Res­cued from the ER

First re­spon­ders in the D.C. area are join­ing oth­ers in a grow­ing trend: Mak­ing house calls to ease pres­sure on emer­gency sys­tems


In the 15 min­utes af­ter fire­fight­ers and a nurse knocked at Thelma Lee’s Mary­land town­house, they checked her blood pres­sure, told her what foods would keep her blood sugar from sky­rock­et­ing and set up an ap­point­ment — and a ride — to visit her pri­mary-care physi­cian.

They also changed the bat­tery in her chirp­ing fire alarm and put a scale in her bath­room so she could mon­i­tor her weight. Then they rolled out in an SUV to their next house call.

Fire­fight­ers in Prince Ge­orge’s County visit or call Lee at least once a week in a county project that is part of a grow­ing na­tion­wide ef­fort to re­think 911 ser­vices as a way to re­duce non-emer­gency calls, plug gaps in health care and cut costs to tax­pay­ers, pa­tients and in­sur­ers.

Lee, 48, who suf­fers from health is­sues that put her at risk for stroke and other lifethreat­en­ing ill­nesses, had been call­ing 911 three times a week and head­ing to an emer­gency room al­most as of­ten. Now she is one of about 1,400 fre­quent call­ers in the county’s three-month-old pi­lot project.

For decades, peo­ple have been trained to call 911 for help, but now they over­whelm fire­fight­ers and paramedics with calls that are not true emer­gen­cies.

“What we are do­ing now is not good medicine,” said Robert Hol­man, in­terim med­i­cal di­rec­tor for the D.C. Fire and EMS De­part­ment, which is plan­ning to ex­pand mo­bile health pro­grams. “These sore throats, blad­der in­fec­tions and, be­lieve it or not, mos­quito bites do not need to go lights-and-sirens through city traf­fic.”

In one of the more es­tab­lished pro­grams, in Ari­zona, the Phoenix sub­urb of Mesa added nurses in its 911 cen­ter to help as­sess the ur­gency of calls and part­nered with a hospi­tal to send nurse prac­ti­tion­ers with EMS per­son­nel on house calls.

In Texas, a com­bi­na­tion of 911 nurse-triage and pre­ven­tive-care ser­vices for 15 cities in the Fort Worth area is cred­ited with sav­ing more

“We talk about med­i­cal his­tory, med­i­ca­tions, check the house for safety haz­ards, call Meals on Wheels to elim­i­nate what we can to pre­vent [ac­ti­va­tion of] the 911 sys­tem.” Brian Goldfeder, a Prince Ge­orge’s fire­fighter/para­medic and the county’s co­or­di­na­tor of mo­bile health ser­vices

than $11.5 mil­lion in trans­port costs, emer­gency de­part­ment vis­its and hospi­tal ad­mis­sions over roughly the past four years.

The ef­forts have earned ap­proval rat­ings above 90 per­cent in pa­tient sur­veys, said Matt Zavad­sky, chief strate­gic in­te­gra­tion of­fi­cer for the hospi­tal net­work MedS­tar’s mo­bile health-care ser­vice.

Lo­cal hos­pi­tals cover the costs of the trav­el­ing nurses. Pa­tients avoid un­nec­es­sary and costly emer­gency room vis­its, Zavad­sky said, and the some­times lengthy ER waits.

“It’s so suc­cess­ful now that we have pa­tients who call [911] and ask, ‘Can I speak with the nurse?’ ” Zavad­sky said. “We thought pa­tients would be an­gry at this ser­vice. We were dead wrong.”

At least 230 EMS sys­tems in the United States have pro­grams op­er­at­ing as “mo­bile in­te­grated health” or “com­mu­nity paramedicine,” said Zavad­sky, who also chairs a na­tional com­mit­tee on mo­bile health.

The re­vamp­ing takes dif­fer­ent forms. Some pro­grams co­or­di­nate house calls and telemedicine through 911 sys­tems, fire depart­ments or lo­cal health depart­ments. Fire depart­ments and hos­pi­tals also may ar­range trans­porta­tion to ur­gent-care cen­ters or doc­tors’ of­fices.

Joseph Ciotola Jr., EMS med­i­cal di­rec­tor and health of­fi­cer for Queen Anne’s County in Mary­land, said the pro­grams fill holes in the health-care net that can be par­tic­u­larly im­por­tant in ru­ral parts of the coun­try or in com­mu­ni­ties with doc­tor short­ages. “What we’re do­ing is link­ing them with both pri­mary care and link­ing them to nec­es­sary ser­vices,” Ciotola said.

The District is con­sid­er­ing a plan to em­bed a reg­is­tered nurse in the 911 op­er­a­tions cen­ter. The nurse would talk with call­ers iden­ti­fied with non-lifethreat­en­ing med­i­cal prob­lems af­ter an­swer­ing ques­tions from op­er­a­tors.

