Excellence in fire-based EMS: Chesterfield (Va.) Fire and EMS Department’s MIH program
The program brings together a broad network of partners to provide better care for 911 users and reduce patient transport to ERs
The Congressional Fire Services Institute (CFSI) and Masimo announced the two fire departments to be honored with its annual Excellence in Fire Service-Based EMS Award – the Chesterfield County (Virginia) Fire & EMS and the San Antonio (Texas) Fire Department.
First presented in 2011, the Excellence in Fire Service-Based EMS Award recognizes fire departments from across the nation for developing and enhancing the delivery of EMS to address the growing challenges in delivering emergency medical care. By showcasing these practices, the award program seeks to provide fire departments across the nation with ideas for enhancing their own fire service-based EMS.
I was honored to serve with the women and men of Chesterfield County Fire & EMS (CFEMS) for 26 years. Following news of the award, I connect with Dr. Allen Yee, the operational medical director for CFEMS, and Lt. Dan Stamp, program manager for the department’s innovative Mobile Integrated Healthcare (MIH) Program.
FireRescue1: What can you share about the department’s MIH program?
Yee: Traditionally, our people encounter the patient, assess them, treat them, and take them to the hospital and then get ready for the next call. What this MIH program does is it allows us to assess what problems led to the 911 call, to make their life better, and to make them healthier.
What prompted CFEMS leadership to pursue this initiative?
Yee: When we started this project back in 2013, we initially were focused on heart failure patients, COPD patients that were having frequent readmissions to the hospital. The hospitals were seeing these patients repeatedly, and EMS was getting called, and we were taking care of these patients over and over again. But what we learned was we are below the national average, especially for heart failure, so we transitioned to other gaps in the community. And we focused on the needs of the 911 patients – the loyal customers – who had a lot of resource needs and didn’t know how to access the systems of care.
Who is part of the MIH?
Stamp: I’ve been the program manager now for about three years and there are three firefighter paramedics in the unit with me. Their assignment varies between 2½ and 3 years and then they move back to the Emergency Operations Division.
There’s also a peer support specialist who’s on loan from the county’s Mental Health Department, the local community services board. We also work with the county’s Social Services Department, Adult Protective Services, Child Protective Services, the Sheriff's Office, the Senior Advocates Office, and any nonprofit group or church group you could possibly imagine. We work with all the hospital systems in the region with their case managers.
Yee: And doctors’ offices, the police department and building inspectors.
Stamp: As you can imagine, the integrated part has really become integrated in the whole area, not just with the county’s resources.
How are you managing the communications with all those different entities being involved?
Stamp: When I assign a case to one of my medics, they are essentially the case manager. They attempt to contact the person that's in question and then if they make contact to try and figure out, like Dr. Yee said earlier, what we can do to help, how we can connect all the resources to make their lives better, and then they come back to the office and start connecting those dots.
Over the past few years, we made enough really positive relationships with all these departments to where most of us just contact each other by cell phone or by office phone and we get together and meet, sometimes one-on-one and sometimes as a group to discuss the patient's needs. And then we go from there.
Yee: The philosophy is not to look at it solely from the fire department's point of view. I mean, the strategy is really to put the patient in the middle and have all of us who are stakeholders surround the patient and bring what we can to bear to help this individual. It's about the individual and it's very patient, and patient family-centric.
How does MIH work?
Every case is completely different, and there's really no cookie-cutter way of doing things. We brainstorm on each case and bring all the resources in. Sometimes it can take 2 or 3 days to solve a problem, sometimes it might take 3 weeks, all the way to 6 months to work on a case.
So, how does a case come to your attention?
Yee: We take referrals from many sources, including our 911 folks [911 Call Center and Dispatch] and hospitals that email Lt. Stamp, so outside sources generally call us directly or email us.
For our personnel in Operations, there's a button within their patient care reporting system that they can hit, and a drop-down box appears to gather information on why they’re referring the patient to MIH.
Stamp: And then I research their name, look at their call volume, look at their medical history, and I create a case – in another program that we have through our reporting system – and the medic is able to see that in their file.
