When we talk about “frequent flyers” and other high-utilization patients that account for large percentages of overall healthcare spending, we’re often talking about mental health conditions in varying stages of diagnosis, treatment and management. How EMS providers respond to and work with these patients can have a dramatic impact on the bottom line and continued success of the agency.

Technological solutions

The city of San Diego has been widely recognized for its work in countering a problem shared by many urban EDs, a category of patient that James Dunford, the city’s medical director, calls “the chronic homeless alcoholic.”

Typically uninsured, these patients have either failed or refused treatment on numerous occasions. They occupy beds and consume resources every time they’re admitted—be it to the ED, prison or a rehabilitation center. Frustrated by this revolving door, Dunford and his team set out to identify the top 10–20 patients in this category and find out how much money they were costing San Diego’s healthcare system. The answer turned out to be $1.5 million over an 18-month period—enough to gain the attention and the financial support of key stakeholders in the city. The next logical step was to develop a program to get this number down.

The resulting serial inebriate program (SIP) is a unique collaboration between healthcare providers, law enforcement agencies and behavioral health specialists. SIP exists within San Diego’s broader resource access program (RAP), a paramedic-based surveillance and case management system that intercepts frequent 9-1-1 callers. RAP focuses on those people and assigns each one a case worker who can link them with up to 30 different agencies to get them the care they need in non-emergency situations. The team dedicated to responding to homeless and SIP cases consists of a police officer, a psychologist and a case worker. In non-violent cases, the police officer is replaced with a paramedic.

But how do the paramedics and case workers know that their RAP and SIP patients are calling 9-1-1 for help? The answer lies in the city’s information exchange, San Diego Health Connect, and a sophisticated computer-aided dispatch (CAD) system plus additional software.

RAP and SIP patients are flagged in the information exchange, and dispatch software runs an automatic scan of current 9-1-1 callers against people of interest. If there’s a match to a RAP or SIP patient, the dispatcher notifies the case worker, who determines an appropriate response. In a true emergency, the patient is always transported to a hospital, but more often than not what the patient actually needs is a taxi to their primary care physician or, in the case of SIP patients, a hot meal and a blanket.

Dunford says that caller “hot spots” (homeless shelters, nursing homes and any other location that generates frequent calls to 9-1-1) are mapped and reported to physicians. The most frequent flyers and chronically homeless are flagged and the entire database is searchable by a number of functions, including behavioral and psychiatric needs. The city can also track the time and distance traveled by ambulances and fire trucks to estimate the cost associated with responding to the homes of 9-1-1 callers.

Eventually the city was able to work with United Way to obtain a round of funding that went toward housing vouchers for SIP patients. In the first year, Dunford says the program saved the city almost $8 million and proved that with proper care, attention and data monitoring, it’s actually possible to stabilize people who had long been thought to be a permanent problem.

Achieving the triple aim

Regional Emergency Medical Services Authority (REMSA) in Reno, Nev., is known as one of the standouts in community para-medicine programs, and project director Brenda Staffan frequently reiterates the agency’s “triple aim” of 1) improving patient care, 2) improving population health, and 3) lowering costs. Figuring out how to best care for mental health patients was a key challenge in achieving this goal.

REMSA’s first move was to establish ambulance transport alternatives. Not every person who calls 9-1-1 needs to be taken to the ED. Instead REMSA’s ambulance fleet can now transport patients to an urgent care center, a triage center or a mental health facility depending on their needs. Similar to the San Diego system, this process starts in the communications center as soon as the 9-1-1 call is received.

Reno staffs nurses who work in the comm center alongside the emergency medical dispatchers (EMDs). As the dispatchers go through the EMD protocol, a computerized triage algorithm determines the appropriate level of care for the caller, even if the appropriate level of care is to transport that person to the hospital. There is another set of protocols for the 9-1-1 dispatcher to identify callers who do not require an ambulance transport at all.

