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How Cities Are Bringing 911 Into the 21st Century

Community paramedicine is changing the way some places respond to health emergencies.
by | August 2019

An ambulance’s wailing sirens, a fire truck’s flashing lights: These are a constant feature of urban life, as ubiquitous as a Starbucks on every corner or a traffic jam at 5 p.m. 

But nearly a third of the times an ambulance or a fire truck speeds by to answer a 911 call, there is no actual emergency. The number of 911 callers who don’t need to go to a hospital emergency department sits at around 30 percent, according to Kevin McGinnis of the National Association of State EMS Officials. 

The “false alarms” are more than an annoyance; they are a drain on the public purse, a frustration for responders and often an unhelpful source of assistance for the caller. It’s a problem that’s been around almost as long as 911 systems have. What is changing is the approach some cities and counties are taking to the way emergency medical services are delivered. Namely, a number of EMS officials are working to align their services with other community health goals. For instance, instead of automatically dropping a 911 caller at a hospital’s emergency department, an ambulance could, when appropriate, be rerouted to bring a person in distress to a sobering center, an urgent care clinic or a warming center. “Frequent flyers” -- those who call 911 more than once a month -- could be enrolled in a program that would help them address their chronic health conditions. Health issues that aren’t truly an emergency could be triaged by a nurse watching via an iPad in a call center when the call comes in. 

There is a new program that, in a number of localities, is helping get the job done: community paramedicine. Although the concept first appeared in health literature nearly two decades ago, it started to gain real-world traction about five years ago. Since then, the adoption momentum has been increasingly swift. 

Community paramedicine programs, sometimes referred to as mobile health care, work to address the underlying causes of why someone called 911. If the caller would be better served in a non-emergency room setting, they’ll take her there. If the responders can dress a non-urgent wound and book an appointment the next day with a caller’s primary care provider, they’ll do that. 

There are currently more than 200 community paramedicine programs in the country of varying degrees of size and scope. Many of them were started in response to a specific community problem. One program in Wake County, N.C., for instance, began as a way to reroute chronically inebriated callers to a sobering center instead of the ER. In Fort Worth, Texas, a community paramedicine program was born after uncompensated emergency care for just two dozen frequent flyers cost the city close to $1 million in a single year. 

Whatever the incentive, the concept is attracting attention for the way in which it addresses the immediate pressure of the 911-misuse problem, as well as the possibilities it holds for a long-term answer. EMS officials across the country all sing a similar refrain: Our health-care system can’t continue with this status quo. In too many instances, high-priced, technically sophisticated health resources are serving health issues that could and should be treated in less expensive and more effective ways. 

It’s not only the high cost of the current system that’s an issue. It is also demoralizing for EMS personnel, says Janet Coffman of the Healthforce Center at the University of California, San Francisco. “Folks feel frustrated,” she says of EMS responders. “They start to see the same people over and over again. They think, ‘I can take Mr. Smith to the ER every time he’s having a psychotic break, but I know that’s only going to help for a little time.’” Or they know a person is homeless and doesn’t take his meds, and what he really needs is longer-term help. 

Community paramedicine is not without its critics. Still, localities that have gotten programs underway report that they’re making progress toward moving their 911 EMS programs into a more sustainable, less siren-blaring future. 

 


(United Ambulance Service)

 

The first 911 call in the U.S. was completed on February 16, 1968, by Sen. Rankin Fite in Haleyville, Ala. AT&T soon began rolling the service out in places across the country. In 1973, Congress passed the Emergency Medical  Services Systems Act, which set the first federal guidelines for emergency services and put in place a dedicated stream of funding for EMS.  

EMS services haven’t evolved much since. Better call-tracking technologies and increasingly sophisticated GPS mapping have helped reduce response times, but the basic mechanics of the system -- a call is placed, a vehicle is dispatched, the caller is whisked away to receive emergency care in a central facility -- remain unchanged nearly 50 years later. That’s left the 911 system bloated and unable to respond to changing attitudes about public health care. As policymakers in recent years have become more focused on addressing the drivers of health outcomes that happen outside of doctors’ offices, including things like housing insecurity, food deserts and unclean air, emergency services have remained a stubbornly antiquated outlier.  

In 2012, Minnesota became the first state to recognize community paramedics as a health-care provider, allowing their services to be covered by Medicaid. The state also was the first to create a formalized training program for community paramedics, establishing certification programs at two community colleges. At the local level, Fort Worth is another leader in the field. Its MedStar Mobile Healthcare kicked off a community paramedicine program a decade ago when the city found that it was spending hundreds of thousands of dollars a year on just a handful of high-frequency users. The city set up an “EMS Loyalty” plan that automatically enrolls people who call 911 15 or more times within 90 days. Under the loyalty plan, a paramedic trained to treat chronic conditions makes house calls to the enrollee to address the underlying health issues behind the 911 calls. 

Typically, the paramedic will do an assessment of the person and figure out what she needs. “Some people need to be checked on twice a week; some people, it’s more,” says Matt Zavadsky, chief strategic integration officer at MedStar Mobile Healthcare in Fort Worth. “Generally, we keep them enrolled for 90 days. We work to wean people off, so we’re going to teach you how to manage your health so that you don’t need us.” Zavadsky says the program has saved the city $16 million in health-care costs. 

Other approaches are also promising. Two years ago, California created a pilot program for community paramedicine that comprises a dozen different localities. Some of the cities enrolled frequent flyers in a case management program; some provided follow-up care for those with chronic conditions until a more permanent caregiver could be put in place; and some provided alternate transport to places like urgent care clinics, sobering centers or mental health facilities.  

