Case study: How EMT health screening program helps seniors

By The Agency for Healthcare Research and Quality (AHRQ)

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

Summary

The Livingston Help for Seniors program uses emergency medical technicians to screen rural-dwelling older adults for depression, medication-related problems, and falls when they respond to an emergency call. A case manager reviews the screening results and contacts at-risk individuals to schedule a free home visit that includes a psychosocial assessment and referrals to needed medical and social services. The program enhanced access to these services for at-risk, rural-dwelling older adults and generated high levels of satisfaction among those served.

Evidence Rating

Suggestive: The evidence consists of data collected on the percent of older adults identified as being at risk and receiving in-home assessments and referrals during the 14 months prior to December 2010. The evidence for satisfaction is based on data collected during the pilot test of the program.

Developing Organizations

Genesee Valley Health Partnership; Livingston County, NY Department of Health; Livingston County, NY Office for the Aging; Tri-County Family Medicine; University of Rochester School of Medicine

Date First Implemented

2006

Patient Population

Age > Aged adult (80 + years); Vulnerable Populations > Frail elderly; Rural populations; Age > Senior adult (65-79 years)

What They Did

Problem Addressed

Rural-dwelling older adults often have difficulty obtaining needed medical and social services. A variety of factors contribute to this problem, including physician shortages, lack of transportation, and financial limitations.¹ Emergency medical technicians (EMTs) represent a potentially effective but largely underused resource for screening these individuals and helping connect them to needed services.

• Lack of access to health care: Health manpower shortages and recruitment and retention of primary care providers are major rural health concerns among state offices of rural health. In addition, state and local rural health leaders across the nation most frequently identified access to quality health services as the most important rural health priority.²
• Physician shortages: Only approximately 10 percent of physicians practice in rural areas despite the fact that one-fourth of the U.S. population lives in these areas.² Furthermore, fewer and fewer primary care practitioners and other health care providers practice in rural areas, with some leaving to join managed care organizations in nonrural areas.¹
• Lack of transportation: Older, rural-dwelling adults often have to travel long travel distances for care and frequently have difficulty obtaining public or private transportation to appointments.¹
• Financial limitations: Poverty and lack of health insurance often prevent older adults in rural areas from seeking needed health care.¹
• Unrealized potential of EMT screening: EMT screening of older adults when responding to emergency calls provides health care systems with an additional opportunity to identify those at risk for preventable illnesses.³

Description of the Innovative Activity

A free screening and referral program, Livingston Help for Seniors, uses EMTs to screen rural-dwelling older adults for depression, medication-related problems, and falls when they respond to emergency calls. A case manager reviews the results and contacts at-risk individuals to schedule a home visit that includes a psychosocial assessment and referrals to needed medical and social services. Key program elements include the following:

• Patient screening by EMT: Once a patient has been completely stabilized, the EMT explains the program and conducts a brief screening to address the following:
  1. Is the patient is at risk for falling (e.g., falls in the past year, risks in home such as poor lighting, rugs, obstacles)?
  2. Does the patient feel down, depressed, or hopeless?
  3. Does the patient have medical or social needs that could be helped by followup? (e.g., help with daily care, meals, taking medication, physical therapy, alcohol?)

The EMT has four options for recording the patients responses:

• Yes—if the patient is at risk;
• No—if the patient is not at risk;
• Unknown—if the patient does not respond; and
• Not Asked—if the EMT did not screen for a specific reason.

There is also a text field in the patient’s care record for additional comments or concerns identified by the EMT.

• Recording patient care and risk factor information: Using an Internet-based, electronic medical record (EMR) system the EMT records patient care and risk factor information, which case managers review online. The technician informs patients that a case manager will review their information and contact them within 2 weeks, if necessary, to set up an appointment for an assessment. The EMT also leaves an informational card about the program.
• Case management team review and preparation for home visit: Members of a transitional case management team (a nurse and social worker) review screening results online, call at-risk individuals to ask if they would like a home visit, and schedule one if they do. Before the visit, a team member contacts the individual’s primary care physician (PCP) to inquire about any concerns the doctor may have, identify and discuss specific problems, and obtain a current medication list.
• In-home assessment: A case manager (either the nurse or social worker) comes to the individual’s home to evaluate nutritional status, drug and alcohol use, existence and severity of depression, ability to perform activities of daily living, level of cognitive impairment, risk of falling, and existing social support. Additional areas of concern (beyond those identified during the initial screening) often become apparent during these visits.
• Planning and referral: Based on the assessment, the case manager develops a care plan that is reviewed with the patient and family members (if present). The plan proposes medical and social service interventions to reduce any risks identified during the assessment. Interventions may involve medical care, such as a referral for immunizations, physical therapy, or other needed services, or a recommendation for one or more medication changes. Others involve social services, such as modifications to the home (e.g., installing a bar in the shower, removing loose rugs and other tripping hazards), “meals-on-wheels” or other similar programs, or transportation service for nonemergency medical appointments.
• Followup with physicians and community organizations: The PCP receives a written summary of the assessment and proposed interventions. The case manager sends referrals to service providers, who then initiate contact with the older adult.
• Ongoing education and reporting: EMTs receive monthly newsletters that cover relevant geriatrics issues and provide information on the program’s success in identifying and referring at-risk seniors to needed services.

