Every EMS system deals with “frequent users,” that group of patients who call 911 for problems that would be better dealt with by a primary care physician, a substance abuse treatment center, a mental health provider or other social services.
Among frequent 911 users, Lonzel McPeters and Cesar Arana, two middle-aged homeless men in Fresno, Calif., were in a class unto themselves. In 2009, McPeters called 911 21 times; Arana, 119 times. In 2010, that shot up to 329 times for McPeters and 471 times for Arana. In 2011, despite attempts by EMS and homeless outreach workers to direct them to alternative care, the men called 911 a combined 1,363 times—making up more than 1 percent of the 135,000 responses by American Ambulance in Fresno County that year.
“Even with our engaging them in 2010, they doubled their numbers,” says Dan Lynch, emergency medical services director for the Central California EMS Agency, the EMS administrator for Fresno and nearby Kings, Madera and Tulare counties. “We were making no headway with them at all. In fact, we lost ground. They were very defiant. They refused all help. And I couldn’t get anybody to help me deal with it.” That included police and the district attorney’s office, who could have prosecuted the men under a California law that prohibits misuse of the 911 system, Lynch says.
With the situation growing worse by the week, Central California EMS Agency officials, with the support of local government and public health authorities, adopted an unusual “no transport” policy for system abusers. Under the policy, anyone who continually calls 911 for non-emergencies will be counseled about the proper use of 911. If a patient continues to call unnecessarily, he can be given three written warnings. After the third warning, EMS will still respond to his 911 calls, but they can decline to transport the patient, according to the policy, which went into effect April 6 and also covers Kings, Madera and Tulare counties.
EMS experts are divided about whether such a policy is the right solution for a difficult problem. Some say the EMS system did what it had to do to protect the public interest. “What they did makes a lot of sense,” says Sean Burton, clinical programs manager for MedStar in Fort Worth, Texas. “It’s a hard decision to make, but a lot of communities are going to feel forced to do this. For so long we built the culture, ‘You call, we haul.’ But as we move forward, health care and health care funding are going to drive us to create different models that are more appropriate for patients, for hospitals and for payer groups.”
Others warn that the policy opens up the EMS agency to lawsuits and contend that there are ways of dealing with system abusers such as McPeters and Arana that Fresno hadn’t yet fully explored. “I’ve dealt with hundreds of those types of guys, and you can get through to them. It’s frustrating and they’re annoying, but you can,” says Niels Tangherlini, a paramedic captain with the San Francisco Fire Department who is trained as a social worker—and who is often called on to deal with his city’s system abusers. “Just showing up and saying, ‘Oh, it’s you again. We’re not taking you’ isn’t a good idea. The risk is too high.”
How the program came to be
For more than a year, Lynch and his team tried to get through to McPeters and Arana, who hung out together on city streets. Though the men had medical issues, their complaints were rarely emergencies, Lynch says. Instead, they would call 911 and ask to be transported to the hospital because they were hungry or cold, or had slept poorly. “They’d say, ‘I hurt my foot three days ago,’ or, ‘I’m looking for my friend,’ or, ‘I feel like I’m going to have a seizure,’” Lynch says.
On many occasions, responders tried to talk the men out of going to the hospital, but they insisted. Paramedics fumed that if the men had to wait longer than they wanted to in the emergency department, they’d walk out and call 911 for a ride to the hospital later, Lynch says.
Realizing something had to be done about them, the Central California EMS Agency launched a frequent user program in 2011 to steer the men—along with about 60 others who call 911 more than 20 times a year—to alternative care. Lynch enlisted the help of other health and social services agencies, including a clinic serving homeless and indigent patients, the county department of behavioral health and substance abuse services, and local hospitals.
The program worked … for some patients. From 2010 to 2011, transports for the city’s 60-plus frequent users had risen by 60 percent. From 2011 to 2012, after the frequent user program was launched, transports dropped by 32 percent.
It might have dropped more, were it not for McPeters and Arana. Their calls continued to increase, prompting Lynch to hand-deliver letters to them, warning them that 911 abuse is against the law. Their response shocked even Lynch: Arana made an angry phone call to his office, which Lynch recorded. Arana threatened to call a lawyer. “If I want to go to the hospital and call the ambulance, I will,” he said on the recording.
A turning point came when Lynch told a reporter from The Fresno Bee about the men. “It was time to get that out in the news,” Lynch says. In February, the Bee published a story about Arana and McPeters. In an interview, the men were unapologetic about their frequent use of 911, blaming alcoholism, liver issues and a seizure disorder for needing to go to the hospital so often.
The article outraged the community—and put Lynch in the middle of the controversy. Some members of the public thought the frequent transports were an example of government wastefulness. Lynch spent weeks doing interviews and radio shows to educate the public about how EMS works, how it’s funded and the rules it has to abide by—including the obligation to transport patients.
With the public and government officials eager for a solution, the Central California EMS Agency, the Fresno County Department of Public Health and the Fresno County Department of Social Services seized the opportunity. After consulting with attorneys, they adopted a no-transport policy for system abusers, defined as those who have accessed the EMS system 12 or more times over a three-month period.
Once a person has been flagged as a system abuser, the EMS medical director and EMS director review the case to determine if further action should be taken, according to the policy. That may include counseling the patient about the proper use of 911; notifying police, social services, mental health departments or the patient’s physician; and delivering the three written warnings.