The de­part­ment says it han­dles more than 200 calls a day where city res­i­dents need med­i­cal care but are not ex­pe­ri­enc­ing life-threat­en­ing crises.

“We’re ac­tu­ally send­ing peo­ple who don’t need an emer­gency room into an emer­gency room and po­ten­tially in­ter­fer­ing with the de­liv­ery of emer­gency medicine to crit­i­cally ill pa­tients,” Hol­man said.

Care be­fore a cri­sis

Af­ter a re­gional flu epi­demic in 2007 in­un­dated emer­gency sys­tems in Mesa, the fire de­part­ment in­no­vated.

“It’s ba­si­cally ur­gent care on wheels to reach the in­di­vid­ual in their home to re­fer them to the ap­pro­pri­ate health care af­ter we treat them,” said Tony Lo Gi­u­dice, com­mu­nity care project di­rec­tor for the Mesa fire and med­i­cal de­part­ment.

In Prince Ge­orge’s, the fire de­part­ment iden­ti­fied res­i­dents who have called 911 five times or more in a cal­en­dar year and tar­geted some for home vis­its with nurses from Doc­tors Com­mu­nity Hospi­tal and the county health de­part­ment.

“We talk about med­i­cal his­tory, med­i­ca­tions, check the house for safety haz­ards, call Meals on Wheels to elim­i­nate what we can to pre­vent you from ac­ti­vat­ing the 911 sys­tem,” said Brian Goldfeder, a Prince Ge­orge’s fire­fighter/para­medic and the county’s co­or­di­na­tor of mo­bile health ser­vices.

The pi­lot pro­gram costs roughly the price of two fire­fighter salaries — which coun­ty­wide av­er­ages to about $69,000 a slot — and was cov­ered when the de­part­ment sim­ply shifted Goldfeder and his part­ner from other jobs.

The num­ber of calls to 911 sys­tems re­mains high be­cause many com­mu­ni­ties are short of pri­mary-care doc­tors or be­cause peo­ple don’t know how to ob­tain health care out­side of hos­pi­tals, Goldfeder and oth­ers said.

New strate­gies spread with re­cent health-in­sur­ance over­hauls, said John Sin­clair, pres­i­dent of the In­ter­na­tional As­so­ci­a­tion of Fire Chiefs and chief of Kit­ti­tas Val­ley Fire and Res­cue in Wash­ing­ton state.

In­sur­ers do not typ­i­cally re­im­burse fire depart­ments and paramedics who pro­vide med­i­cal ser­vices un­less they phys­i­cally trans­port pa­tients to a hospi­tal, mak­ing it fi­nan­cially un­fea­si­ble for EMS work­ers to of­fer pre­ven­tive med­i­cal ser­vices, Sin­clair said. But the Af­ford­able Care Act, sev­eral emer­gency med­i­cal of­fi­cials said, cre­ated grants and en­cour­aged pro­grams that de­liver care be­fore a per­son needs a costly visit to an emer­gency room.

“If we get a per­son to the right place, you pay a lit­tle bit up front but save a lot on the back end,” Sin­clair said. “It just makes fis­cal sense.”

Of­fi­cials na­tion­wide re­port that only 39 per­cent of those trans­ported to emer­gency rooms are ad­mit­ted to hos­pi­tals, ac­cord­ing to Zavad­sky, leav­ing more than 60 per­cent of pa­tients with a one-day treat­ment and bills that can be more than $4,000.

Com­mu­nity paramedicine will be­come more ur­gent as aging baby boomers con­tinue to strain a sys­tem al­ready short on pri­mary-care doc­tors and nurses, Sin­clair said.

But build­ing a long-term fi­nan­cial model for that could take leg­isla­tive ac­tion.

As it works now, “If we’re not trans­port­ing some­thing, there’s noth­ing to re­im­burse,” he said. “There needs to be leg­isla­tive changes to iden­tify com­mu­nity paramedicine as pre­ven­ta­tive health care for it to be par­tially re­im­bursed and sus­tain­ably funded.”

Changes in the District

In early 2016, D.C. fire of­fi­cials in­vited nine gov­ern­men­tal agen­cies and the of­fice of Mayor Muriel E. Bowser (D) to sug­gest ideas for tack­ling the city’s flood of 911 calls while still ad­dress­ing pa­tient needs.

Twenty-six gov­ern­ment and med­i­cal-group staffers from sev­eral agen­cies showed up, a sig­nal that many city ser­vices and city in­sti­tu­tions are af­fected by the 911 sys­tem.

D.C. Fire Chief Gre­gory M. Dean said his de­part­ment has a man­date from Bowser and the D.C. Coun­cil to bet­ter man­age the vol­ume of emer­gency calls.