Collecting and analyzing data led REMSA to implement one of its most successful changes to date: a non-emergency nurse’s hotline. After reviewing the data on hand, Staffan’s team found that 75% of ambulance transports were for patients on either Medicare or Medicaid, or the uninsured. This is a population that didn’t have a phone number they could call to ask a nurse a question, so they dialed 9-1-1 instead.

Now, thanks to REMSA, the people of northern Nevada have a non-emergency line to dial for their basic health concerns. The number goes to a comm center monitored by EMDs and nurses who follow a set of protocols, just like 9-1-1. REMSA compiled a complete directory of resources and services that dispatchers can connect callers to: behavioral specialists, food and housing programs, senior services, charitable organizations, etc.

Since its launch, the non-emergency line has become so well known in the community that call volume is now nearly equal the call volume to 9-1-1. Staffan says she believes the 9-1-1 call volume will actually start to decrease over time as REMSA is able to improve public awareness of the different options available. In the meantime, REMSA continues to track 28 different measures that it reports to the Centers for Medicare and Medicaid Services (CMS). This includes balancing measures such as repatriation, when patients who were triaged as non-serious end up in the ED at a later date for the same condition that spurred the original call.

Human care

In a significantly more hands-on example, the Center for Emergency Medicine in Pittsburgh works to connect paramedics with vulnerable patients on a personal level that often surpasses any kind of medical care.

Vice president and cofounder Dan Swayze shares an example of a wheelchair-bound bariatric patient who called 9-1-1 because she couldn’t get out of her house. When paramedics arrived, they found an unsupported piece of plywood that the woman’s son was trying to use as a wheelchair ramp from the front step of the house to the sidewalk. They also discovered that the woman’s primary motivation for leaving the house was to get to the bank to withdraw money for an injured family member’s bills. Rather than responding only to the woman’s medical condition—the severe obesity that kept her in a wheelchair—paramedics called on a couple other supporting agencies and went to work building a reinforced ramp able to withstand the load of getting the woman out of the house so she could go to the bank.

“In the old system we would only be able to treat this woman for her obesity, but clearly her top priority was elsewhere,” Swayze says. “By recruiting resources to help her with her top priority, it opened the door for us to go back and do a healthcare assessment in-home to help her get on the right track. If we hadn’t been able to help her with her top priority, she wouldn’t have trusted us to help with anything else.”

Building patient trust is a key component of Swayze’s strategy for providing mobile integrated healthcare (MIH) in a county that has 45 different EMS provider agencies. In traditional emergency systems, the access point for patients was 9-1-1, with definitive care provided in the ED. In the case of Swayze’s bariatric patient and so many others, definitive care is a long, gradual process that is beyond the scope of the ED. Effective treatment means much more than diet and exercise, because there’s a host of psychological ailments associated with the root cause of the obesity.

That’s where Swayze says the power of persistence comes into play: “EMS can actually stick with a patient a lot longer than hospitals and sometimes even social workers can.”

The program he developed from this way of thinking is one of voluntary enrollment targeting high utilizers and vulnerable patients. The goal for community paramedics is to find out what gets in the way of patients managing their own health better, engage with them for a two- or three-month period, and then assess their progress and their satisfaction. This required a workflow to be built into the public safety answering point (PSAP) to get these patients referred to services outside of 9-1-1.

Swayze emphasizes assessment techniques that look beyond biological systems to factors such as mental health history, social network, environment, economics and community engagement, then learning how to interact with all of these patients on a human level. The new focus is on navigation and advocacy: finding appropriate resources in the community, learning who is eligible and how they can apply, and then helping patients get enrolled. An example might be something as simple as helping a person with ADHD or dyslexia enroll for health insurance on healthcare.gov.

The availability of mental health resources will always be a challenge to the healthcare field; there’s just not enough funding to keep up with demand. As EMS providers redefine their role in the communities they serve, helping mental health patients find the proper care will be a growing proportion of the overall model.

Kristina Ackermann is the managing editor of EMS Insider . Reach her at .