The Front Door to Care: EMS in Louisville Grows Beyond Simple 9-1-1 Response

The history of EMS in Louisville is characterized by change. The city started its first municipal emergency medical service in the 1970s, and over the next 30 years, the provision of prehospital care would take many shapes. Initially a freestanding agency, Louisville EMS merged into the Louisville Fire Department in the 1990s. Jefferson County EMS, a separate stand-alone agency, served the suburbs surrounding the city’s urban core. After Louisville merged the two governments that operated the city and its surrounding county, Louisville Metro EMS (LMEMS) was born. The third-service emergency prehospital system began serving the entire newly merged city in 2005.

With the new service came numerous challenges, not the least of which was combining two existing EMS systems into a single unified force. The service also had to integrate with a new 9-1-1 communications center that, for the first time, served all of the city’s first responders. But along with the challenges came numerous possibilities, including the introduction of new cutting-edge EMS technologies and a redirected clinical focus as a service led, for the first time, by an emergency physician.

However, the same old issues that plagued EMS across the country remained. Increasing call volumes were rampant, particularly nonemergent, low-acuity calls that could be better handled by a primary or immediate care provider. Municipal budgets were tight, so funding to address the growing call volume wasn’t likely. Lastly, Kentucky was facing a shortage of paramedics, making it difficult to find trained personnel.

Nurse-Based Triage

In 2008 LMEMS leadership decided to address these endemic issues, starting with the low-acuity calls. Each year LMEMS received more than 100,000 individual calls for service. However, more than 20,000 of those were considered nonemergent or low-acuity. The agency investigated a number of new concepts to tackle the problem. The answer came in the form of a nurse-based triage program supported by medical algorithms developed by a subsidiary of Priority Dispatch, the provider for Louisville’s MPDS 9-1-1 communications center dispatch algorithm. This new algorithm, then known as Priority Solutions Integrated Access Management (PSIAM), integrated seamlessly with MPDS’ ProQA call-processing system, which had been used in Louisville for several years.

The triage program colocated a trained nurse in the 9-1-1 center. Instead of dispatching ambulances to low-acuity calls categorized by ProQA as one of a certain subset of nonemergent call types, those calls were referred to the nurse, who used a second, more in-depth algorithm to identify a more appropriate care solution. The nurse could also assist the patient with transportation, if that was a barrier to the patient’s ability to seek care.

LMEMS applied for and received a $50,000 grant from the local Medicaid managed care provider to launch a PSIAM program in 2008. It also developed a care and transportation resource list the triage nurse could use when referring a patient for nonemergent care. This was critical to the success of the program. If the nurse had no alternative resources available, the call for service ultimately returned to the 9-1-1 system for dispatch.

LMEMS pitched the concept to community medical organizations, healthcare providers, urgent care centers and physicians, asking them to accept patients referred by the triage nurse. The next step was to assemble a network of alternative transport providers that would eventually include private ambulance services, wheelchair van transportation services and even the local cab company.

In the newly merged Louisville metro, all police, fire and EMS dispatch functions were handled by a single stand-alone communications agency called MetroSafe. The implementation of PSIAM meant significant changes to how the MetroSafe communications center did business, and there were understandable concerns about whether a secondary nurse-based triage program would negatively affect the center’s ability to quickly and efficiently handle calls. In addition, a link had to be built between the PSIAM technology and the computer systems used by the 9-1-1 call center—a process that required a great deal of effort to ensure it was 100% secure and reduced risk to the call center’s daily operations, especially regarding dropped calls and time to dispatch.

After several months, all of the critical pieces finally came together. In April 2010, PSIAM in Louisville was born.

Because LMEMS had no resources to hire a full-time nurse to operate the triage line, the agency partnered with a local university nurse practitioner master’s degree program to provide students to staff two four-hour shifts each day while earning clinical hours. An internally produced database logged all available care and transportation resources and tracked patient referral data. Customer satisfaction surveys were sent to every patient triaged by the nurse. In the first year, the volunteer nurses triaged nearly 550 low-acuity calls.

Like a Negotiation

Leading the PSIAM charge in the call center was Maj. Rick Roller, a veteran paramedic with a nursing background. After a few months manning the phones, he realized that, while PSIAM may look like ProQA, its purpose is completely different. Instead of using an algorithm designed to be read verbatim to ensure call-processing accuracy and efficiency, the nurse had to engage the patient in an in-depth conversation, explaining the benefits of seeking alternative care. It was almost like a negotiation. After years on the streets providing care to patients whose medical concerns didn’t require an emergency response, it made sense to him.

Customer satisfaction surveys revealed that 90% of patients who went through the PSIAM process were very satisfied with their experience. Care providers began contacting LMEMS and asking to be listed in the community referral network. Patients who didn’t have primary care physicians were getting access to the healthcare system for the first time, without an ambulance bill or a long wait in the emergency department.

It was clear from the beginning that the main driving factors behind low-acuity patients’ activation of the 9-1-1 system were not lack of health insurance or inability to access primary care. More often than not they simply lacked transportation. It was also clear that, in order for the PSIAM program to reach its full potential, LMEMS would need to dedicate consistent full-time resources to its growth.

In 2011 LMEMS replaced the part-time volunteer nurses with a full-time triage nurse. A second nurse was added a few years later, and the phone lines are now open from 8 a.m. to 8 p.m. weekdays and 8 a.m. to 4 p.m. weekends.

