Tight municipal budgets and shrinking tax revenues, along with increasing calls to EMS, have locked the fire service and EMS into something of a tug-of-war in some cities. While the two share certain similarities in mission and training, there’s competition for a limited pool of resources, whether those resources are from taxpayers, insurance companies or Medicare.
Cleveland Fire Department and Cleveland Emergency Medical Services, both city agencies, are no strangers to that tension. For years, city leaders periodically brought up the idea of combining the two departments, but there was worry from both sides about what such a change would mean for everything from seniority to the supervisory structure to retirement plans, says EMS Commissioner Edward Eckart. Paramedics in particular worried about being pushed aside in a merger with the much larger fire department. (The fire department has about 860 employees and an annual budget of $90 million, while EMS has 240 employees and a budget of $22 million.)
But attitudes toward joining forces started to shift in recent months, when budget issues began to make it clear that integration was inevitable. With the city facing a projected $23 million budget gap, 23 firefighters were laid off and others took cuts in pay and benefits. On the EMS side, six paramedics were laid off but were later rehired when spots became open due to attrition. Nevertheless, response times have crept up because EMS is running 15 ambulances, down from 21 ambulances four years ago, according to Eckart. Meanwhile, the fire department has instituted brownouts at some stations.
“Cleveland is facing some tough financial times and has struggled to maintain a level of fire protection,” says Fire Chief Paul Andrew Stubbs. “We are looking at dwindling resources, personnel and equipment.”
At the same time, both fire and EMS began to recognize some of the potential benefits of integration. The two operations had cooperated on some purchasing, training and performance-improvement efforts in the past. And to meet the growing needs of the population and reduce response times caused by an EMS staff that’s stretched increasingly thin, Cleveland firefighters—who are also trained as EMTs—began responding to some medical emergencies about a year and a half ago. Still, it was becoming increasingly apparent that even greater coordination was needed.
“The mayor asked us to look at ways to be more efficient and effective as far as training, quality assurance and performance improvement for prehospital care go,” Eckart says. “To get to the level of cooperation the mayor wanted, we really needed to take it to an operational level where we have a complete integration of services right down to the street level.”
Ever-growing needs
Cleveland certainly has a need for an efficient, high-performing EMS service. The city has been struggling financially since the 1960s and ’70s, when manufacturing jobs headed overseas and factories closed. The latest recession brought rampant foreclosures and soaring unemployment. More than one-quarter of the city’s population is uninsured or underinsured. “Many of them call 911 for primary care services,” Eckart says. Last year, EMS responded to 80,000 calls and transported 66,000 patients, with reimbursements representing about 60 percent of the budget.
Eckart understands firsthand the demand placed on EMS. He got his start as an EMT for the city in 1981 and soon after became a paramedic. He worked his way up through EMS management before leaving the field for a few years to work as the city’s assistant to the director of public safety and then as manager of operations for Cleveland Public Power, the electric utility. After several highly publicized response time issues, a former mayor conducted a national search for a new EMS director, says Eckart, who was on the selection committee. When the chosen candidate turned down the offer at the last moment, the mayor surprised Eckart by asking him to fill the role. He’s held the position for more than 10 years.
Even before the decision was made to integrate, Cleveland EMS had been looking for ways to cope with the crush of 911 calls. Earlier this year, dispatchers began to divert some non-urgent 911 callers to clinics instead of emergency rooms. In a program similar to those tried in Richmond, Va., and recently launched in Louisville, Ky., Cleveland is using a system developed by Priority Solutions of Salt Lake City. When a call is deemed to be low-priority and non-life-threatening, instead of sending an ambulance, dispatchers refer the caller to a 24-hour hotline at Huron Hospital, part of Cleveland Clinic, which schedules patients to be seen at the clinic. The hospital then sends a van, free of charge, to bring the patient to the appointment. “Most of the time, the issue is transportation,” Eckart says. “You have to make it easy for them to get seen by a medical professional.”
Rather than just a reaction to budget pressures, Eckart sees the integration of fire and EMS as an opportunity to vastly increase the EMS workforce—and in doing so, have the personnel to try new community outreach initiatives and expand the role of EMS in public health and even into primary care-type roles. Ultimately, the goal is to reduce the burden on 911 and emergency departments.