So an example referral coming from a medic in the field might be something like: “Responded to this patient’s address for a congested heart failure (CHF) episode four times in the last four months and transported them to the hospital for treatment of their CHF.”
For an external referral, let’s say that Chippenham Medical Center contacts you and says, “Hey, this is the fourth time that CFEMS has brought in this patient for treatment of a CHF episode,” is that also a trigger for MIH?
Stamp: Yes, it is.
Yee: Chippenham can call us and say, “We have a patient [brought in by another service] who lives in Chesterfield County. Can you help us?”
Stamp: And with our people in Emergency Operations being so used to making referrals, they’re catching those patients before it gets out of hand. They're giving me really good summaries of somebody so that they can kind of forecast that a patient is not doing so well.
From my experience, I could see that my observations of the patient’s home environment could be the basis for a referral to MIH. What are some others?
Stamp: For any drug overdoses that happens in the county, I get those through our reporting system as well. As I mentioned, we have that peer support specialist through mental health, and she’s focused on the overdose epidemic model, and we use the same model as a case kind of format for her.
We go visit people who’ve overdosed on heroin or opiates and try and get them in contact with the right resources.
Yee: There’s also medication inventory where the patient doesn’t know what meds they should be taking or they’re not taking their meds.
Stamp: There’s also history of falls, requests for lift assists.
Yee: And there’s a drop-down field in that referral section of the patient care report that lists resource needs like hospice, homecare nursing, and patient can’t care for themselves.
When did the process to develop MIH begin?
Yee: In the fall of 2013 we brought in Captain John Murray to explore the feasibility of such a program, and in January 2014, we started working on our first referrals.
And what are the desired outcomes for the program?
Yee: A decrease utilization of the healthcare system, for both us and the hospitals as well as keeping patients at home. You know healthy and safe.
MIH is now into its sixth year of operation. How would you rate its performance?
Stamp: I think we’re doing well. We've been able to decrease our number of calls, and clearly, we've helped numerous people to really improve their lives.
We've been able to help a lot of single seniors that have fallen socially, and we've been able to place them in different facilities. We’ve had some good successes with breaking the chain of poverty on some. With the opiate program we’ve been very successful in contacting people who need help and getting people those resources. Overall, we’re very pleased with the program’s the successes.
On scale of 1 to 10, where 1 is awful and 10 is outstanding, what kind of scores would you give MIH?
Stamp: On the opioid program, I’d say a 10 because the program blew away our expectations. We started that program in 2017 but really began making headway in 2018. What would you give the overall MIH program, Doc?
Yee: An 8!
Stamp: It's like I said, every case is different. So, we’ve had some successes and we’ve had some failures. We’ve had some people that we can't contact, we have some people that turned us down.
What kind of feedback do you get from your patients who’ve been referred to MIH?
Yee: They’re surprised that the fire department engages in such activities.
Stamp: And they’re generally surprised that there are so many resources out there willing to help them. When you think about it, somebody in their 70s or 80s, you know they're probably not technologically savvy. With everything switching to the internet, people in those age groups aren't looking on the internet every day to find out what's going on. They're still trying to use the White Pages and Yellow Pages and the telephone to get answers. So when we bring the resources to them that they need, they are very pleased and very surprised.
A message from Jenaway
With the news about the two departments being honored with the Excellence in Fire Service-Based EMS Award, CFSI President Bill Jenaway shared the following: “Changing demographics are placing greater demands on our fire departments, requiring them to enhance their EMS capabilities to reduce the burdens being placed on emergency rooms. The two departments we are honoring with our 2020 award exemplify the commitment of our nation’s fire service to provide the best level of emergency medical services to their citizens.”
Note: The awards were scheduled to be presented at the 32nd Annual National Fire and Emergency Services Dinner in Washington, D.C., on April 30; however, the event has been postponed due to the COVID-19 pandemic.
Editor’s Note: Watch for Part 2 on the San Antonio Fire Department’s fire-based EMS program coming soon to FireRescue1.com.