In 2013 the program handled almost 3,000 low-acuity 9-1-1 calls—five times the volume of its first year. Eighty-five percent of PSIAM patients are transported to care by a non-LMEMS resource, freeing up ambulances to serve the most critically ill and injured.

Frequent Utilizers

In 2011, with the support of a grant from Bloomberg Philanthropies, LMEMS began developing plans to address frequent utilizers of the 9-1-1 system. A closer look at the 10 addresses that generated the largest number of 9-1-1 emergency medical calls showed that low-income senior-living facilities and shelters serving the homeless topped the list. LMEMS hypothesized that the number of 9-1-1 calls from these locations could be reduced by giving patients there access to preventive care.

LMEMS identified one senior-living and one shelter facility for the pilot medical outreach program. Working with two community partners, LMEMS provided access to primary care in these locations, then measured to see if access to care had a positive effect on patient outcomes.

Working with the local university, a weekly walk-in clinic was established at one of the city’s largest emergency shelters. With oversight provided by a licensed nurse practitioner, students conduct basic examinations and prescribe medications as needed. These students also work with shelter staff to help volunteers distinguish between emergencies that require EMS and medical needs that can be handled in a nonemergent setting.

This pilot was launched in February 2014. With the help of the university and the New York Academy of Medicine (NYAM), LMEMS is in the process of developing tools to evaluate the effect it’s having on patients and the 9-1-1 system.

LMEMS launched a similar project in the senior-living facility, partnering with MD2U, a nurse practitioner-based in-home primary care practice that operates in eight states and member of the PSIAM community provider network. An MD2U nurse practitioner visits the selected facility daily to see patients who have requested medical assistance. If the patient already has a primary care provider, the MD2U nurse will devise a care plan and work closely with that patient’s physician to ensure they are aware of their patient’s condition. If the patient does not have a physician, MD2U will offer the opportunity to receive regular visits from the MD2U staff. MD2U bills the patient’s third-party coverage for the visit. Patients are billed for a copay later. No patient has been discharged for inability to pay their bill.

The senior-living project was launched in July 2013. Since it began, MD2U has visited 58 patients. LMEMS is currently collecting data showing the number of times these patients called 9-1-1 in the six months prior to and after their enrollment in the pilot project. The agency will develop patient outcome measurements with assistance from NYAM.

To address calls for service from patients living on their own who don’t require regular transport to a hospital, LMEMS started a third pilot project, training a group of senior-level paramedics as paramedic patient care navigators (PPCNs). Typically these patients do not need the services of a paramedic, but they do need the skills and judgment a paramedic brings to determine whether there is a more emergent underlying issue causing their medical concerns. LMEMS hypothesized that paramedics could help these patients stay in their own homes, resolve low-acuity medical issues on site and maintain ongoing relationships with patients whose chronic conditions were difficult to manage.

The PPCN pilot was launched in November 2013. Of the 64 patients seen by PPCNs during the pilot phase, 55 were either treated in-home or received alternative transport to a medical facility, for an 86% diversion success rate.

Where From Here?

Though limited in scale, LMEMS’ pilot alternative care programs have validated the initial belief that the “you call, we haul” method of providing care to 9-1-1 patients is outdated and outmoded. In fact, these pilots have encouraged LMEMS to reevaluate its entire business model and rethink the way care is provided in both the prehospital and hospital realms.

Moving forward, LMEMS hopes to recreate itself once again as an “out-of-hospital” medical care provider, delivering higher-quality care to patients and preserving critical 9-1-1 resources for the most seriously ill and injured, while reducing costs to Medicare, Medicaid and third-party payers.  

Neal J. Richmond, MD, has been the chief executive officer and medical director for Louisville Metro EMS since 2004. His primary focus has been on the engineering and evolution of a stand-alone third-service model for prehospital care. This work has been featured in USA Today and top emergency-services publications. Prior to joining Louisville Metro, Dr. Richmond served in a variety of roles and capacities following his post-graduate training in emergency medicine, including associate program director for the emergency medicine residency at Long Island Jewish Hospital and assistant professor of emergency medicine at the Albert Einstein College of Medicine. From 1996–2004 Dr. Richmond served as deputy medical director for the Fire Department of New York (FDNY), as well as program director for the affiliated fellowship program in EMS. He was also medical team manager for FEMA’s Urban Search and Rescue New York Task Force 1 during both the FEMA response to Hurricane Georges in the Dominican Republic and in the FDNY response to the World Trade Center on September 11, 2001.

Kristen L. Miller is the chief of staff for Louisville Metro EMS. She received a BA in journalism and government from Western Kentucky University in 1997 and a JD from the Brandeis School of Law at the University of Louisville in 2000. She was admitted to the Kentucky Bar in 2001. Kristen has spent most of her career in public service, working in communications for Gov. Paul E. Patton, as a staff attorney for Court of Appeals Judge William E. McAnulty and as special assistant to Mayor Jerry E. Abramson. In 2005 she came to the newly created Louisville Metro EMS to assist with the agency’s organization and management. Since then she has focused much of her efforts on special projects to create alternative care and transportation programs for LMEMS, starting with the establishment of one of the country’s first nurse-based triage systems in 2010. In 2011 she was part of a team selected to participate in a government innovation grant awarded to Louisville by Bloomberg Philanthropies, directed toward providing medical outreach to patients in vulnerable populations.