How Using Existing Data is Changing the Way EMS Treats Vulnerable Populations
Raise your hand if you’ve encountered a patient you couldn’t help. (Every provider reading this should have their hand, at least figuratively, raised.)
Keep it up if you’ve encountered these patients more than once. (Again, there should be a lot of hands up.) “Frequent fliers” may have a wide variety of reasons they repeatedly call 9-1-1, but one is very likely because they either have not received, or don’t know how to find, the help they really need.
This is frustrating, for both patients and EMS providers. But technology is starting to make it easier for providers to identify these patients and direct them to appropriate care. Using advanced data to screen vulnerable populations and target patients with specific needs outside the realm of normal prehospital care, agencies are already making life easier on their medics and improving patient care in their communities.
San Diego EMS recognized it had a small population of individuals who were using emergency services at a proportionally higher rate than the general public. Be it chronic medical conditions, mental illness, substance abuse or homelessness, these patients were unable to receive the assistance they needed through the EMS system but they also had no idea where else to turn. What resulted was lower quality care at a higher cost that diverted resources from patients who actually could benefit from EMS care.
San Diego developed its Resource Access Program (RAP) to specifically combat this trend, says Anne Marie Jensen, EMT-P, Resource Access Program coordinator and a paramedic with Rural/Metro Ambulance.
“The Resource Access Program focuses on strategic initiatives for vulnerable populations that impact the public safety net,” Jensen explains. “We consider repeated 9-1-1 calls to be a sign that an individual is experiencing a difficult health or social circumstance. RAP monitors for disproportionate 9-1-1 use, as well as severe vulnerabilities in people who may not call as frequently, but need assistance. RAP then intervenes with the intent to connect them with resources, guide them into treatment or, in more extreme cases, work with the proper agencies to obtain mandated treatment.”
Jensen admits when RAP was developed there was a real lack of awareness about how bad the problem really was, due in large part to the dearth of data about these vulnerable populations.
“When we officially launched RAP, I felt clueless about what was going on in the streets at a systemic level,” she says. “Actually, I WAS clueless. I thought, ‘What IS actually going on how there? How bad is it? How many people are we talking about? How desperate are their situations? How can I use my time wisely?’”
Jensen began searching the agency database to identify frequent callers, making a list of these people and their vulnerabilities. It took a week to compile the data, and when she finished she says she instinctively knew the patient list had changed. “We needed a savvy solution, and were lucky enough to cross paths with Infotech Systems Management. ISM was a company known for agile development and aggressive, innovative programming. They were enthusiastic about the concept and challenge. We were very lucky to find them.”
What resulted was Street Sense, which San Diego refers to as “eRAP.”
According to Jensen, eRAP constantly monitors incoming 9-1-1 information from CAD and from San Diego’s wireless field ePCR transmissions. “Every time a call is posted by field responders (they document on mobile devices and wirelessly upload the information), eRAP looks to see if we have encountered that patient before, and regardless of whether we have or have not, it looks to see if it can identify a vulnerability through computer algorithms,” says Jensen.
“If there is a vulnerability, additional algorithms come into play. Following these additional algorithms, eRAP compiles lists of people into vulnerability groups and ranks them. Additionally, eRAP looks at high traffic areas—the U.S.-Mexican border, nursing homes, correctional facilities, the airport, Sea World, etc.—to identify potential hot spots. Usually, this applies to nursing homes, where we track repetitive falls for facilities. We can also drill down by location and identify individuals per location. We also alert and identify those known to be a danger to others.”
Jensen says eRap essentially looks at:
- Vulnerable people/system abusers. “System abusers are very, very rare,” she notes. “There’s almost always something else going on.”
- Facilities or locations with disproportionate vulnerabilities or 9-1-1 use.
- The impact that these vulnerabilities have on the city as a whole, non-specific to people or facilities.
- People who are a threat to provider safety (past violent encounters, death threats to hospital staff or field responders, etc.)
Field providers can also hit a button on their chart and make a referral to the program, if they think there is a situation that needs to be dealt with.
eRAP does all of this in near real-time (NRT), says Jensen, with a delay of only 3–5 minutes.