“The most dan­ger­ous time for these men and women is when they are re­spond­ing with red lights and sirens,” Dean said. “We re­spond to over 500-plus calls per day. If we have an op­por­tu­nity to not put them at risk for what we would not con­sider a med­i­cal emer­gency, then it’s in­cum­bent on us to do that.”

Cur­rently, D.C. 911 call tak­ers ask ques­tions us­ing a com­puter al­go­rithm to de­ter­mine what ser­vice each caller needs.

Un­der the pro­posed plan, once a sit­u­a­tion is de­ter­mined to be non-life-threat­en­ing, a reg­is­tered nurse would join the call and of­fer the pa­tient op­tions for seek­ing care at a clinic or doc­tor’s of­fice.

D.C. Fire Chief Gre­gory M. Dean, on his de­part­ment’s pro­gram to re­duce the num­ber of avoid­able emer­gency calls

For those with­out trans­porta­tion, District of­fi­cials are con­sid­er­ing us­ing for-hire ve­hi­cles, such as taxis or med­i­cal trans­port com­pa­nies, and re­quest­ing that some man­aged-care or­ga­ni­za­tions of­fer same-day trans­porta­tion.

Cost es­ti­mates have not been fi­nal­ized, but District of­fi­cials ex­pect the hir­ing of nurses to be the main ex­pense, and for that cost to be off­set by sav­ings from fewer un­nec­es­sary am­bu­lance rides.

Hol­man said that be­tween 2 and 4 per­cent of call­ers in the District who speak with nurses prob­a­bly would be re­ferred to 911 for am­bu­lance ser­vice.

There have been some li­a­bil­ity chal­lenges with out­side nurse-ad­vice lines, but peo­ple ap­pear to be more com­fort­able with nurses em­bed­ded with 911 call tak­ers, said Kevin Mun­jal, an as­sis­tant pro­fes­sor of emer­gency medicine at Mount Si­nai Hospi­tal in New York and an ex­pert on com­mu­nity paramedicine. Of­ten, peo­ple who call 911 don’t even want an am­bu­lance, he said.

“If you build in the right safety mea­sures and qual­ity as­sur­ance and pro­to­cols and in­volve the pa­tient in the de­ci­sion-mak­ing, it goes a long way to mit­i­gate risk,” Mun­jal said.

“If we have an op­por­tu­nity to not put [first re­spon­ders] at risk for what we would not con­sider a med­i­cal emer­gency, then it’s in­cum­bent on us to do that.”

‘They’re keep­ing me on point’

In Prince Ge­orge’s, Goldfeder and his part­ner, Ken­neth Hickey, point to sev­eral suc­cesses in the three months since the county be­gan its pro­gram.

For those who called about needs such as catheter changes or pre­scrip­tion re­fills, the de­part­ment set up pri­mary-care vis­its or phar­macy de­liv­er­ies. A man with con­ges­tive heart fail­ure got a de­vice to re­motely alert health­care work­ers to swings in his blood pres­sure and weight, al­low­ing nurses to in­ter­vene from afar.

The way Goldfeder and Hickey see it, the peo­ple they serve would be in­ter­act­ing with fire­fight­ers and paramedics any­way. Now they’re get­ting the right care with­out re­sources be­ing di­verted from true emer­gen­cies.

“The fire de­part­ment is no longer just about run­ning 911 calls,” Hickey said. “We’re try­ing to be more in­volved in the com­mu­nity.”

At Lee’s house, af­ter Hickey called her pri­mary-care doc­tor, Goldfeder took a weight scale up to her bath­room. Since the reg­u­lar vis­its, Lee’s health has im­proved, and she has had only one emer­gency-room visit.

“They’re keep­ing me on point,” said Lee, who had a blood pres­sure cuff wrapped around her arm as she praised Goldfeder and Hickey. “I want to be a suc­cess story.”


Ken­neth Hickey of Prince Ge­orge’s County Fire/EMS and Thelma Lee watch Lee’s blood pres­sure num­bers dur­ing a Fire/EMS visit to her home in Up­per Marl­boro in De­cem­ber. Lee gets such vis­its be­cause she was a fre­quent caller to 911 for non-emer­gency health is­sues. Her emer­gency-room vis­its have plum­meted.


Ken­neth Hickey, right, a fire­fighter/para­medic with Prince Ge­orge’s County Fire/EMS, un­loads shop­ping bags with gro­ceries he bought for Thelma Lee be­fore vis­it­ing her at her Up­per Marl­boro home with his part­ner, Brian Goldfeder, a fel­low fire­fighter and para­medic who is also the county’s co­or­di­na­tor of mo­bile health ser­vices. Such vis­its have helped to re­duce Lee’s calls to 911.

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