Ambulance du Bas Saint-François responds to medical calls in the small, rural community of Pierreville, Quebec. The company operates one ambulance to accommodate its 2,167 residents, and if it’s busy on a call when a second call comes in, the second response is redirected to the next-closest agency.
It doesn’t take a major disaster to monopolize this agency’s services, yet one patient—without any priority symptoms—was able to do so 52 times last year. “The patient complained about trouble breathing, so we transported,” says supervisor Chantal Laforce. “Yet the hospital assessment never resulted in identifying a problem.”
Ambulance du Bas Saint-François provided counseling. She kept calling, sometimes twice a day. The calls finally stopped when Quebec’s social assistance program refused to reimburse the ambulance expense, which by year’s end had amounted to nearly $60,000. In a second similar situation, an asymptomatic superuser was taken to court, which ruled she must stop calling the number connected to medical services. She did—and instead started calling police.
“You never want to go [to that extreme],” Laforce says. “You try to do everything else possible before taking the person to court.”
While the parameters to define superusers differ, it’s generally held that 3–11 emergency department visits in 12 months constitutes a frequent user, and 12 or more makes a superuser. However you define it, the problem is universal in EMS.
Roughly 1% of the U.S. population accounts for 22% of total annual healthcare expenditures, and the same rough proportion applies outside the States. Canadian studies conducted in Ontario, Manitoba, and Alberta consistently identified frequent users as a small proportion of all ED users: 3.1%–3.6% of the overall ED patient population for a given year.1
This disproportionate volume of calls jeopardizes patients in life-threatening situations and consumes a huge chunk of a company’s or department’s budget. Public health and private insurers do not reimburse transport to alternative destinations or treat-and-release. No reimbursement is allowed for readiness, response, triage, patient assessment, or any other treatment provided unless that patient is transported to a hospital for medical necessity. Then there’s the potential wait time involved: Nonacute conditions come behind traumatic illness and injury and consequently can take an ambulance out of circulation for an undetermined amount of time.
It’s not about acute illness or injury, says Marie Leroux, chair of the International Academies of Emergency Dispatch’s College of Fellows. “A lot comes from human misery,” she says. “People are in distress. They’re lonely. They want someone to talk to.”
These patients typically experience chronic medical illness and sometimes mental illness or substance use disorders, as well as social barriers that drive them to seek care in acute-care settings. A typical patient might have multiple ED visits related to mental illness or substance use or multiple admissions for poorly controlled chronic conditions such as diabetes or migraine headaches.
These individuals desperately need attention, even if it means knowingly manipulating the system, such as giving a chief complaint that forces an ambulance response. “They get to know the triggers,” Leroux says. “Emergency communications is open 24 hours, and they know someone will come.”
Frequent calling is a symptom of the patient’s larger problem, says Lt. Brian Goldfeder of the Prince George’s County (Md.) Fire and EMS Department. “They don’t know where else to turn,” he says. “These patients are not receiving coordinated care. They’re not connected to resources.”
The New York-based Northwell Health network found a solution for patients with multiple chronic conditions when their symptoms prompt calls for help: It keeps them at home as much as possible.
“Most of these patients prefer it that way,” says Karen Abrashkin, MD, director of Northwell’s emergency call center. “That’s where they’re comfortable, and it’s better for them and their family if their condition allows treatment [outside a medical facility].”
The Advanced Illness Management (AIM) program is closely associated with the Northwell communication center, making access as easy as a phone call away.
Northwell’s EMS communication center is a secondary PSAP and the nucleus of telephone triage and care management for the state’s largest medical complex. Patients with advanced and complex medical conditions (e.g., COPD, diabetes) call the center for assistance, and if their symptoms are low-acuity, they are routed to a nursing clinical call center. Patients are triaged using algorithms built into the Emergency Communications Nurse System (ECNS), a protocol-based system developed by the IAED and tied to the Medical Priority Dispatch System (MPDS) and medical software ProQA.
A certified emergency communication nurse (ECN) at the clinical call center gathers information from the patient and, after verifying there are no priority symptoms (e.g., trouble breathing), conducts additional assessment and selects a symptom-based protocol—there are more than 200 in ECNS—and recommends a level of care, from immediate dispatch of an ambulance to giving self-care instructions. If the care level requires response, the ECN can access the patient’s electronic medical records to provide background such as medications, recent medical history, and any advance directives.
In addition, the patient’s provider can be connected via the communication center for three-way conversation (ECN, provider, and patient). Community paramedics (CPs) trained as physician extenders can be sent to the patient’s home for symptoms requiring advanced care but not hospitalization.
There are an average 1,200 of patients with advanced medical conditions able to stay at home because of Northwell’s integrated approach to healthcare, says Debra Tomassetti, program director for the Northwell clinical call center. The average call takes about 16 minutes prior to referral, and 1–4 ECNs are on duty at a time, depending on the shift.
Patients also have a larger say in their care. The nurse asks the patient, “Do you want to remain at home?” and offers scenarios describing the various care options. “The patient trumps everything,” Tomassetti says.
Jeffrey Pick, the center’s QA director, says it’s a matter of expectations. “Once you explain, the patient feels more comfortable,” he notes. “It’s not a perfect program, but it truly offers a multidisciplinary team approach for the homebound patient.”