References/Related Articles

Shah MN, Lerner EB, Chiumento S, et al. An evaluation of paramedics’ ability to screen older adults during emergency responses. Prehos Emerg Care. 2004;8:298-303. [PubMed]

Shah MN, Clarkson BS, Lerner EB, et al. An emergency medical services program to promote the health of older adults. J Am Geriatr Soc. 2006;54:956-62. [PubMed]

Shah MN, Rajasekaran K, Sheahan WD III, et al. The effect of the geriatrics education for emergency medical services training program in a rural community. J Am Geriatr Soc. 2008;56:1134-9. [PubMed]

Contact the Innovator

Manish N. Shah, MD MPH
Associate Chair for Research
Chief, Division of Prehospital Medicine
Associate Professor of Emergency Medicine, Community and Preventive Medicine, and Geriatrics
University of Rochester School of Medicine
Phone: (585) 463-2920
Fax: (585) 463-2966
E-mail: manish.shah@rochester.edu

Did It Work?

Results

The program enhanced access to medical and social services for at-risk, rural-dwelling older adults and generated high levels of satisfaction among those served.

• Increased access to medical and social services: The majority of older adults (600) seen for emergency care were successfully screened, and there is currently a 35-percent acceptance rate for in-home assessments and referrals (250 visits).
• Satisfaction with the screening and referral process: Ninety-two percent of the 130 individuals contacted in a follow up survey, indicated satisfaction with the overall program, with 90 percent indicating satisfaction with case management followup and 96 percent indicating satisfaction with case management responsiveness.

Evidence Rating

Suggestive: The evidence consists of data collected on the percent of older adults identified as being at risk and receiving in-home assessments and referrals during the 14 months prior to December 2010. The evidence for satisfaction is based on data collected during the pilot test of the program.

How They Did It

Context of the Innovation

Livingston County is a rural region in upstate New York with approximately 7,333 residents aged 65 and older, many of whom have unmet medical and social service needs. The impetus for this program came from a growing recognition that having EMTs screen individuals in their homes provided an opportunity to identify health and safety needs that often were undetected because the individual did not require transport to the hospital or was only cared for in the emergency department.

In response, representatives of the department of health, the office for the aging, Tri-County Family Medicine, and the University of Rochester came together to design and implement this program, in collaboration with emergency medical services (EMS) providers. These organizations had an established relationship through the Genesee Valley Health Partnership, a nonprofit, rural health network comprised of approximately 40 health and social service organizations.

EMS providers within this partnership had previously participated in a project to screen older adults for vaccination status and risk of falls, which contributed to their willingness to collaborate on this program. With support from the other stakeholders, the department of health applied for and received a grant to fund the initial program from the Health Resources and Services Administration (HRSA), Rural Health Outreach Grant Program.

Planning and Development Process

Key elements in the planning and development process included the following:

• Developing organizational structure: Under the auspices of the Genesee Valley Health Partnership, the four primary stakeholders designed an overall organizational structure. They created five separate groups that would be responsible for program design and implementation, including a community oversight board; a project oversight board to review progress and provide advice to the program director; an operations committee to develop the program structure, processes, and services; an education committee to devise EMT training (see below for more details); and an evaluation committee to develop and monitor process and outcome measures to gauge the program’s impact.
• Identifying lead organization(s): The stakeholders decided to make the department of health and the office for the aging the lead organizations for the program. The department of health played an especially critical role, as it qualified for the HRSA grant that provided initial program funding. Once the program became fully operational, the office for the aging took responsibility for paying and overseeing the case managers.
• Educating and training EMS providers and EMTs: Program leaders met with county EMS providers to educate them about the program and to develop EMS instructors who could provide training on the appropriate care of older adults. Instructors used a course developed by The American Geriatrics Society (“Geriatric Education for Emergency Medical Services”), integrating use of the screening tool into the curriculum. Initially, only two EMS agencies received training and began screening in the field. This approach allowed program developers and instructors to improve the training and screening processes before broader program implementation. Twelve EMS providers now participate in the program.
• Designing system to transfer information: EMTs initially faxed paper-based records to case managers. Later, the EMS agencies jointly purchased an Internet-based EMR system that allows for electronic screenings and for case managers to review results online.
• Developing case management tools: Program leaders developed forms to guide each aspect of case management, including collecting demographic information, conducting the telephone interview, performing the home visit, making referrals, and following up with physicians and community organizations.
• Promoting program: To maximize participation and buy-in, program staff met with numerous community stakeholders to describe the concept and solicit ideas for improving the proposed program. Stakeholders included the county medical society, physician practices, home health agencies, social service agencies, and EMS agencies. Staff also created a monthly newsletter that was very helpful.
• Developing standardized letter for PCPs: Program leaders developed a standardized letter for physicians that explains the program and informs them when one of their patients has accepted a home visit. As noted earlier, these physicians receive a followup letter after the case manager visit.