The policy applies only to patients who are determined to be “competent to make their own decisions or [have] the ability to care for themselves.” Patients who have psychiatric or medical conditions that leave them unable to care for themselves are exempt.
In April, McPeters and Arana were given their three warnings, and then paramedics began denying them transport. Almost immediately, the number of times the men were transported dropped to twice in May and five times in June, although they are still transported when there is a legitimate medical issue, Lynch says.
“We still feel an obligation to respond, to make sure they are not having a true medical emergency or injury,” Lynch says. “But if they can sit up by themselves or walk, we will not transport them, regardless of the chief complaint. We will tell them, ‘You’ve been identified as a system abuser and per our medical director we are not to transport you.’”
Paramedics were relieved. “They go through a lot of training and education, just to respond to someone who is unabashedly abusing the system and there is nothing they can do about it. They feel they have been empowered a little bit … and it’s been a big morale boost for the system,” Lynch says.
Different approaches to the same problem
Not everyone, however, is convinced that a no-transport policy like Fresno’s is the right tactic for dealing with frequent users. Liability is one concern, including the risk that medics might refuse to transport, and moments later, the frequent user—who very likely is dealing with some combination of chronic diseases, substance abuse issues or mental health problems—really does have an emergency. “Maybe they get drunk and fall down, or they run out into traffic,” Tangherlini says. “You have opened the question that if the ambulance had taken them, maybe this wouldn’t have happened.”
Other EMS experts say they doubt a no-transport policy will work over the long term. Determined frequent users will find ways around it, says Skip Kirkwood, Wake County (N.C.) EMS chief. “Many of these guys are not stupid,” he says. “They will figure out that if they say they are having chest pain, there is no way a paramedic can disprove they are not having a heart attack. They know the magic words to get in the back door of the ER.”
Another challenge is being sure paramedics are making the right call. Determining whether to transport has never been part of a paramedic or EMT’s job description; nor is it part of their training or curriculum, Kirkwood notes.
“It’s OK to tell somebody you are not going to transport them, as long as you get it right,” Kirkwood says. “The problem is there are a multitude of peer-reviewed articles that say when EMS providers undertake to make this decision, they don’t get it right often enough.
“You have to do it for the right reasons—not because it’s a poor, homeless, smelly person who is calling you at 3 a.m. when you’re tired,” he adds. “You need a protocol. If you follow that, then you’re probably OK.”
Since January 2011, MedStar has tried to do just that. System abusers are identified based on medical history, call history and feedback from medics and hospitals, Burton explains. When those patients call 911, an advanced practice paramedic, who has more than 250 hours of additional training, is dispatched along with the regular ambulance unit.
After assessing the patient, the advanced practice paramedic contacts the medical director, who helps to determine the appropriate point of care, such as a clinic, mental health facility, substance abuse center or doctor’s appointment. If the patient refuses to seek help at the facility that is deemed appropriate, with the medical director’s OK, advanced practice paramedics can refuse transport. “We have guys that, as soon as they see the advanced practice paramedic vehicle roll up, they walk away from the scene,” Burton says.
MedStar’s advanced practice paramedics are a step in the right direction, Kirkwood says. But more research is needed into whether having a physician consultation over the phone improves decision-making, or whether it just helps to protect the EMS system from legal action.
Live video feed from the scene to physicians at a hospital would make it easier to determine if a patient needs transport, says Jim Dunford, M.D., medical director for the city of San Diego, whose serial inebriate program has garnered national attention.
“Physicians are currently reluctant to get involved in denying transport for these cases, just as EMS providers are, for fear of litigation,” he says. “Once on-line EMS physicians can have ‘eyes on’ patients and see for themselves what is happening, and EMS is no longer paid only when an ED transport occurs … recidivist patients won’t enjoy the luxury of having guaranteed transport to an ED.”
When dealing with frequent users, paramedics and EMTs should keep in mind that people who call 911 frequently see EMS “as their savoir and their rescuer,” Tangherlini says. “You can build on that.”
If the offer of community-based support fails—the “carrot,” so to speak—EMS also has a stick: the threat of conservatorship. Conservatorship happens when a judge determines a mentally ill or mentally disabled person consistently presents a danger to himself or others and is incapable of caring for himself. In such cases, the court assigns a family member or professional public guardian to act on the person’s behalf, including to provide housing and, if necessary, mandate treatment in a locked psychiatric facility. “Most of these guys would fear conservatorships and locked facilities, and EMS may be able to use that to persuade them to accept other forms of help,” Tangherlini says.
Still, he acknowledges that conservatorships can be difficult to get and that it’s often police, and not EMS, that initiates the process, although in the state of California paramedics are permitted to do so. (The process begins with what’s known as a 5150 hold, or a 72-hour mental health hold.)
San Diego uses a form of “coerced rehabilitation” for serial inebriates, Dunford says. Serial inebriates who misuse the 911 system can be court-ordered to participate in treatment.
Lynch acknowledges the no-transport policy isn’t the ideal solution. In a perfect world, he says, they would have found help for all of their system abusers. “We want to help them get out of the system. That’s always been our goal,” he says. “We don’t want to shut them out.”
So far, no other system abusers in Fresno have been denied transport, although one, a young meth addict who is refusing treatment, may receive his final warning soon. “Most people can be helped, but there are going to be the defiant ones who choose not to participate,” Lynch says. “Unfortunately, a policy like ours has to be implemented to deal with it.”
