Taking 911 Off Speed Dial

City eyes expanding program to proactively help chronic callers, while the hospital's effort already in full swing

Sometimes people who call 911 don’t have the kind of emergency you’d expect. They’re reporting shortness of breath that may just come back to a need for human contact. They’re calling on behalf of someone else who needs a safe place to sober up. Or they simple need a ride to the doctor and think an ambulance is the best way to get there. Some of them end up calling emergency dispatchers several times in a six-month period.

In fact, the same 250 people make up nearly one in every five calls to 911 in the city.

The reasons why they seek help this way are complex, yet programs intended to head off health issues for those individuals before they reach emergency status and to give more appropriate assistance seem to have promise in Santa Fe.

The city's fire department, which also operates the ambulance service, is nearing the full launch of the Community Protection Initiative, a program kicked off in 2014 as a pilot.

While the efficiencies seem obvious—fewer ambulance rides save those resources for when they're needed and reduces health care costs—the program itself is also about increasing the overall health of the community.

If funding from the private sector shakes out as anticipated this fall, the department plans to reach beyond the people targeted in the pilot. Rather than just 25 of those 250 frequent fliers, who make up 18 percent of emergency calls, it hopes to include them all. Individuals who called 911 more than four times in 2013 or twice in a six-month period will be the program's focus, earning a visit from a team that includes two EMTs and, on a part-time basis, a physician, a social worker and a pharmacist, who will meet in their homes to check on health concerns.

"Treating individuals that have nonemergency problems through the emergency system is very expensive, and being reactive instead of proactive with a lot of these emergency patterns that we see is very expensive," says Andres Mercado, a city paramedic and firefighter who is the point person for the Community Protection Initiative. "So we'll be keeping very close data on program costs and very close data on any savings that accrue to the system."

Yet Mercado says the program is about way more than the bottom line.

"It's not about making money or saving money," he says. "It's about making sure that the care that we provide has value in it."

The team will assess patients' connections to resources and community services, whether they have health insurance and a primary care provider, whether prescriptions have been refilled and if fragmented care means multiple physicians have prescribed a dangerous combination of medications. Problems with addiction and basics like food, shelter and transportation may also be addressed.

Some of the repeat callers, early findings suggest, are using the emergency room as their primary care and mental health providers. If those enrolled in the program do call 911, they'll still trigger the full emergency response.

The program and its users suggest a more holistic flaw in the way the medical system is functioning. Mercado says, as a nation, we spend more money on health care than we do anything else, and yet we don't seem to be getting a great return on that investment.

"Eighteen percent of our [gross domestic product] would be a great investment if we were getting great health outcomes, but we've got an infant mortality rate worse than Cuba or Croatia," he says.

And if emergency calls were fixing the health issues for these callers, they wouldn't be regularly cycling through the emergency response system. Repeatedly, he says, they've found substance abuse and mental health at the core of the issue for peak utilizers. Those problems aren't likely to be solved with 24 hours in an ER bed.

That's where those people might find themselves in Christus St. Vincent Regional Medical Center's High Utilizer Group Services, or HUGS, a program for frequent users of the emergency department.

"We have a social services system here in Santa Fe that is above the heads of these high utilizers. It is essentially a web of services that the high utilizers cannot reach," says Kristin Carmichael, a social worker who is director of community health at Christus. "Their functionality is really impaired, and their ability to process information and to participate in different programs and to even have the social skills to maybe wait in a waiting room are not the same as other people, so what you see is that this population essentially has become a class of untouchables."

So, they end up in 911 calls, emergency rooms and jails. HUGS focuses on the 15 highest emergency room utilizers from the previous six months. High utilizers might have five or more visits to the ER during that time, though some have had as many as 20, and one made 50, Carmichael says.

HUGS staff connects these individuals with existing services, often those targeted at behavioral health and substance abuse issues; irons out difficulties like, for example, a ban from the bus system or their tribal lands; and solves some basics that can make a big difference—a bus pass or $8 mobile phone, for example, or, in one case, a $75 mattress cover for someone with bedbugs. They've documented a 35 to 50 percent reduction in ER visits among participants during the six months in the program, and the reduction carries over into the months that follow.

The group HUGS works with has similar issues to what the fire department sees in repeat 911 callers, though it's not the same population, Carmichael says. There's overlap, but not total overlay.

"One thing people in our community don't understand about this population—these are the homeless people you see downtown living under bridges, folks downtown talking to themselves—what people don't realize is that these folks can change if they're given the right kind of care and the right kind of service, and that means a service where you go to them, you help them with these very basic building blocks. You don't wait at your desk. You go into the arroyos, and you find them," she says. "What we have is a myth in our community that you shouldn't waste time on these people, that they're noncompliant, they're bad, but what's really happening is that in many cases, we don't give them what they need."

Nationwide, the number of programs to address chronic callers for emergency help is growing, according to Christopher Blake Carver, with the National Emergency Number Association. What prompts a 911 call has dramatically changed in recent decades, he says, and across the country, the percentage of calls to 911 for non-life-threatening emergencies has increased.

"We only have so many firetrucks, we only have so many ambulances, we only have so many police cars. It's not an unlimited resource, and any use of those resources for nonemergency situations has a negative impact on response times, and that can potentially be severe, depending on the kind of emergency that we're talking about," Carver says. "Ensuring every part of the system works to meet the demands of the public as they are, not as we would expect them to be or maybe assume them to be, is a very wise use of emergency resources and a very wise use of taxpayer dollars."

Not only have 911 centers started seeing calls from people who basically just need a ride to the hospital—one municipality has created a taxi voucher program to reroute those calls from ambulances—but emergency services requests have become incredibly complex, often exceeding the purview of EMS and fire agencies and demanding a collaborative approach. In addition to life-threatening emergencies like fires and cardiac arrest events, fire and EMS agencies now handle other public safety matters, from hazardous-materials incidents to rescuing people from a stuck elevator.

"One thing that this cannot be about is, 'Well, we figured out that we need more social workers, so we can close 15 firehouses or we can lay off 25 cops or we can lay off ambulances.' It's not that at all," Carver says. "But getting them in the room and having them develop creative solutions to these issues is really better for everybody in the end."

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