Resources Used and Skills Needed

• Staffing: Program staff includes a part-time administrative person (approximately 2 hours per week) and 2 part-time case managers, who spend an average of 4 hours on each individual receiving a home visit. Program leaders hired a nurse and social worker as case managers and have found that their complementary skill sets enhance the ability of each to perform effective assessments.
• Costs: The program’s annual operating budget averages roughly $50,000. Startup costs range from $25,000 to $50,000, depending on the need to enhance existing information systems, conduct community outreach, and hire case managers.

Funding Sources

• Livingston County, NY Office for the Aging; Health Resources and Services Administration, Rural Health Outreach Grant Office

Tools and Other Resources

Additional information about the program and a toolkit are available at: http://www.gvhp.org/tabid/104/Default.aspx.

Information on EMS geriatric training is available at http://www.gemssite.com.

For information on screening criteria and development see:

• Guideline for the prevention of falls in older persons. American Geriatrics Society, British Geriatrics Society, and American Academy of Orthopaedic Surgeons Panel on Falls Prevention. J Am Geriatr Soc. 2001;49:664–672. [PubMed]
• Whooley MA, Avins AL, Miranda J, et al. Case-finding instruments for depression. Two questions are as good as many. J Gen Intern Med. 1997;12:439–445. [PubMed]

Adoption Considerations

Getting Started with This Innovation

• Establish stakeholder management group: Successful organization and design requires participation from key providers of medical and social services and a commitment from EMS providers. Working with an existing network like the Genesee Valley Health Partnership facilitated this process in Livingston County.
• Designate lead organization: Success also depends on designating a lead organization to promote and potentially house the program. For example, having the office for the aging serve as the lead agency provided credibility and a focal point for program outreach.
• Gather information and obtain buy-in from other stakeholders: Gathering information on screening elements, program processes, and community resources helps to build stakeholder support and improve program acceptance and operations. For example, during program startup, PCPs requested that case managers make referrals directly to service providers and then notify them, a suggestion that program leaders adopted. This information-gathering and buy-in process can take significant time. For example, developers of this program spent approximately 6 months on these tasks, using paid staff. Would-be adopters might need to allocate up to a year for this activity, depending on the size of the community and staff availability.
• Identify screening criteria and questions: Would-be adopters should develop screening tools based on the needs of older adults in the area and the availability of services to meet those needs. For example, the Livingston program chose its screening criteria based on the prevalence of the problem, the level of community concern, and the potential for increased morbidity and mortality. Once criteria have been selected, would-be adopters can obtain guidance on specific screening questions from health research literature. (See the Tools and Resources section.)
• Consider online information system: Would-be adopters will need to adapt or create a system for transferring information from the EMTs to the case managers. Although a paper-based system can work, an online system improves efficiency.
• Train EMTs: Would-be adopters need to identify instructors who can train EMTs on the appropriate care of older adults and the requisite screening protocol. Although most EMS providers have budgets for training, each state has different guidelines and certification requirements for continuing education.
• Use part-time case managers: It is unlikely that this type of program will have sufficient volume in a rural community to keep an individual busy full-time. Therefore, it would be advantageous to use independent contractors as case managers or staff who have other responsibilities.

Sustaining This Innovation

• Transfer training to EMS providers: EMS provider-based instructors should take ongoing responsibility for staff training once they have been fully prepared for this role.
• Collect information on why seniors refuse home visits: Although improving, the acceptance rate for case manager home visits remains too low. To address this issue, periodically confer with service providers and community members to identify barriers to accepting home visits.
• Continually promote program: Make formal and informal presentations about the program on a regular basis to medical societies, other medical groups, and social service organizations. As appropriate, make inquiries about referral patterns (e.g., which services older adults are most likely to need) and policies that can improve case management activities.

References

1. Shah MN, Caprio TV, Swanson P, et al. A novel emergency medical services–based program to identify and assist older adults in a rural community. J Am Geriatr Soc. 2010;58:2205-11. [PubMed]
2. Gamm LD, Hutchison LL, Dabney BJ. et al, editors. Rural Healthy People 2010: A Companion Document to Healthy People 2010. Volume1. College Station, Texas: The Texas A&M University Health Science Center, School of Rural Public Health, Southwest Rural Health Research Center.
3. Shah MN, Brooke Lerner E, Chiumento S, Davis EA. An evaluation of paramedics’ ability to screen older adults during emergency responses. Prehosp Emerg Care. 2004;8(3):298-303. [PubMed]