As found in numerous articles recently on EMSNetwork.org , due to budget shortfalls, some cities and counties across America are closing fire stations, others are limiting first responses to only truly life-threatening calls, or considering changing from Advanced Life Support to Basic Life Support service.

Ambulance services are experiencing increasing call volume and decreasing revenues due to higher numbers of uninsured patients and insurance companies who are limiting ambulance benefit payments to reduce costs to the premium payers.   Our entire healthcare system is under significant strain for the same reasons.   This situation is bound to get worse with the aging of our baby boomers, and more acutely with the rising cases of H1N1 and seasonal flu.

If adversity is the mother of invention, our current state should be a virtual Petri dish of ideas, or at least the perfect medium to finally cultivate ideas that have been germinating under the surface without blooming for far too long.

Faced with rising costs, limited resources and rising demand, it's time for every emergency medical services system to evaluate how it is providing services to people who use EMS as a safety net into the healthcare system.   It's time to provide the right resource, to the right patient, at the right time and in the right setting.    Responding red lights and siren with BOTH a fire truck and an ambulance to a diabetic patient who is so non-compliant with their treatment regimen that they go into DKA at 3am, thus requiring an emergency department visit and admission to the hospital for three days meets none of those criteria.  

Similarly, sending an ambulance to the home of a patient who calls 9-1-1 three times in one day for transport to three different hospitals seeking primarily social interaction is equally counterproductive.   So, what to do with these people?  

EMS systems should consider starting a Community Health Program (CHP) specifically designed to address at risk patients and those who are frequent users of emergency medical services.  

The goal of a CHP should be to try and keep people healthier, manage their care in a more appropriate setting, and to decompress the demand on the EMS system, including emergency departments, by keeping patients out of the EMS system who do not need to be there.  

Here's an example of a CHP MedStar EMS has started in Fort Worth and 14 surrounding communities.

The MedStar Plan:

The start of the program involved MedStar reviewing call volume records to identify patients who requested EMS on a frequent basis.   The records for these calls were then evaluated to determine if the reasons for the calls appeared to be conditions that could be better managed proactively rather than reactively.   MedStar then found and focused on 11 patients who accounted for 461 ambulance transports and admissions to local emergency departments in the most recent 12 months.   Most of these transports were for preventable conditions such as asthma, diabetes, seizures, falls and more often than not, social interaction.  

Each potential CHP client (we call them clients to avoid the confusion of the role we are providing for the enrollee) was then contacted by our community health paramedic and asked if they could come visit them and discuss a new program designed to help keep people from needing emergency care.   All 11 clients agreed to the visit and consented to being enrolled in the program.   Each client had an individualized care plan created which was reviewed by the EMS medical director.   The medical director also reviewed many of the care plans with the patient's primary care provider, if the patient had one.

Clients of the CHP are visited on a regular basis, typically three to four times a week.   During the visit, the client's vital signs are assessed, medication compliance monitored, and an assessment specific to the client's care plan is provided.   If the paramedic notices changes over time that may lead to an acute condition, the paramedic can arrange for the client to see their primary care or other appropriate medical provider.   In many cases, the paramedic arranges for non-medical, transportation, or may even transport the patient themselves to the clinic or doctor's office if necessary.

A key component of the CHP is providing the client with a reliable and personable alternative resource for seeking medical care.   The clients are given the non-emergency phone number to MedStar's Communications Center they can use to reach the on-call CHP paramedic.   It is not unusual for CHP clients to call seeking answers to minor medical issues, or more often than not, simply wanting reassurance and social interaction.   When the CHP client calls MedStar's communications center, the on-call CHP is paged and calls in to be connected with the client.   The call is recorded and documented with an "incident" number, just like any ambulance call.   The same emergency medical dispatch certified call-takers answer the non-emergency numbers as the 9-1-1 lines, so all calls - regardless of source - can receive EMD for an ambulance if indicated.

One of the benefits of the program is that the CHP paramedic develops a rapport with the patient which not only can be psychologically reassuring for the clients, but also provides the CHP paramedic the base understanding of the client's needs and medical history to know if there is truly something different in the client's condition warranting a home visit, appointment with a primary care providers, or even an ambulance transport to the hospital.

Records for the client visits and phone conversations are kept electronically and can be accessed by any of the CHP paramedics to see what has been done recently for any of the CHP clients.   The clients agree to this sharing of information as part of their enrollment in the program.   This allows for consistency of care and can even be used by the client's primary care provider to see trends in the client's medical conditions.

CHP Results:

Since implementation of MedStar's CHP in July 2009, the 11 enrolled patients have only used 9-1-1 for an ambulance response 33 times.   This represents a 53% reduction in ambulance and emergency department use.   At an average EMS and emergency department cost of $3,500, that is a savings to our healthcare system of $750,000 annually.   It has also made 53% more ambulance and emergency department resources available for other patients needing these services.

But more importantly, the clients enrolled have enjoyed an overall health status improvement.

The Future:

More patients are referred to the CHP program regularly.   Referrals come from field crews and even from the billing office which can identify trends in patient requests for service.   Eventually, MedStar plans to offer the service on a referral basis to other members of the healthcare community.   A local cardiology group has already asked if MedStar would be willing to provide daily follow-up assessments for patients recently discharged after STEMI treatments.  The goal would be to identify trends in the patient's assessments for the first 30 days post discharge that may be indicators of impending re-admission to the hospital and intercede by seeing the patient in the cardiology office in advance.

Read the first few pages of virtually any newspaper, or watch any news broadcast for more than 30 minutes and you are bound to hear something about the current state of America's healthcare system.   Perhaps by taking a good hard look at programs like MedStar's Community Health Program that provide the right care, to the right patient, at the right time and in the right setting, we can help keep patients healthy AND make more effective use of our scarce healthcare resources.