Case study: How an EMS agency tackled frequent flyers

By The Agency for Healthcare Research and Quality (AHRQ)

What They Did | Did It Work? | How They Did It | Adoption Considerations

Summary
The Area Metropolitan Ambulance Authority (more commonly known as MedStar), an emergency medical service provider serving the Fort Worth, Texas area, uses advance practice paramedics to provide in-home and telephone-based support to patients who frequently call 911.

Working as part of MedStar's Community Health Program, these paramedics conduct an in-depth medical assessment, develop a customized care plan based on that assessment, and periodically visit and/or telephone the patient and family to support them in following the plan. Support generally continues until they can manage on their own.

A separate, similar program serves individuals with congestive heart failure, and the same concept is being tested with hospice patients and may later be expanded to serve those with other chronic conditions. The program significantly reduced 911 calls, leading to declines in emergency medical service and emergency department charges and costs, and to freed-up capacity in area emergency departments.

Evidence Rating

Moderate: The evidence consists of pre- and post-implementation comparisons of 911 calls from program participants, along with estimates of the cost savings generated and ED capacity freed up as a result of the reduction in calls.

Developing Organizations

Area Metropolitan Ambulance Authority
Fort Worth, TX

Date First Implemented

2009

Patient Population
The program serves those who frequently call 911 in situations not considered to be an emergency.Vulnerable Populations > Medically uninsured; Insurance Status > Uninsured

What They Did

Problem Addressed
Inappropriate calls to emergency medical service (EMS) providers and unnecessary use of the emergency department (ED) occur frequently, with a handful of "super users" accounting for a disproportionate share of the problem. These individuals generally lack health insurance and a medical home and face multiple barriers to accessing care, causing them to repeatedly turn to EMS providers and local EDs with problems that could have been prevented and/or do not require immediate care by EMS or ED staff. The net result is higher costs and the diversion of valuable resources away from true emergencies.

• High utilization, dominated by a few (often uninsured) users: A few "super users" often account for a disproportionate share of 911 calls and ED visits. In 2009, MedStar found that 21 patients had been transported to local EDs a total of 800 times over a 12-month period, generating over $950,000 in ambulance charges and even larger ED expenses. Most of these individuals did not have health insurance and relied on EMS and local EDs for health services. Other cities have found similar problems. For example, the Tucson Fire Department identified 50 individuals who accounted for more than 300 nonemergency 911 calls over a 12-month period.¹
• Often for nonurgent needs or those ED not equipped to handle: Various studies have found that between 11 and 52 percent of 911 calls come from individuals who do not face serious health problems.² Many ED visits by super users are for conditions that should be treated in a primary care setting, including acute upper respiratory infections, viral infections, otitis media, and acute pharyngitis. Super users also routinely call 911 and visit the ED with exacerbations of chronic conditions that could be avoided with adequate ongoing care and for psychosocial problems that cannot be effectively treated in the ED, such as alcohol or drug dependency and depression.
• Leading to high costs, diverted resources, little lasting value for callers: Handling nonemergency calls raises the costs of providing EMS and ED services and diverts scarce resources away from true emergencies, leading to longer response times. In addition, although those who respond to these cases can resolve the immediate problem(s) at hand, they lack the resources and knowledge to educate the individual about appropriate self-management and the many community-based resources (e.g., home health care, behavioral health services, public health clinics, substance abuse services) that could better address their needs in the future.

Description of the Innovative Activity
An EMS provider uses advance practice paramedics (APPs) to provide in-home and telephone-based support to patients who frequently call 911. The paramedics conduct an in-depth medical assessment, develop a customized care plan based on that assessment, and periodically visit and/or telephone the patient and family to support them in following the plan. Support generally continues until they can manage on their own. A separate, similar program serves individuals with congestive heart failure (CHF). Key program elements are described below:

• Identifying eligible individuals: MedStar identifies eligible individuals in various ways, including internal analysis (a monthly report lists those with 10 or more 911 calls in the past month) and referrals from ED case workers at local hospitals, other first-responder agencies, and MedStar employees working in the field. Currently, the program serves those who have called 911 at least 15 times in the past 90 days. (Those close to this threshold may be tagged as someone to monitor for enrollment at a later date.) For the CHF program, staff at local cardiac intensive care units (ICUs) identify and refer patients who are at risk for bounce-back to the ED within 30 days and/or could benefit from ongoing support; these patients need not meet the 15-call threshold.
• Brief enrollment visit: Anyone deemed eligible for the program receives a phone call and/or visit from an APP, either at home or in the hospital. The APP explains the benefits of the program to the patient and his or her family members and other caregivers. Those interested sign a release form authorizing the sharing of relevant information with appropriate parties.
• In-depth medical assessment: An APP conducts a 1.5- to 2-hour in-home visit with the patient, family members, and caregivers. The visit includes a full medical assessment, including checking vital signs, blood glucose levels, oxygen saturation levels, and other key indicators. During the visit, the APP reviews the following:
  o Current medication use, making note of any potential problems (e.g., taking two medicines for the same condition, potential drug-drug interactions) to be discussed with the prescribing physician(s).
  o Any chronic conditions the patient may have, focusing on appropriate self-management of those conditions and related comorbidities.
  o Existing support and resources available to the patient and family, including financial resources, insurance coverage, and access to non-emergency medical care (including primary care and home health), mental health services, transportation, and other relevant social services.
• Individualized care plan based on assessment: The APP who conducted the review works with the patient and family to develop an individualized care plan that outlines their needs and responsibilities related to managing health and health care on an ongoing basis.

