Can metro fire departments afford community health programs?

By Sharon McDonough

Because we are the safety net that most rely upon, fire-based EMS departments nationwide are realizing an increased demand for non-emergent care. In an effort to meet this need, many are implementing programs like mobile integrated health and community paramedicine.

These programs permit crews to get to know their patients in a less-rushed setting than that of traditional, emergent EMS, allowing for home visits, personalized care plans and in-home post-hospital care.

So why are so many municipal departments opting out? The reason is simple — current program models can be costly.

And while they are conducive to the rural environment, they don't provide enough bang for the buck in the larger, busier urban setting. Big departments have different challenges and must find a more suitable solution.

In FY2016, the Tucson Fire Department responded to over 91,000 calls for service, more than 90 percent of them EMS in nature. Like many, our call load continues to increase while our budget remains stagnant.

With disparities like these, leaders are asking how we can incur the cost of staff hours and resources to provide community paramedicine? How can we allow crews to stay out of service longer while "real emergencies" stack up? How can we afford to provide this additional tier of service?

The better question is more likely, how can we afford not to?

System strain
Tucson Fire has responded to more than 82,000 EMS calls in the past 12 months. Of those, only 41 percent have resulted in emergent on-scene interventions and/or an advanced life support level transport to the hospital.

Statistical evidence tells us that in our city the percentage of non-emergent EMS calls is rising and at a precariously faster rate every year. Due in large part to a fragmented health care system that is increasingly difficult to navigate, the EMS system has become over-taxed and with limited transport destination options; local emergency rooms are sharing the heat. 

As a result, the entire system suffers — response times to our time-dependent big four (cardiac arrests, heart attacks, strokes and trauma) are increasing and crews are suffering from burnout.

The reality for most large departments is that we are already providing this lower tier of service. But because we have not adapted to the shift in call type and volume, we aren't doing it very efficiently.

For most of us, a disproportionate part of this problem can be attributed to the frequent 911-user population within our communities. In 2014, 50 of Tucson's frequent users accounted for almost 1,400 calls, with most culminating in an ambulance ride to an emergency department.

They call 911 reporting an emergency, we send big red, we provide an ambulance ride to an emergency department, they receive the most expensive care of the medical system and are released home with some paperwork telling them to follow up with a primary-care doctor.

Only they don't, and the next day they call 911.

Unsustainable model
How many times can we afford to apply a code-three bandage fix in the name of rapidly returning to a response ready state?

The impact of the frequent-user population is not limited to fire and EMS agencies; it affects the whole community. At national average costs of $1,200 per transport, staffing and resource costs of $500 per response and $2,100 per emergency room visit, the financial burden alone is evident.

As this group ties up dispatch, fire, EMS and law enforcement resources, as well as emergency department staff and beds, the impact grows. Personnel suffer from compassion fatigue, sleep deprivation and decreased job satisfaction evidenced by increased sick leave use and decreased interest in overtime.

Effects on system reliability and community readiness are significant, with emergency resources responding from greater distances to transport to overcrowded hospitals with extreme wait times. Customer service suffers and tensions between agencies skyrocket as both public and private providers look for quicker ways to pass off non-emergent patients and return to a mission-ready status.

Individual reasons for repeated use of 911 resources are numerous and significant — mental health, substance abuse, chronic and unattended disease, non-compliance with care plans, inaccessibility to definitive care, nutritional limitations, lack of transportation, pharmaceutical misunderstanding, legal status, poor living conditions, homelessness and financial barriers are among the common factors.

Resource and need disconnect
Although our study focused on frequent users, the issues presented by this group are mirrored and compounded by low-frequency users as well. The problem is that although most communities have a wide variety of social and human service resources to help those in need, and a like abundance of at-risk persons needing those services, the two often are not easily connected.

Even when caseworker relationships are established, maintaining these connections remains difficult for many reasons. Our system suffers from severe fragmentation, entrenched interests, an absence of system-wide coordination and planning, and a lack of fiscal accountability. 

While successful in the rural setting, the smaller-community mobile integrated health programs simply lack the quantitative means necessary to deliver services on a larger scale in much busier urban settings.

Models that include a nurse at the 911 communications center are bound by the what-if liabilities of triaging unreliable callers to a no-send status. Nurses and physician assistants on day trucks are helpful, but they are expensive and outreach is limited to a few visits per day.

After-care may be best suited to private entities capable of providing scheduled service for less money.

So what is a big department to do? How do we best capitalize on established resources and infrastructure to address this growing problem, and how do we do it in a cost-effective manner?

Cannot afford to do nothing 
An often overlooked but key component of municipal fire departments is that they almost universally have the trust of both their community leaders and residents. Fire department first responder's ability to gain initial access to homes and the homeless allows them to obtain a comprehensive picture of the patient situation.

This includes living arrangements, home conditions, family support, transportation options, medication history, domestic or substance abuse indicators and many other barometers that are not available to traditional care providers.

