By BRENT BURGETT
Innovation is a word bandied about in corporate boardrooms and municipal planning meetings to describe the goal of a select few who strive to do things better or more economically with the hope of improving outcomes.
The need for some innovative thinking, coupled with the economics of 2006, prompted the Mesa (AZ) Fire and Medical Department (MFMD) to launch a pilot program into uncharted waters. Because of the economy, budget cuts had taken a toll. This is particularly problematic in a city where many services derive funding from a sales tax. Concurrently, there was an increase in response times citywide as well as in the demand from the city’s growing population.
The department realized that more than 75 percent of its responses were medical in nature and approximately 10 percent were for behavioral health issues. Ignoring these facts cost money and resulted in missed opportunities to address some calls with the most appropriate resources and response.
In 2013, the MFMD ran approximately 55,000 calls, which included attempted or threats of suicide, psychiatric emergencies, anxiety, depression, intoxication, or drug overdoses categorized as “behavioral.” Many calls that could be classified as low level or nonlife-threatening required a response tailored to the unique needs of those circumstances. Paired with the right professionals, a transitional response vehicle (TRV) can handle a call that might normally be assigned to a four-person engine and ambulance; this is also true for behavioral calls. Hospital emergency room (ER) visits are reduced, and medications can be prescribed on the spot. The area’s many visitors during the winter months, who have left their primary care doctors back home, also benefit from this approach. In their local doctors’ absence, they are often compelled to call 911 or to go to the ER for something that can be low acuity.
The original program was started in 2006 because of the excessive demand on our busiest department units. In our busiest battalion, we have six engine and two ladder companies. In 2013, all but two of those units ran more than 3,000 calls annually. The heavy demands placed on these engine and ladder companies create a domino effect; other units now had to begin responding into other first-due areas, increasing response times.
The MFMD needed to come up with something creative because there was not enough money to staff another fire engine to absorb some of the calls. The TRVs, which are strategically placed, ran a combined total of 2,000 calls in the busiest battalion. Every response by a TRV created availability for an engine or a ladder to go to a fire or a critical medical call.
URGENT CARE CLINIC ON WHEELS
The MFMD partnered with Mountain Vista Medical Center, a 178-bed, state-of-the-art hospital in Mesa. The partnership with Mountain Vista was established when MFMD administration reached out to local hospitals and asked if they were interested in taking part in a public-private partnership. Mountain Vista expressed interest, and the partnership was formed.
In 2012, we partnered Tom Morris-a nurse practitioner (NP) with 28 years of experience and a Mountain Vista employee-with a captain/paramedic; Morris has since been riding in the MFMD’s TRV. We call this nurse practitioner unit “PA 201.” Morris has worked in emergency rooms in large metropolitan areas, in family practice, in small rural community hospitals, and in urgent care facilities.
Morris had never been on a fire truck in his life. The environment and conditions that he would face would challenge his experience as a clinician. “I feel like I have worked in the zoo my whole career, and now I got released into the Serengeti,” Morris said. The squawking of the radio, driving to calls, working in the elements, and arriving at a scene with armed law enforcement are all outside the daily routine to which most NPs are accustomed. With no model to follow, the captain/paramedic received on-the-job training. Frequent consultations with the medical director confirmed that we were doing things the way we were supposed to.
There is a lot of shared responsibility; a NP and a captain are used to delegating work. Working together, both parties had to get their hands dirty and work collaboratively to accomplish a shared goal. The unit works 40 hours a week. PA 201 is in service from 9:00 a.m. to 7:00 p.m., Tuesday to Friday. These hours were selected from our research and planning, pulling peak call times for specific calls.
Program costs have been shared between the MFMD and the private provider. The MFMD pays the salary of the captain, and Mountain Vista Hospital pays the salary of the nurse practitioner. The MFMD is not currently billing, so it is up to the private partner to have the billing in place.