EMS currently has three people assigned to do community outreach such as CPR training and health screenings. With the addition of the firefighters, they plan to offer blood pressure and glucose checks at any time of the day at all stations throughout the city. “This will be adding more than 800 people available for community outreach,” Eckart says. “That’s why I get excited about integration. We have a small army of medical professionals who can make a big impact on the community, as far as awareness and prevention go.”
The outreach won’t stop with the screening, Eckart adds. One goal of the screenings will be to refer patients to “medical homes,” where they can be seen by primary care physicians and receive more comprehensive—and, ultimately, less costly—care for chronic illnesses. Eckart and his team have already started working with city health clinics, Centers for Medicare & Medicaid Services-qualified health centers and local hospital systems about handling the patient load.
That attitude—putting patients and the community first—may serve Cleveland well as it joins the two services, says Gary Wingrove, president of the National EMS Management Association (NEMSMA). NEMSMA does not take a position about the relative merits of various service delivery models, Wingrove adds, because there is no evidence that one particular model delivers superior service or greater efficiency than any other model.
“We believe that communities should make fully informed decisions that are rooted in what’s in the best interest of the patient and the citizens of the community, not in what’s best for any particular labor group or political interest. I am not aware of any other community that has undertaken an examination of the way it delivers emergency services in the way that Cleveland is approaching the topic,” he says. “It is refreshing to see that even with competing city unions in Cleveland, leaders are actually providing leadership, considering the needs of the patients and the citizens. … It appears to be a sound process, based on the unique needs of the community, with all of the interests at the table and having a shared vision.”
Making integration work
Yet much work remains to be done. Since Cleveland’s mayor made the final decision in May to combine the two departments—the new one will be called the Division of Fire, Rescue and Emergency Medical Service—leaders within EMS and the fire department have made a concerted effort to ensure discussions about joining the two organizations are transparent to all employees. One way they’re doing that is by taking detailed notes at all meetings and distributing copies of the notes to employees every two weeks, Eckart says.
Despite some initial trepidation, both sides are committed to the success of the new department, with even union leaders getting behind the agreement, Eckart says. Many details still need to be hashed out with the unions, including the pension issue. The two agencies have different retirement plans, with EMS eligible for full benefits after 30 years of service, while fire has a “25-year and out” plan, Eckart says.
To address EMS concerns, they are also going to give the paramedic job classification an “elite status” in the organization. Specifics about wages, benefits, working hours and assignments will need to be negotiated with the union, Eckart says, but the purpose is to send a message that paramedics are highly valued.
Some employees have also raised workplace culture concerns. With far more women working as paramedics than firefighters, some female employees wonder if they will be accepted by the primarily male firefighters, Eckart says. “We can’t legislate long-term firefighters welcoming paramedics with open arms, but we can send a clear message to everybody involved about what we value in the organization,” he adds.
One of the keys to making the arrangement work is keeping the focus on improving patient care and service, rather than just plugging budget holes, according to Eckart. They are also careful to call the new arrangement an integration rather than a merger, which would imply that one department is being taken over by the other.
That type of arrangement—or perception of such an arrangement—has backfired in other cities, Eckart says. “Around the country you hear about these hostile takeovers or absorptions,” he says. “Our goal is to build a brand-new division that takes the best of both EMS and fire and creates that from the ground up. It’s about collaboration and service delivery to the community.”
Chief Stubbs echoes that sentiment. “This is designed to take advantage of both divisions’ strengths,” he says. “It seemed like we were moving in this direction all along. Discussions centered around being more effective and more efficient and more seamless. It seemed logical that the ultimate goal would be to integrate and take advantage of what we both do best.”
There are no precise timelines for the integration, with both saying they want to accelerate the process but also be careful to set things up correctly the first time.
To Eckart, the new arrangement presents an opportunity to do EMS better. The new arrangement offers the opportunity to structure a department based on the needs of the community in 2010 and beyond. Though there may be some cuts to support staff, Eckart says staff reductions are not the focus of the merger; rather, improving service while holding down budgets is.
In many communities, Cleveland included, the fire service grew up along with the community. EMS evolved later, with fewer resources devoted to it. “It was retrofitted, almost as an afterthought,” Eckart says. “This gives us the opportunity to change that.”
