Emergency departments nationwide—from the largest medical centers to the most remote critical access hospitals—spend a disproportionate share of staff and financial resources providing non-urgent care to patients who often would have been better served in the home or a primary care setting.
I recently participated in the West Health Advisory Council on ED to Home-Based Care—a multidisciplinary council comprised of emergency physicians, geriatricians, home health nurses, policy makers, and caregivers brought together to discuss how to expand the use of home-based care options for patients initially seen in the ED.
I sat down with one member of the Advisory Council—Dr. James Dunford, Professor Emeritus of Emergency Medicine at the University of California-San Diego and Medical Director for the City of San Diego—to discuss the development of the City of San Diego’s community paramedicine program and his team’s efforts to improve the health of medically and behaviorally complex members of San Diego’s community.
Q: Can you tell us about your role and background as the Medical Director for the City of San Diego?
I became the City Medical Director for San Diego in 1997 and prior to that, I was the Medical Director for San Diego Fire-Rescue where I supervised 850 fire fighters and 550 paramedics. I also have been a professor of emergency medicine at the University of California-San Diego for 35 years and have spent my career caring for patients in the ED.
Q: What was the impetus for the launch of San Diego’s community paramedicine program, called the Resource Access Program (RAP)?
We launched the RAP initiative in 2008 with a single pilot, aiming to case manage frequent users of acute care services. We realized that people who have issues with housing instability, job insecurity, alcoholism, and drug abuse, in addition to medical and mental health conditions default to the ED, which is the worst place to go to solve a chronic problem.
Through the RAP pilot, we showed the potential to save money and improve the quality and coordination of care for the most complex patients in San Diego. We focused on those frequent ED users who had a significant impact on a broad spectrum of community resources including law enforcement, the health care system, and EMS services.
We initially risk stratified people by the number of ambulance transports, focusing on those “mega users” who had 50+ ambulance transports in a given year. At the beginning of the RAP program in 2008, we had approximately 25-30 “mega users” being case-managed by just one community paramedic. Since then, we have increased our staffing to five community paramedics and have succeeded in reducing the number of mega users to approximately five. We’ve also increased scope of the patient populations with whom we work, including those patients who call 9-1-1 over six times per year.
Q: Many programs find it difficult to track the impact of their services. What metrics have you tracked to measure ROI and how have you done so?
We use a patient-centered (as opposed to incident-centered) cloud-based EHR program called "Street Sense." This home-grown software tool allows us to track a host of metrics (before and after RAP) including 9-1-1 calls and ambulance transports, the interval between a given patient’s 911 calls, charges per patient, unit hours logged to fire trucks, and even the miles logged on ambulance tires.
The Street Sense system operates in the background of the City’s cloud-based electronic health record system. It can rapidly recognize and notify a RAP community paramedic whenever a one of their frequent users calls 9-1-1. The RAP paramedics can pull up information from a patient’s prior 9-1-1 calls to get a holistic view of the patient during a call. The system can also simultaneously alert a patient’s case manager or care team to the fact that their patient has just called 9-1-1 and is being transported. The Street Sense system will soon begin pushing patient-specific community care plans to RAP paramedics who (under a 2-year California Community Paramedicine Pilot Project) will determine whether treatment other than transport to an ED is best for the patient.
In our pilot program, we found that EMS charges fell by 32% (from $689,743 to $468,394) as a result of the decline in encounters. Fewer encounters also translated into a 40% drop in the number of hours spent by EMS workers caring for the 51 frequent callers, and a 47% reduction in the number of miles traveled by emergency vehicles in response to calls from them.
Post-pilot RAP program data from 2012 and 2013 shows an estimated net savings of approximately $700,000 a year, after accounting for program costs.
Check out part two of my interview with Dr. Dunford, where we discuss the details about the RAP program services, the community collaborations necessary to scale this program, and what’s next for the City of San Diego EMS. For more information on the research PHA is doing on community paramedicine, email me at WildC@advisory.com.