As part of this process, the APP may talk with other providers who serve the patient (as identified in the assessment), including primary care clinicians and mental health providers. The resulting plan includes concrete steps to be taken by the APP to help in accessing needed resources, such as securing insurance coverage or other financial resources and linking the patient and family to county hospital-affiliated clinics and other local agencies and resources that serve low-income and uninsured individuals (e.g., transportation, home health, hospice, Meals-on-Wheels).

The plan also includes mutually-agreed on goals for the patient and family to manage their health, such as checking their own blood pressure and/or blood glucose levels, eating an appropriate diet, exercising more regularly, taking medications appropriately, and scheduling and attending needed appointments. Patients and family members receive a copy of the care plan, and the plan is also entered into the patient's electronic medical record (EMR) where it can be accessed by APPs and other authorized providers as appropriate.

• Ongoing support via home visits and phone calls: Based on the needs identified in the care plan, an APP conducts periodic 30- to 60-minute home visits with patients, with the frequency of visits determined by need. (The same APP may not conduct each visit, but all have access to the patient's information, and most know all patients enrolled.)

Visits initially occur two or three times a week, with the frequency tapering off to one or two visits a week over time. As warranted, the APP may conduct telephone calls instead of in-person visits if the patient is making adequate progress. Visits provide an opportunity to ensure the patient and family are following the plan. As appropriate, the APP will intervene, providing referrals and support in accessing needed services.

For many patients, visits also provide an opportunity for much-needed social interaction. All APP contacts with patients get entered into the patient's EMR, including current vital signs, medications, and other relevant information. Patients are also given a 10-digit phone number to call to request an APP home or phone visit as an alternative to calling 911.

• Special protocols for CHF patients: Going forward, APPs who work with CHF patients will be able to take point-of-care blood values (e.g., potassium levels) at the patient's home and use standing-order protocols to adjust doses of diuretic medications based on a patient's weight gain and other indicators. The APP will immediately notify the patient's primary care doctor and/or cardiologist whenever an adjustment occurs.
• Multiple paths for leaving program: At some point, patients receiving services (designated "active" patients) formally leave the program. This process can occur in several ways, as outlined below:
  o "Graduating" from program: Most patients successfully "graduate," which occurs when the APP believes they can effectively manage their own health and health care without proactive support. Graduation typically occurs in about 30 to 60 days, with the shortest time being 2 weeks and the longest time being 6 to 8 months. Graduates can call a special 24-hour nonemergency number that will trigger an APP or ambulance visit within an hour to check on their well-being and intervene as necessary. Before graduating, some individuals may be placed on "watch" status, which means they are almost ready to graduate, but their 911 use remains elevated or has recently ticked up, suggesting they still need some support.

     o Designation as system abuser: Those who do not change their habits and continue to call 911 repeatedly may be terminated from the program. These individuals are either designated as "pending system abusers," meaning they do not have any medical issues that require ongoing care, or as "system abusers," meaning they have ongoing medical issues. If a pending abuser calls 911, the APP goes to the house (in addition to the regular response team) to conduct a full medical evaluation and then works with the medical director to determine the right course of action. System abusers get assigned to a designated home hospital, and whenever they call 911 the ambulance takes them to that facility so they can be monitored by providers familiar with their condition.

• Regular case discussions with hospital caseworkers: Once or twice a month, MedStar's Community Health Program coordinator meets with hospital, ED, and cardiac ICU case workers to discuss patients enrolled in the program. The caseworkers provide information on recent ED visits or hospitalizations, including diagnoses, treatments and tests performed, medications prescribed, and discharge and follow up instructions.

This information, which gets entered into the EMR, helps APPs determine the appropriate level of ongoing support and identify those who may be abusing the system by seeking care (e.g., medications) at multiple facilities. The Community Health Program Coordinator also shares relevant information with hospital-based caseworkers about recent contacts that APPs have had with patients.