Coffman’s research with the Healthforce Center found that the follow-up care saved the state $1.3 million in potential hospital readmissions. However, the state has struggled to expand beyond the pilot programs. The legislature passed a bill in 2018 to expand the program and allow local emergency medical services agencies to develop community paramedicine programs under prescribed state rules. Gov. Jerry Brown vetoed it, saying the bill would restrict the types of facilities to which patients could be transported and limit the discretion of local governments to design and manage their projects. A similar bill was reintroduced this year, but it has failed to gain momentum.  

The law has been vehemently opposed by the California nurses union, along with home health and hospice associations. At the heart of that opposition is one of the basic arguments against paramedicine: that community paramedics simply aren’t qualified substitutes for nurses and the full array of services that a hospital can provide. Stephanie Roberson, government affairs director for the California Nurses Association, points to a pilot in San Diego County to loop frequent 911 users into a home program. It was cancelled because EMS workers didn’t have capacity to also respond to real emergencies. This is a prime reason the association says these programs aren’t a great idea: Paramedics simply cannot take on all of these multiple roles. “In California we have a growing number of wildfires. We have real emergencies. Our EMS needs to be ready to go in those emergent situations,” Roberson says. “We all agree that something needs to be done about emergency room bloat. But we need to make sure that those patients with emergency situations go to the ER. Under triage care, paramedics are not making the appropriate determinations.”

Coffman disagrees. She says her research has shown that California’s community paramedics complement the work of nurses and other providers by addressing holes in the health-care system. Paramedics don’t appear to be taking away jobs from nurses or home health aides. “If anything,” she says, “it’s more of a partnership. Paramedics reach out to home nurses and ask, ‘This is what I’m seeing, what do you think?’” 

 


(Mike Legeros)

 

Jurisdictions that want to set up a community paramedicine program might be inclined to look at what’s already working in other parts of the country and then replicate it back home. But that’s a mistake, say veterans in this field, such as Wake County Chief of Medical Affairs Mike Bachman. “If you are trying to build a program off of someone else’s program, that’s not going to work,” he says. “If you’re filling in the gaps of care in your community, that will work.” In other words, identify the deficiencies in your own 911 response network and then build a program that can address them. 

In Wake County, EMS officials knew that a sizable bulk of their 911 calls were related to underlying mental health and substance abuse issues. “We also knew we had places to take them to, but didn’t know how to get them there,” Bachman says. Once that disconnect was understood, the new program fell together. EMS started coordinating with the local mental and behavioral health providers and came to an agreement that those providers would be an alternate transportation spot instead of the ER, when appropriate. “We were all talking to the same patients anyway. We just had to all get to the table, and understand our different capabilities. From there it was just about collaboration,” Bachman says. 

Community paramedicine can’t provide a solution in every case. Fort Worth considered a proposal to enroll patients with multiple comorbidities -- such as someone living with diabetes, hypertension, emphysema and obesity -- in a home care program run by the mobile health-care unit. The idea was to reduce the financial burden of the most expensive patients in the health insurance industry. But those types of patients with complex needs require more than once-a-week visits from a paramedic, Zavadsky says. Moreover, the goal of community paramedicine is prevention, something that does not usually apply to someone living with multiple chronic conditions. “The reality is there’s no intervention other than palliative care that is going to change that dynamic,” he says. “A community paramedic won’t help them.”  

For many communities, the biggest obstacle to setting up a paramedicine program is funding. Bachman says he fields calls all the time from other jurisdictions that want to start a community paramedicine program. He’ll ask them what resources they have, and they tell him they don’t have any. But a new federal program could offer help. In February, the U.S. Department of Health and Human Services announced a new payment model for EMS providers to test out different ways of rerouting 911 calls. Under the new model, known as Emergency Triage, Treat and Transport, or ET3, the Centers for Medicare and Medicaid Services will pay participating ambulance providers not only for transporting an individual to the usual emergency facilities but also to alternative destinations, such as a primary care doctor’s office or an urgent care clinic, or to provide treatment in place. 

That new model likely means that paramedicine will soon be standard practice. Until now, local jurisdictions have had to be creative in how they fund these programs and reimburse for ambulance expenses. “If you’d have asked me in December whether I thought community paramedicine was the future, I wouldn’t have been so sure,” says Brenda Staffan, chief operating officer for integrated services for the community paramedicine program in Reno, Nev. “But now that the federal government has announced this, my answer is a definitive yes.”  

As the role of EMS continues to evolve, public attitudes are likely to shift as well. That’s already been the case in Fort Worth, Zavadsky says. “At MedStar, we are no longer viewed as the ambulance service,” he says. “We’re viewed as a mobile health unit that happens to answer 911 calls.” There are other societal changes afoot. People no longer assume that they need to call an EMS ambulance to take them to the emergency room. Uber and Lyft can do that. “Governing bodies and public safety agencies need to evaluate the services they’re paying for,” Zavadsky says. “This concept of ‘fire, ready, aim’ is not sustainable. We can’t afford it as a country.” 

As community paramedicine takes hold, McGinnis of the national EMS association foresees a world with far fewer flashing lights and abrasive sirens as ambulances careen through city streets. The alarms will be a rarity, he says, because EMS will have the ability to treat people where they are. “I believe if you see lights and sirens in the future, it’s only because we have something we truly can’t deal with.”

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