Indianapolis EMS Reaches Community with CORE Care Team

Indianapolis EMS Reaches Community with CORE Care Team

News Jun 18, 2013

Ed's Note: Interested in learning how your agency can start a community paramedic program? Attend the 1-day Mobile Integrated Healthcare Summit at EMS World Expo 2013 in Las Vegas, NV, September 8–12.

Indianapolis, June 18, 2013 – Marcia Hendrix suffers from asthma and often has trouble with the machine that helps her breathe. Every three weeks, she also receives infusions for her pancreatitis, and these treatments typically make her feel sick. Not knowing where to turn to solve these problems, Marcia used to call 9-1-1 for help—sometimes twice a day. She called 39 times last year.

Indianapolis Emergency Medical Services (EMS) recognized this problem and has created a solution. The Community Outreach and Resource Efficiency (CORE) Care Team was developed to provide services to people who previously depended upon the 911 system for routine support, as well as follow up with congestive heart failure (CHF) patients to ensure compliance with physician instructions, a part of the program that was launched last week.

The team utilizes this two-pronged approach to connect people with the care they need while keeping the health care system in Indianapolis working efficiently. The first prong is the community outreach effort targeted toward frequent 911 callers like Marcia. Indianapolis EMS maintains a list of the most frequent callers and utilizes its resident social worker, Tawanna Montgomery, to evaluate the patients’ needs and connect them with the appropriate resources.  

Data shows that since this aspect of the program first launched two years ago, the list of the top 10 callers averaged about 100 calls each per year. Now, the top 10 callers average around 30 calls per year.  

Dr. Dan O’Donnell, deputy medical director for Indianapolis EMS and lead physician in CORE’s efforts, says the team has now become proactive, not just reactive, reaching out to people who need care before they pick up the phone. 

"People need the right support to utilize the health care system and produce the best outcome for their health," Dr. O’Donnell said. "That’s what the CORE Care Team is designed to provide." 

Indianapolis EMS emergency medical technicians and paramedics, Indianapolis Fire Department personnel and other public safety and health care providers submit referrals to the team for people they see who need services. Some are immobile, needing ramps, lifts or other tools to live their daily lives; some are hoarders; some need medication refills; and some simply need a ride to their doctor’s appointment.

Also in line with this proactive approach is the second prong of the team’s efforts: community paramedicine. Beginning last week, Indianapolis EMS has begun working with the Butler University School of Pharmacy and Wishard-Eskenazi Health Transitional Care, Pharmacy Department and Cardiology Department to decrease the 30-day readmission rates of Wishard-Eskenazi Health congestive heart failure (CHF) patients. 

For CHF patients who are released from the hospital, the first 30 days after discharge pose the highest risk for complications. Lack of support, misunderstanding of instructions or non-compliance with instructions is often what brings patients back to the hospital. 

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The goal of this part of the team’s program is to pair a pharmacy student with a specially trained paramedic to provide care to these patients after discharge. These two-person teams contact patients within 72 hours of discharge to assess their needs. They then visit the patients at their homes for medication reconciliation, finishing with a follow-up phone call to make sure patients continue to understand and follow their instructions.  The CORE Care Team is already planning to expand the effort to pediatric asthma patients in the future.

"CORE is providing a crucial service to the city of Indianapolis," said Dr. Charles Miramonti, chief of Indianapolis EMS. "By fine-tuning and expanding this program, we can greatly enhance the care that our community receives."

About Indianapolis EMS

Indianapolis EMS was formed in 2010 as a partnership between the City of Indianapolis, Indiana University School of Medicine and Health and Hospital Corporation of Marion County, with Wishard-Eskenazi Health as the supervising health system. Indianapolis EMS operates as a division of the Department of Public Safety and was formed via unification of Wishard and Indianapolis Fire Department EMS services. The service benefits from medical leadership in quality, education, training and research from the IU School of Medicine.

To learn more about Indianapolis EMS, visit You can also follow Indianapolis EMS on Facebook (, Twitter ( and Instagram (



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