• Ongoing monitoring via electronic database: The coordinator regularly reviews an electronic database to check on the progress of individual patients and update classifications as appropriate. This information is regularly shared with the associate medical director.

References/Related Articles
Mitchell M. In Fort Worth, MedStar's Community Health Program cutting costs, improving patients' well-being. July 9, 2011. Fort Worth Star-Telegram. Available at: http://www.star-telegram.com/2011/07/09/3209806/in-fort-worth-medstars-community.html#tvg

Johnson K. Responding Before a Call Is Needed. The New York Times. September 19, 2011. Available at: http://www.nytimes.com/2011/09/19/us/community-paramedics-seek-to-prevent-emergencies-too.html?_r=2
Contact the Innovator
Matt Zavadsky
Associate Director of Operations
Area Metropolitan Ambulance Authority
551 E. Berry St.
Fort Worth, TX 76110
(817) 632-0522
E-mail: MZavadsky@medstar911.org

Did It Work?

The program significantly reduced 911 calls, leading to declines in EMS and ED charges and costs, and to freed-up capacity in area EDs.

• Significant decline in 911 calls: Between the formal launch in July 2009 and August 2011, the volume of 911 calls from the program's 186 enrollees fell by 58 percent, from an average of 342.3 monthly calls during the 6-month period before enrollment to 143.3 monthly calls afterward.
• Corresponding declines in EMS and ED charges and costs: The decline in calls has led to a corresponding drop in MedStar's charges and costs, with annualized EMS transport costs for these patients falling by over $900,000 (from $1,577,472 to $660,128) and charges falling by over $2.8 million ($4,929,600 to $2,062,899).

Based on information provided by area EDs, MedStar estimates similarly large declines in ED charges and costs for patients transported by MedStar to area EDs, with charges falling by nearly $9 million and costs by over $1 million. (The large difference between charges and costs stems from the many uninsured patients being served and the low rate of reimbursement by public payers, particularly Medicaid. Consequently, full charges are set at a level that allows adequate collections to cover costs.)

• Freed-up ED capacity: MedStar estimates that the decline in patients being transported by ambulance has freed-up more than 14,000 bed hours at area EDs, allowing these capacity-constrained facilities to better serve those facing real emergencies.

How They Did It

Context of the Innovation
The Area Metropolitan Ambulance Authority, also known as MedStar, operates as the sole provider of emergency and non-emergency ambulance service for 15 cities in Tarrant County, Texas, including Fort Worth. More than 880,000 residents live in this area, making roughly 10,000 911 calls a year that are handled by a fleet of 54 MedStar ambulances.

The impetus for this program came from MedStar's current medical director (associate director at the time), who in preparing for another busy summer season in 2009, began thinking about how the organization could better serve 911 callers who repeatedly use the system for nonurgent situations. He knew many of these individuals personally and felt the current approach did not serve them or the community well.

Planning and Development Process

Key steps included the following:

• Quick analysis to document problem: To test his theory, the then-associate medical director ran a quick analysis and found that 21 patients accounted for more than 800 calls in 2008, with the vast majority being for primary care and other nonurgent needs.
• Pilot test with subset of patients: MedStar reviewed information on the 21 identified individuals and enrolled 9 of them in a 60-day pilot test of the program. These individuals had a long history with and were very familiar to MedStar staff. During the trial, two paramedics on "light duty" (due to recovery from an injury) who had experience in primary care served as the APPs. The test proved quite successful, leading to a 77-percent reduction in monthly 911 calls.
• Funding plan to support rollout: Because home visits and other services provided as part of the program are not eligible for reimbursement by third-party payers, MedStar lacked a funding source to cover the costs of shifting paramedic time from their traditional duties to program activities. To address this issue, MedStar leaders decided to "marry" the Community Health Program to a new critical care transport program, a service not previously offered by MedStar that involves transporting critically ill patients from facilities that cannot adequately care for them (usually in outlying areas) to those that can (often tertiary facilities in urban areas).
•  Paramedic training: The medical director and associate medical director developed a 16-day program, delivered 1 full day a week, to train existing paramedics on how to provide Community Health Program services (which was covered in three sessions) and how to conduct critical care transports (the focus of the remaining 13 sessions).

The community health portion emphasized how to assess patients for long-term, chronic conditions, in contrast to the paramedic's traditional approach of identifying and addressing life-threatening issues. Specialists from the local mental health authority provided in-depth education on common mental health issues facing this population, including schizophrenia and bipolar disorder. Training also focused on how to intervene with patients, and how to access community-based medical and social services that can help them.

