Among the ripest areas for greater integration of care is the prehospital environment. Emergency medical services providers treat large numbers of patients whose immediate complaints link to underlying complex medical and social problems. These high-cost high utilizers can stress systems and payers with repeat ED visits and suffer the suboptimal outcomes of fragmented care.
Many efforts are underway to reduce that, and there’s particular enthusiasm in many quarters for the idea of nurses on ambulances. That model is most linked with Mesa, AZ, and is now being trialed in Southern California as well.
Anaheim Fire & Rescue leads the SoCal project; partners include Care Ambulance, Kaiser Permanente of Orange County and the local emergency communications body, Metro Net. The goal is to reduce transports and ED use by low-acuity patients.
On what’s called the Community Care Response Unit (CCRU), a certified nurse practitioner will respond to low-level calls with a fire captain/paramedic. They’ll be able to treat and release patients or refer them to primary care. In Mesa nurses have brought capabilities like suturing, UTI tests, giving flu and tetanus shots, and writing prescriptions to the field. Gary Smith, MD, who provides Mesa’s EMS physician oversight, is also serving as the Anaheim project’s medical director.
The CCRU debuted May 31. To make sure things went well, it operated into September alongside the standard paramedic engine/truck and ambulance response, but after that was expected to begin responding solo. The project will run for a year.
A large chunk of the costs of the program were footed by Kaiser Permanente, which contributed $210,000 to get it launched.
“We think it serves the greater good,” says Todd Newton, MD, KP’s regional chief of emergency medicine in Southern California. “What we’re trying to do is have a positive impact on the system like they’ve seen in Mesa. ER visits are up everywhere, and we think caring for people in more appropriate settings, where they get the best service, with the least impact on the system as a whole, and more affordably, makes the most sense.”
The nurses are “remarkably good at history and physical,” Newton adds, “sometimes even superior to physicians.” This suits them to interviewing patients in the field.
Through the first three-plus months, crews treated and released or referred around 40%–45% of the low-acuity patients they saw. Complaints included things like infections, postoperative catheter problems, lacerations needing suturing and unexplained swellings.
That those cases didn’t clog up emergency departments was an immediate benefit. Last year around 85% of the department’s 30,000-plus calls were medical, about 35%–38% of them nonurgent.
“Our ERs right now are completely overimpacted with nonacute calls,” says Capt. Dave Barry, EMS director for the Anaheim FD. “They can have people sitting on gurneys for three or four hours, waiting for a bed. If that person can be treated at home and referred to their physician in the next day or two, that’s a great benefit to our system. It frees up ambulances and frees up our 9-1-1 system for someone in full arrest or having a heart attack.”
The nurses also bring field providers a link to physician expertise they didn’t always previously have. “They can actually call in to the doctor’s office, and I don’t think we’ve had a situation where they haven’t actually talked to the physician,” says Chief Randy Bruegman. “As paramedics, we can’t do that—there’s no way we’re going to get to a doctor. But they can talk directly to one. A lot of these are postsurgical patients, and that’s been a real benefit.”
There’s no doubt patients are happier staying home. “A lot of these folks are seniors,” Bruegman adds, “and the last thing they want to do is go to the emergency department at 7 o’clock at night and sit there for several hours and wait to be treated and released.” Thus the CCRU program improves the individual experience of care, one of the goals of the Triple Aim.
A second is reducing per-capita costs, which also seems likely. The CCRU program is expected to cost around $500,000, and Mesa has saved six times that, according to Smith.
Demonstrating savings will be a key to whether the program continues in Anaheim, along with patient safety and deployment improvements for the FD. Bruegman estimates the CCRU will cost around $500–$600 per call, while in Orange County ambulance bills typically run around $700–$1,000, and total bills can double or triple that with ED tests and treatment.
Says Newton: “Right now we’re keeping more than 40% of the patients being seen by this team out of the ER. I already consider that a success. Every one of those beds is freed up for a sicker patient. If you can keep 1,000 patients out of local ERs, that pays for itself many times over.”