-time team and one part-time team, but for the pilot study and limited resources, we hoped it would give us some good data points.

We spent time creating training for our entire department on the types of calls that CHAT would take, how to request them, and that they could hand off care to the CHAT team when they arrived on scene.

The idea that a crew could respond to a call, have CHAT already en route, provide a quick medical clearance and then turn the call over to social workers was received very well.

It meant that crews would be able to go back in service quicker, while the social workers could remain on scene to determine what the best care options were for the patient.

Picking Realistic Goals

To prove the CHAT concept, we had to determine what we wanted to accomplish. We were able to quickly identify a few areas that would be indicators of success:

  1. Decrease transport to the emergency room.
  2. Reduce dispatches of ALS and BLS engines on calls.
  3. Cancel ALS and BLS engines on scene more rapidly.
  4. Reduce police department responses or return them to service more quickly on calls.

ER Reduction

A trip to the ER is generally all that EMS can offer. There are many situations where the ER simply “treats and streets” the patient putting them back into the community without really solving the needs of the patient. One of the core goals of CHAT was to break the ER revolving door cycle.

After spending time with the patient, CHAT looks for ways to provide appropriate care that allows them to stay home in the care of family or friends or be transported to a facility that better serves the patient’s need.

This requires creating a care or crisis plan and having access to resources not generally associated with EMS. Our ambulance provider, Gold Cross, has partnered with CHAT to transport to the appropriate non-traditional locations as needed.

Reducing Dispatches of Engines

One of our core beliefs is that every patient needs to be medically evaluated prior to CHAT taking over care. By assigning the social worker to the MRT, the EMT’s can provide immediate medical evaluation while the CHAT member watches and listens to the patient.

This allows for a faster assessment and less time asking the same questions when the patient is turned over to CHAT. In our model, using an expanded CHAT/MRT district, the team can handle many of the calls by themselves that previously required a BLS or ALS engine response.

Canceling Engines More Rapidly

When CHAT is asked to respond outside of its first due district, the CHAT member responds to an area directly behind the EMTs or paramedics giving care. They observe and listen to the assessment.

Once the crew providing care determines that no emergent transport is warranted, they turn the patient over to the CHAT/MRT team for ongoing evaluation and assessment. This allows the BLS or ALS team to provide a rapid assessment, then return to service quickly.

The CHAT/MRT team can complete an assessment, then determine if the patient needs transport to the ER or other location, referral to community services, or help with some other aspect of psychosocial care.

Our Gold Cross ambulance provider stays on scene until a final determination of disposition is made. Each of these patients will be referred into the CHAT system for ongoing follow-up in the next few days. Our goal is to provide approximately two weeks of care and follow-up while getting them connected to more long-term care.

Canceling Police and Returning Them to Service

There is a nuanced difference between needing police intervention for scene safety or needing them for treating a patient that is a danger to themselves or others. In Utah, we call involuntary hospitalization a “pink sheet.”

In the past, the only way we could pink sheet a patient was to have police respond and issue the pink sheet. Now, each of our CHAT members are trained to issue pink sheets.

We can cancel the police call when the patient is non-violent, not necessarily wanting to go to the ER but mostly cooperative when told they must legally go to the ER by our social workers.

If a call would normally include a police response to secure the scene, we still have them respond. The goal is to determine if they can be canceled based on the incident details, or shortly after arrival based on the patient interaction. We will not knowingly put the CHAT member, or any of our EMTs or paramedics into a violent situation.

We fully recognize that many calls mandate the need for a police response and that fire/EMS/CHAT should stage until the scene is secure.

Our goal is to defuse a situation using CHAT members to assist with treatment and transport. Ultimately, patient cooperation with fire/EMS and CHAT has been significantly better in these situations. In the past, the mere presence of police caused some patients to escalate negative behavior.

Success by the Numbers

The CHAT pilot program just hit the one-year mark. Evaluation of the DATA has been remarkable.

During the last year, we have avoided dispatching an ALS or BLS engine on 42% of calls in the CHAT district.

  • When CHAT was dispatched, 41% of the time, the patient did not need to go to the ER.
  • When CHAT was dispatched to an ALS or BLS engine or truck district, they were able to release the unit on 63% of the calls and get them back in service quickly.
  • When calls came in with police unit dispatched, CHAT was able to cancel them prior to or shortly after arrival on 43% of the calls with no police intervention needed.

All this data has been made available to the fire chief and city administration on a daily updated basis. They can see where the calls are, what type of call they are, and a brief description of the care offered. This transparency has allowed our leadership to understand the needs and niche that CHAT fills, as well as the challenges that our entire EMS team is facing daily.  

The single chief complaint received regarding the CHAT program has been the limitations of its availability. We knew from the beginning that only having one unit in service for fourteen fire station districts would be a limiting factor.

What we did not fully appreciate was how much our firefighters, community, city leaders, resource partners, residents, and even patient population would appreciate the service being provided.

The team has received many mentions in local media, conducted many interviews, forged numerous partnerships, and even been given a significant state EMS award for innovative support to EMS.

Moving Forward

Based on data and the success meeting our goals, the team has earned its place in our department and city. Recently, the city’s administration agreed to end our pilot program and fund the expansion of CHAT by increasing to two MRT/CHAT teams in service Monday through Saturday for 12 hours each day. A team will be staffed on each side of the city.

This will reduce CHAT response times and get ALS and BLS units back in service faster. We will also have dedicated case managers working in the Medical Division office to handle referrals, patient follow-up, and coordination with other resources. The goal of SLCFD is to provide a rapid and appropriate response to any type of emergency call. The CHAT expansion will put us on the path to making that goal a reality.

Conclusion

The need for EMS is ever-changing. Our residents and visitors in Salt Lake City expect that when they call 911, somebody will respond and be able to handle whatever emergency or crisis they are experiencing. Z

For many years, a large share of those calls has been for services not typically associated with local fire and EMS agencies We are fortunate in Salt Lake City to have progressive leadership from city administration and fire administration that not only supports change but embrace the challenges that it creates.

Our firefighter/EMTs and firefighter/paramedics have been instrumental in utilizing the CHAT team. They have recognized that just like on the fireground, there is an appropriate tool for each job. Finally, we were fortunate to find three incredible social work clinicians to start up the CHAT program in Salt Lake City.

They have broken new ground and set a high standard of care, compassion, and professionalism. They are on the cutting edge of what is possible when people who care are put in situations to make a difference, one life and one call at a time.

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