• Forming partnerships with community-based organizations: MedStar leaders forged partnerships with community-based organizations serving the same population, including hospitals, EDs, the county health department, the local Medicaid office, mental health organizations, home health and hospice agencies, and Meals-on-Wheels. They first met with organizational leaders to explain the program and gain their buy-in, and then discussed how the APPs could coordinate with them on an ongoing basis, including how each party should make referrals to the other.
• Expansion to CHF and other chronic patients: In September 2010, the program expanded to serve CHF patients. The CHF program continues to evolve, as MedStar leaders have been working with local cardiologists to develop the aforementioned standing-order protocols that will allow APPs to adjust medication doses. Once the CHF model has been "perfected," MedStar leaders hope to use the same basic approach to support those with other conditions that frequently lead to EMS and ED use, such as chronic obstructive pulmonary disease, asthma, pneumonia, and diabetes.
• Pilot test with hospice patients: In partnership with local hospice agencies, MedStar is conducting a small pilot test where APPs support patients and families receiving in-home hospice care who call 911. Traditional first responders lack the time and training to play this role, which requires patience and compassion as family members deal with stress- and panic-inducing episodes in loved ones who are terminally ill. Often, these events lead to a decision to abandon hospice care, triggering a painful end-of-life scenario that includes multiple hospitalizations and ED visits.

Resources Used and Skills Needed

• Staffing: To date, the program has not required additional staff. Existing paramedics serve as APPs, and MedStar managers (e.g., medical directors, operations managers) participate in program-related duties as part of their regular job responsibilities. One APP is on duty at all times (7 days a week, 24 hours a day), with individuals serving 12-hour shifts. APPs, however, do not spend all of their shift time on the Community Health Program, as some time goes to critical care transports and other duties. For budgeting purposes, 4.5 full-time equivalent staff have been allocated to the Community Health Program, but MedStar has been able to reduce its budget for non-APP paramedics by a similar amount due to the reduction in call volume generated by the program.
• Costs: The program required an upfront outlay of roughly $46,000 to buy and equip a response vehicle for the APPs. This vehicle houses specialized equipment and computer technology, including monitors. Other upfront costs include the time spent by paramedics in training, while ongoing costs include uniforms and supplies for the APPs.

Funding Sources
Area Metropolitan Ambulance Authority
The program is funded internally by MedStar.

Tools and Other Resources
More information on the program can be found at www.medstar911.org/community-health-program.

Adoption Considerations

Getting Started with This Innovation

• Consider financial implications: This program can present financial challenges, because it provides services (e.g., in-home visits) that are often not covered by payers and, if successful, eliminates some EMS transports that potentially would have been reimbursed. MedStar has thus far found revenue losses to be fairly minimal, because most people served by the program lack insurance or are covered by a payer that either does not reimburse or pays very little for ambulance transports in non-emergency situations. As noted, MedStar leaders decided to couple the program with a new revenue-producing one (critical care transports) to make the finances work.
• Identify community needs: The population served by this program will have different needs in every community. Consequently, potential adopters need to survey the local environment to understand the situation faced by heavy users of 911 services and the community resources available to serve them.
• Begin with small pilot test: Test the program with a small group of patients, using the testing period as an opportunity to build relationships with patients and potential community partners. Over time, the various organizations serving these individuals will come to realize that they can and should depend on each other.

Sustaining This Innovation

• Continue investing in partnerships: Ongoing communication based on transparency, honesty, and respect is critical to keeping partners together. In particular, the various organizations must honor their commitments to each other. MedStar has forged good relationships with virtually all key stakeholders, including four competing hospitals that have a tense relationship with each other but freely share data and collaborate with MedStar.
• Approach payers about funding support: Third-party payers may be interested in supporting the program once they understand how it can benefit them. To that end, MedStar leaders plan to meet with representatives of the three largest payers in the area to find out what aspects of the program would be most meaningful and beneficial to them (e.g., its ability to reduce EMS transports, ED visits, and hospitalizations). MedStar will then hire an independent party to evaluate and document the program's impact on these metrics, and share that analysis with the payers as part of a conversation about reimbursement.
• Prepare for reimbursement changes: As accountable care organizations, pay-for-performance, and other new payment and care delivery programs become a reality, health systems and other large provider organizations will increasingly take responsibility for covering EMS transport services (rather than traditional insurers). Consequently, those adopting this program should consider partnering with organizations that plan to participate in these new initiatives.

Use By Other Organizations

Approximately 10 other EMS programs have visited MedStar to learn more about the program.

References

1. Referred services and alpha trucks: Norma Battaglia leads Tucson Fire Department toward response efficiency. JEMS. 2009 Apr;34(4):4-5.
2. Dale J, Williams S, Foster T, et al. Safety of telephone consultation for "non-serious" emergency ambulance service patients. Qual Saf Health Care. 2004;13:363-73. [PubMed]