Diverting Frequent Fliers

     Every 9-1-1 system has its frequent fliers. They drive up call volume and consume resources others might need more urgently. They have needs of their own, but they're often needs EMS isn't suited to meet. How, then, can a system reduce the burden these callers create while still fulfilling its basic mission to help them?

     The 9-1-1 Alternatives program conceived by the Memphis Fire/EMS Department seems to be doing both. It's an effort to divert superutilizers out of the system through directed interventions to help them get their needs met in other ways.

     Department leaders kicked the program off by identifying the 10 addresses to which they were called most often. These included both private homes and care facilities, and the numbers they represented were startling.

     "Those top 10 addresses accounted for around 4,500 runs a year," says medical director Joe Holley, MD. "The top few individuals were all more than 100 calls a year."

     With these initial targets identified, the department reached out. A lieutenant dedicated to the job contacted each of the top 10 to figure out why they were calling so much and how their nonemergency medical needs might be better met. The department would then work to connect them with more suitable resources.

     This required dual approaches: Among the top 10 were some assisted-living facilities and clinics where staff knew no better than to call 9-1-1 for things like routine transports. Intervening for these users meant, in some cases, teaching staff to utilize private services for nonemergencies.

     "We spent time educating people about what qualifies as an appropriate call to 9-1-1," says Holley. "Many facilities have never actually thought about having a contracted transportation provider, when it's really an emergency, and trying to utilize the right level of service for the circumstances."

     That component has been challenging for several reasons, including issues of communication and turnover among facility staff, as well as liability worries if a patient waiting for a nonemergency ride should suddenly deteriorate, but efforts continue. Meanwhile, comparable interventions among individual superutilizers have led to clearer results.

     Generally, the callers in this group were each going to multiple Eds with myriad medical problems and complaints. Many times, social services and other support entities were working to help them, but without knowledge of what was happening with the same patient at other hospitals and elsewhere in the community. The proverbial right hand was oblivious to its counterpart. Efforts were being duplicated, and care wasn't integrated.

     Integrating it meant bringing the right people from various hospitals, government agencies and charitable organizations together to work jointly on customized plans to help each patient. This meant a lot of leg work up front. One of the top utilizers faced first was the source of 275 calls in one year.

     "Initially what that took was us going to her apartment every other day and checking on her," says Holley. "We'd take her to the drugstore to get her drugs, we'd get her to her doctors' appointments, we got her a psychiatric evaluation, all these things. It was a huge effort for about three months, above and beyond in many ways."

     Once the basic template was established, though, the process of helping subsequent superutilizers, who were making fewer calls, became easier. It continues today (see Finding, Helping Superutilizers, page 84). And the results have been good: The woman above hasn't called 9-1-1 in a year, Holley says, and that's been typical.

     "In every case," he says, "while it took an intense proactive effort, we were able to fill in the gaps and ultimately move that patient through the system."

     Beyond helping these patients, redirecting the superutilizers has helped control the department's call load; its alpha-level calls dropped by 3%, or 3,000 calls, in the first year. And establishing the social services and other connections across the community has been invaluable to helping future patients. What's more, the limited initial investment—a full-time staffer, vehicle and ancillary support—was quickly recouped. Many of the calls eliminated were ones that couldn't be billed to Medicare or other payers because they weren't medically necessary.

     "And, quite honestly, it's also reduced our risk," notes Holley. "Because when you're seeing that patient for the 22nd time this month, is that going to be the MI? Are you going to miss it because you're just so fed up with this person?"

     That trap did present itself to Memphis providers. On the 236th of her 275 calls, the woman above had exactly that: the big MI.

     "Fortunately, the guy who picked her up knew her well, but was objective and didn't blow her off," says Holley. "She got great care."

     With the most misguided superutilizers of their services being helped elsewhere, Memphis providers are now freer to deliver that to those in need.

Finding, Helping Superutilizers
     The frequent flier described in the accompanying article called just about every day, sometimes twice. Sometimes she'd call from a pay phone outside one ED to go directly to another. The emergency department was her primary source of healthcare, and she'd "hospital-shop" until she got what she needed. She'd been utilizing EMS as a gateway to healthcare and treatment for her mental illness for more than 20 years, racking up an estimated $12.9 million in ambulance and ED charges. She'd even been "banned" by several local Eds.

     What this lady had really become was a victim of the system. She was the kind of caller the 9-1-1 Alternatives program was designed to assist. The goal of the first-of-its-kind program, created in 2005, is to create awareness of possible alternatives to 9-1-1 for nonemergent requests for transport, thus decreasing economic strain through more proper utilization of resources.

     According to Mark Heaston, manager of the Memphis Fire Department's PIER (Public Information, Education and Relations) program, callers requiring intervention are identified by department providers, who get first-hand views of their problems. The service's QI team also examines run reports for repeat users; if they find, for example, three or more responses to the same address in a month, then contact is made with that individual or institution to evaluate their needs. If it's found they could be better served with alternative resources, they are asked if they would accept other kinds of assistance. In nonemergent cases, contact is made with a hospital case worker, and Heaston and the caseworker begin locating resources to assist the individual.

     At the community level, this assistance is facilitated by the CARE (Community Awareness Reaching Everyone) Team, which includes hospital case workers, government agencies and a Memphis Fire Department program manager. Team members work together to customize care plans for those who utilize emergency services for nonemergency needs. This process involves daily communication with outside agencies and the person in need. An important element is facilitating communication and ensuring follow-through until the person is plugged into proper resources and no longer misusing 9-1-1.

     According to Deputy Chief Gary Ludwig, who catalyzed the program's creation, the vision is to prevent problems before they occur. "Public-access defibrillation, CPR training, fall prevention for senior citizens, bicycle helmets for children, car seats for babies—that's our vision of where our PIER programs should go," Ludwig says. "What the fire service has done for the last 30 years through education and fire prevention is a model the EMS community can follow."

     To learn more, e-mail jim.logan@memphistn.gov.