We are in the best position to get these folks to competitive and specialized human service agencies that can best offer long-term resolution of chronic patient issues.

The frequent users have shown by word and action that handing them phone numbers and pamphlets doesn't work; the system is too complex, fragmented and siloed. We must instead take these people by the hand and navigate them through the intricacies of insurance and social service offerings to get them, and keep them, connected to the help they need.

A person who falls repeatedly must have the cause examined, the care provided, the step fixed. The trust that patients have with fire personnel that allows us into their homes must be extended to the trust of a caseworker-type relationship. Without this trust, an essential bond rarely exists and patients voluntarily opt out of assistance.

Building TC-3
Earlier this year, Tucson Fire introduced Tucson Collaborative Community Care, or TC-3, a program designed to do just that. The direction given was simple: find the people where they are, find the resources available to help them and solve their problem — no matter what it is, don't say no.

With no revenue to launch this pilot program, we reallocated three uniformed staff and set about collecting a large, ever-growing group of diverse community partners. Initially we had four partner groups; that has grown to 40.

The results have been noteworthy.

911 responses to our TC-3 clients have dramatically declined with some completely removed from the 911 cycle, all showing improvement and the vast majority reporting that their quality of life has improved.

Our crews are feeling supported, our reliability for time-critical incidents has improved and our clients are finally able to get the right help for their often multi-faceted issues.

The work of the TC-3 team is two-fold, focusing on the care of the individual and coordination of resources within the community.

How it works
With the click of a button and a consent signature, responding crews use an electronic patient care reporting system to begin the enrollment process for an at-risk individual. A notification is immediately sent to the TC-3 operations manager, who runs a full query on all previous visits made to the individual, looking for patterns, needs and outcomes.

A file is created, and based on severity and urgency, the individual is entered into Tucson Fire's web-based Human Services Referral Program and/or placed into queue for a scheduled in-home visit with our TC-3 coordinator team.

The HSRP program immediately gets the wheels rolling via an auto-generated email to key staff at community agencies with which formal HIPAA-compliant business agreements have been made. There they can weigh in on pertinent offerings and communicate with us on any visits, care, services and follow-up provided to the client. 

An un-hurried, in-home visit with the TC-3 team allows our personnel to better understand the individual's specific needs and limitations through conversation and examination of their environment. A thorough assessment is conducted and findings are matched to the services and qualifiers of local community partners.

Because real-time follow up is crucial, TC-3 clients are then identified to the 911 communications center to allow immediate notification to the TC-3 team each time a TC-3 client activates 911. 

The help provided by TC-3 is active rather than passive; appointments are scheduled, contacts are made, paperwork is filled out and transportation is arranged.

Some individuals find solution immediately, coming out of the 911 system as they are connected to long-term disease management, palliative care, hospice, home repairs, housing, pet solutions and dietary care. Others require on-going assistance and contact to keep them engaged and their needs managed.

Catching insurer's eye
TC-3 personnel navigate clients through the maze of the health care system, providing customized, person-centered, inclusive attention, pertinent to their specific and multiple needs.

The TC-3 program also coordinates community-wide quarterly meetings to discuss, understand and add to our growing bank of resources.

Representatives of the Behavioral Health Court System, the Regional Behavioral Health Authority, Affordable Care Organizations, hospitals, Veterans Affairs, law enforcement, county health, pet welfare, palliative care and hospice programs, private subsidiaries, volunteer groups and many specialized agencies have collaborated with us in a joint effort toward resolving this wide-spread issue.

This referral model has attracted the attention and collaboration of some of the nation's largest insurance agencies looking for ways to meet the highly sought after triple aim of the Affordable Care Act: enhance the patient experience, reduce health care costs and improve the population's health.

The misalignment between the critical care priorities of yesterday's EMS system and the appeal from constituents for non-emergent, total-person care necessitates a change to our service delivery model. The demand of our communities must be met by the supply side of the equation.

Fire-based EMS must remain relevant to the needs of our constituents and meet those needs in a fiscally responsible manner by facilitating better care, better outcomes and lower costs. Each agency must find or create a program that realistically suits its ability and its community's needs.

TC-3's proactive, preventative, navigate – refer – follow-up model is well suited to the dense population of the urban setting.

Here in Tucson, it is saving stakeholder's money and frustration, augmenting a reliable and efficient emergency response system and most importantly, is helping our at-risk population get the care they so desperately need.

City and department leaders should indeed ask themselves: "Can we afford to start a mobile integrated health program in our area?" The truth is, you can't afford not to.

About the author
Deputy Chief Sharon McDonough was hired by TFD in 1990 and has moved through the ranks of firefighter/EMT, paramedic, captain, battalion chief and deputy chief. During her 11-year tenure as a chief officer, she has been tasked with the oversight of fire operations, safety and the 911 communications center. She currently oversees medical administration and is the privacy officer for the department. She is the lead officer on TC-3.

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