Easing the Burden on Providers
“We developed our technology with the intent to preserve the working environment of the field responder,” says Jensen. “Meaning, they already have a complicated job to do, and we want to make it easier, not more difficult.”
Everything in RAP occurs “in parallel” to the 9-1-1 system, she explains. The field crews don’t usually have to step outside of normal practice unless they’re instructed to do so during a call. This particular goal of operating with the least amount of disruption to the work environment of first responders has a technological implication—“We have to be concerned with the velocity of our information. If it comes too late, it is no longer actionable.”
Occasionally, RAP will coordinate a pre-plan with the crews, usually in situations where the individual is believed to be in danger or a repetitive danger to others.
“We had a homeless, chronic alcoholic, dementia patient who was activating 9-1-1 10+ times per month,” notes Jensen. “While this is not as excessive as other frequent users, he had two unconscious, hypothermic events (even in San Diego) in one week. The hypothermia was severe enough that he was admitted for a few days each time. We felt he was a danger to himself, so we coordinated an intervention with our San Diego Police Department Serial Inebriate Program (SIP). It required the cooperation of the on-scene medics, firefighters and police officers who had watched him escalate over a few months. He is currently in custody for his own safety and we are working with his Medi-Cal case managers to place him in a nursing home.”
Putting Data to Use
As Jensen notes, San Diego was sitting on information about these vulnerable patients but still didn’t have a grasp on the full scale of the problem.
“As long as we’ve had electronic records, we’ve had this data,” Jensen says. “They are detailed records of our history, our choices, our judgments and our interactions and transactions with other agencies. Most EMS agencies have these data, so this is nothing new. Most of us use it to report to overseeing administrations, or to reference upon requests by patients or investigators. Other than that, our data tends to go untouched, to be nearly worthless—the common phrase is ‘Data rich, Knowledge poor.’
“Additionally, the amount of data we store is overwhelming,” she continues. “There’s no way to make use of it without strategic data tactics. Hidden in these data are unconventional insights. Through data analysis, those insights are accessible. If we can access it fast enough to intervene, the insights are actionable.”
Jensen says the answer to how data analysis techniques can improve operations is in making not just data-driven decisions, but information/knowledge-driven decisions for those who need an advocate. “And we can do it in an effective, orderly way, even though our capacity to serve is far overwhelmed by the social problems that we are tasked to address. It helps us triage, prioritize and preserve our resources—and preserve our sanity.”
Using this data in real-time with eRAP has improved San Diego’s situational awareness immensely, Jensen says. “This program shows us what’s going on out in the streets, the spectrum of vulnerabilities in our frequent user groups and the magnitude of these vulnerabilities. It shows us who is impacting the system the most, and lets us work from the top down so that we can have the greatest impact with our limited resources.”
One thing Jensen says she’s become convinced of is first responders—be it EMS, fire or law enforcement—cannot ignore social issues. “Social issues severely impact our public safety and acute care resources. Whether we like it or not we are, arguably, in one of the best positions to recognize social vulnerabilities that plague a community and effectively intervene. We usually encounter the extreme, too. The most vulnerable members of our society often do not have the ability to comply with rule-heavy treatment programs. By the time they start hitting the 9-1-1 services, it’s usually because they have failed out of every available program. Very few will treat them or allow them back in. Since no one can ‘fail out’ of 9-1-1, we are left with a population with few resources. It’s a tough job, to care for these people, and few are doing it—or want to do it. There is relatively unopposed room for EMS here, and the skills learned in this setting definitely apply to other opportunities we see.”
Jensen is quick to point out that EMS is still early in the process of making data/knowledge-driven decisions are patient care. There’s no one-size-fits-all solution yet, and probably never will be. But a program like RAP is the ground floor to something better.
“As a profession, we need to continue to hone the skill of discovery and strategic problem solving,” she says. “I believe this technology is the initiator to that because it opens the door to analysis of complex, high-level problems that we couldn’t articulate or quantify before. Our patient care will inevitably improve as we earn these skills.”