How REMSA’s Nurse Health Line is changing EMS culture

The new Nurse Health Line has been a huge success, and the Reno, Nev. program is well on the way to becoming sustainable and a model for other agencies

When someone in Reno, Nev. is having a medical problem, many no longer call 911. Instead, they dial 858-1000, the number for the Nurse Health Line — open 24/7.

The nurses triage patients to appropriate services — regardless of insurance. If it’s a real emergency, an ambulance gets dispatched, and they go the ER. Nothing changes.

But if it’s not a real emergency, the patient may go to an urgent care center, or a mental health facility. A community paramedic may go to the home and help the person get the social services she needs, or line her up with a primary care physician.

The Nurse Health Line has been one of the most rewarding aspects of a community paramedicine program launched by the Regional Emergency Medical Services Authority (REMSA) in Reno, Nev.

“This one has been shockingly successful,” REMSA Medical Director Dr. Brad Lee said during the “Moving from Innovation to Sustainability in Community Paramedicine” session at the ZOLL Summit 2014 tradeshow in Denver.

When they launched the line in October 2013, organizers expected to receive about 2,400 calls per year. They currently field about 2,200 calls per month, which has led to a decrease in 911 calls.

Who’s paying for it

The Nurse Health Hotline is just one part of a community paramedicine program that was started through funding from a Centers for Medicare and Medicaid Services Health Care Innovation Grant.

The grant runs out in 2014, but efforts are well underway to create a stable, sustainable program that other agencies can replicate, with the goal of saving the ambulance service $10.5 million over the course of three years, Lee said.

“It probably won’t be much of a problem saving that much money,” he said.

For them, data collection has been a huge part of proving their worth and getting other agencies on board with the program. The numbers show how much the department is saving by not making ambulance runs, Lee said. And although Medicaid does not currently provide reimbursement for such calls, his team recently presented the community paramedicine program to state legislators with an aim to change that.

“Nevada Medicaid came to us, and asked us if we could testify so they could reimburse us,” Lee said.

The data also has the potential to get hospitals to pay for the program by showing its effectiveness in reducing 30-day readmissions for acute myocardial infarction (heart attacks), heart failure and pneumonia, saving them from paying a penalty under the Affordable Care Act’s Hospital Readmissions Reduction Program.

The numbers have already convinced local hospitals to bundle payments for the Nurse Health Line. One, for instance, had already established its own nurse health line, but 40 percent of those calls were still going to the ER. Lee and his team were able to show that their rate was more like 8 percent.

“They took a look at the cost savings and said, ‘Yeah, we can see it, we’ll go with you guys and pay you more,’” Lee said.

A slow rollout

When they first launched the program, they made sure to meet with all the stakeholders – from medical directors to nurses’ unions — and as a result have not had any pushback from other agencies.

“Turn competitors into collaborators,” Lee said.

They started the Nurse Health Line working exclusively with nursing homes for a few weeks. Then, they launched a media blitz that included television commercials depicting 911 calls that were not emergencies.

More people began calling. It’s grown to the point where some doctors have started forwarding their own calls directly to the line, and are putting the phone number on promotional materials in their offices, Lee said.

Community paramedics also make home visits as part of the program, and doctors have started referring patients for that as well. The program is steadily rising, with about 20 new consultations being added each day. The community paramedic makes house calls based on severity; sometimes it’s just a phone call.

“Our patients call us; we can’t seem to get rid of them,” Lee joked.

A big part of those home visits involve community paramedics showing up within three days after patients are discharged from the hospital, which is a time-frame that’s been identified to greatly reduce the chances of 30-day readmissions.

For now, the home visits are covered by grant funds, but Lee said his team is talking with hospitals about having them pay for it, since they’re able to show how much they save in avoided penalties.

Not perfect — yet

The program, however, isn’t without its nuances.

“For all transports, the patient has to consent, and the urgent care must consent,” Lee said. “It’s a little cumbersome. I’m not sure it will be the plan going forward, but that’s what we do now.”

But the reason isn’t restricted to liability.

“The logistics are a nightmare,” he said. REMSA is working with 13 different urgent care centers. Some close at 5 p.m., others close at 8 p.m.; some have X-Ray machines, others don’t. By getting consent from both parties, they’re able to tailor the destination based on factors like patient need, location and time of day.

Is this something EMS really wants to do?

When REMSA started the program, they asked for volunteer EMTs and paramedics.

“We took our best and brightest,” Lee said.

Turns out, it wasn’t the best and brightest idea.

“Paramedics go into paramedicine because they’re adrenaline junkies,” he said. "There’s no intubation, no lights and sirens in community paramedicine, and after a while some of those selected were really craving that fix.”

REMSA has since tailored the program to select medics who more on the empathetic side, and it’s been more successful.

Changing the EMS culture

The ultimate goal, Lee said, is to stop over-triaging patients to the ER.

“If they call, we show up,” he said. But when medics arrive and determine it’s not actually an emergency, they’re shifting to more of a ‘what can we do to not take you to the ER’ mindset.

REMSA eventually hopes to balance trips to the ER with ambulance transport alternatives such as urgent care centers, clinics, community triage centers or mental health facilities. But they’re still taking a conservative approach, with both the transports, and the data.

And still, the numbers speak for themselves.

“It really comes down,” Lee said, “to a change in EMS culture.” 

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