A study of 1,602 individuals enrolled in the AIM program found the integrated care model enhances treatment for homebound patients and saves them the risk of complicating their conditions if hospitalized. Of 1,755 events during the study, 37.8% were CP responses, with an average response time of 21 minutes and an average of 70 minutes spent on scene.2
Although lack of reimbursement for nontransport Medicare patients is an obstacle to programs like AIM, preventing even a few admissions can offset of the cost of administering them, Abrashkin concluded in the study.
Tomassetti says the call center is the hub. “We have the information to look at the full picture,” she says. “It’s a holistic approach that honors an individual’s goals of care.”
Prince George’s County Fire/EMS
She can navigate her wheelchair just about anyplace but depends on the county’s paratransit service for curb-to-curb rides from home and back. She is known for fierce independence and has adjusted her requests to meet the demands of limited mobility. That’s where the problem lies.
She lives on the second floor of a split-level complex. There is no ramp or elevator she can take from one floor to the other. So what does she do? She schedules a county public transportation service that offers reduced rates and curb-to-curb pickup for seniors and people with disabilities. She then calls 9-1-1, leaving a 20-minute window. During 2016 she called 148 times for the exact same reason.
“She has to get down the stairs, and she knows the chief complaints that will send fire department response,” Goldfeder says.
Ambulance response costs the county upward of $800 even when it results in no transport. The fire department could refuse her transport, but then the county runs a medical liability risk. She can cry wolf 147 times, but what happens when call No. 148 is a life-threatening emergency and an ambulance doesn’t show up?
That’s not even a question. “They say ‘Take me to the hospital,’ and that’s the end of the story,” Goldfeder says.
This is not the lone superuser in Prince George’s County. Using a system developed by real-time surveillance organization FirstWatch, Goldfeder and firefighter-paramedic Kenneth Hickey, worked with Prince George’s County public communications to track the number of superusers (five or more calls in 2016) and their transports. Using ProQA software, they identified 250 people in the county who had called 9-1-1 10 times or more in fiscal year 2016, with some calling almost 100 times. Another 1,400 had called five or more times.
“We had to connect them to outside sources,” Goldfeder says. “We had to define the barriers and figure out what to do about them.”
Goldfeder and Hickey spent the next several months developing an integrated approach similar to a program piloted in neighboring Queen Anne’s County to reduce 9-1-1 calls without sacrificing patient care. They partnered with area healthcare agencies, insurance groups, and the county’s health department to help providing more appropriate services. They created mobile integrated healthcare teams that make house calls to identified superusers. These were on the road by November 2016.
“We don’t put anyone on the spot,” Goldfeder says. “We call to offer assistance. We invite their doctors into the program, write down the medications they’re taking, and direct them to agencies that provide services like grooming and housekeeping. A little boost helps start the improvement process.”
Although still in its infancy, the program resulted in a 48% reduction in superuser 9-1-1 calls during its first six months. There are 61 people registered, and in three months a local hospital reported $115,000 in savings due to decreasing numbers of ED visits. The 2017 fiscal budget for the fire department increases staff from the initial two full-time paramedics to eight.
Goldfeder says the program provides insight into the plight of superusers. He better understands the patients and helps the patients better understand the medical system. He thinks outside the box to develop solutions, like building a ramp for the woman on the second floor.
“It should literally get her to zero new calls,” he says.
San Diego Rural/Metro
San Diego’s Resource Access Program (RAP), led by Rural/Metro San Diego paramedic Anne Jensen, addresses frequent 9-1-1 callers based on how many times they called EMS in one year. For example, the “mega-users” are a very small group but have used EMS more than 50 times in a 12-month period.
As the RAP coordinator, Jensen helped develop a software platform called Street Sense, which uses algorithms to sift through EMS patient care reports and identify frequent callers. The program uses tools that look for different spellings of names, combinations of birth dates, and other identifying information, along with other methods of linking incident-based reports to create patient-centric data.
The algorithms provide the ability to search all PCRs for a particular patient to determine whether their frequent use of 9-1-1 is due to psychiatric issues, substance abuse issues, specific chronic conditions, or something else. The software tracks frequent users’ 9-1-1 calls in real time, identifies where these patients can likely be found, and offers their known medical and social service histories.
Jensen finds visiting the frequent users much more effective than phone calls. “When you’re dealing with social vulnerability,” she says, “the only thing that’s going to make a difference is changing their social environment.”
Even before Street Sense the RAP program showed some success, as evidenced by a significant drop in transports among the most frequent EMS users. After Street Sense was added to the program, coordinators estimated that the 20 most frequent EMS users in 2011 made 1,200 fewer calls the following year.
1. Soril L, Leggett L, Clement F. Frequent Emergency Department Users: Who Are They and How Are They Cared For? Health Technology Assessment Unit, University of Calgary, http://obrieniph.ucalgary.ca/files/iph/frequent-users-full-report_may-17-2013.pdf.
Abrashkin KA, Washko K, Zhang J, Poku A, Kim H, Smith KL. Providing acute care at home: community paramedics enhance an advanced illness management program—preliminary data. J Am Geriatr Soc, 2016 Dec; 64(12): 2,572–76.
Audrey Fraizer is the managing editor of the Journal of Emergency Dispatch, published by the International Academies of Emergency Dispatch.