DESIGNING SOMETHING THAT WORKS
More than 33 percent of 911 calls nationwide can be classified as not immediately life threatening; these are the calls that tax the resources of a fire department’s emergency response units. This is where the MFMD realized the need for innovation. We found that matching the response to the level of urgency along with targeted personnel has saved money and resources and improves outcomes.1 The department’s leadership trusted those of us who were the charter members of the program. Reviewing and fine-tuning were integral parts of how things were to proceed, but the approach remained largely hands-off.
Also valuable was the fact that our administration never gave us strict guidelines; we were told to just make it work. We never felt afraid to make the wrong decision and felt constant support from the top, and that is what allowed us to build the program. Although we were responsible and accountable to senior staff and our medical director, the program was also monitored by our research and planning team, which provided us with numbers once a week.
The innovative nature of this approach meant that information had to be shared and fine-tuned. It felt like we jumped off a cliff and were told to build our parachute on the way down. We began meeting once a week for about five months. We then met every two weeks; we now meet once a month. These meetings with senior staff were informative, since this response model was a new experience for all involved. Communicating the problems that we faced sparked a valuable dialogue.
Based on responses to our patient care reports, approximately 25 percent of all patients (13,000 patients annually) who call 911 had been treated in a hospital during the previous 30-day period. Within this group, more than 10,000 are transported by ambulance back to a hospital.
The greatest percentage of patients who require a return visit to a hospital have resulted from cardiac history and symptoms. That group is followed by those with complications of diabetes. Behavioral issues and respiratory concerns rounded out the top four groups.
BEHAVIORAL HEALTH EXPERTISE
By April 2013, PA 201 had been in service for about eight months. Then, much to its benefit, the MFMD added a mental health professional to its staff. Our partner, Crisis Preparation and Recovery, selected Dennette Janus, MA, NCC, LPC, as the MFMD’s licensed crisis counselor to work as part of our behavioral health unit-TRV 202. Janus has close to 20 years of experience in the fields of human services in mental health assessment and counseling, crisis intervention, parent coaching, substance abuse issues, victim advocacy, child protection, domestic violence, and community education. TRV 202 is in service from noon to midnight, Wednesday through Friday. The unit works 40 hours a week based on peak call times; the extra four hours are focused on administrative duties.
Before TRV 202’s deployment, we responded to behavioral calls with a four-person engine and a ladder-two emergency medical technicians and two paramedics. We would typically send people to the ER in a private ambulance just to be safe.
A FEW BUMPS IN THE ROAD
The program has not been without some challenges. Based on the behavioral health unit’s atypical response, we have met resistance transporting directly to an inpatient psychiatric facility. When we arrive, the intake staff wants to see the hospital discharge papers. When we tell them that the patient was brought in from the community, some facilities are not supportive. This creates a bad environment. In the past we have had a patient change his mind and refuse psychiatric treatment. We then had to get him back into the TRV, convince him to get evaluated, and then transport him to another facility when he finally agreed to go.
To deal with this response, we set up meetings with the hospital administrative staff to educate them on our plans, which was a positive step and ensured further communication with their intake people. All in all, the initiative has been successful for all involved.
Adding a behavioral health professional and nurse practitioner to a TRV crew has helped provide behavioral health crisis disposition on scene rather than essentially having every patient be taken to an emergency room by ambulance for the same level of evaluation. The unit allows the department to allocate resources more strategically while saving patients the cost of unnecessary hospital bills and relieving some of the congestion at the local ERs. Although there has been some resistance from area hospitals, the opportunity to prevent readmissions has been welcomed. This has helped build community partnerships.
This model benefits communities nationwide. With the awarding of a new $12.5 million grant from the Centers for Medicare and Medicaid Services in July 2014, the MFMD’s program will better develop a more outcome-measured model, providing a quantitative evaluation for other departments.
Author’s note: Thanks to K. Richard Douglas for help with this article.
BRENT BURGETT, MA, EMT-P, is a captain with the Mesa (AZ) Fire and Medical Department, where he has overseen the nurse practitioner and licensed crisis counselor programs for the past two years. He is also an adjunct faculty instructor with Mesa Community College and AT Still University. Burgett was recognized with an Ace of Hearts Award by Arizona Emergency Medical Systems for providing outstanding contributions that enhance and improve emergency medical and trauma care.
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