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Tip of the Spear
by Dennis Rubin

Case study: Revamping EMS services

These lessons will be in play as the cost-reimbursement gap widens in pre-hospital services in the near future

By Dennis Rubin

As the administration of the 44th President of the United States moves its second term, look for changes to America's health-care system. Expect those changes to affect reimbursement for ambulance service costs. 

These changes will likely widen the gap between the cost of delivering pre-hospital care and what service providers can recover from Medicare, Medicaid and private insurance payments. Knowing that emergency ambulance services will continue to increase in cost and service demand, the fire-rescue service will need to keep looking for measures to control the rising costs. 

Among the issues that have to be addressed in the immediate future are the lengthy emergency response times in urban communities and systemic misuse of the 911 systems for nonemergency conditions or nonmedical needs.  

Reforming D.C.
Perhaps my greatest career challenge was reforming the emergency medical services system in the District of Columbia. As I assumed duty as fire chief in 2007, public confidence in the EMS system was at an all-time low.

Among the issues were poor employee performance, noncompliance with training and certification requirements, lack of proper medical oversight and control, deteriorating ambulance fleet, lengthy emergency response times, critical coverage gaps in several areas of the city, and systemic misuse of the 911 system. The EMS system was truly in crisis; comprehensive reform was necessary.

The incoming Mayor, Adrian M. Fenty, convened a Task Force on Emergency Medical Services to analyze the issues and develop a plan for improvement. Among the critical issues was whether the delivery of EMS would remain a responsibility of the D.C. Fire & EMS Department.

All options were on the table, including privatization or development of an independent third-service EMS agency. I was selected by the mayor as the committee chair and allowed to name a neutral third party to record the information and to produce a final public report describing the work as well as the needed system changes.

The committee was composed of a diverse group including physicians, nationally recognized managers from both fire-based and third-service EMS systems, legislators, and the family of David Rosenbaum — a D.C. resident whose death was a catalyst for the creation of the task force. The group was given six months to deliver a realistic and obtainable action plan to completely overhaul the EMS system.

Transparent process
The final product identified six overarching objectives that would be reached by implementing 50 separate, smaller, measureable and attainable action items.

The funding sources were identified and provided by the mayor's office to allow the department to make sweeping organizational change on a scale never witnessed before.

The full task force report was widely distributed to elected officials, residents and civic groups, and to local and national media outlets. To ensure transparency and accountability, a public website was established that contained the 50 actions items and the up-to-the-minute status of each one.

To add additional pressure, the Rosenbaum family had filed a civil lawsuit against the District of Columbia for $20 million. The resolution of this lawsuit was contingent upon the family being satisfied with the results of the District's reform efforts.

Recommendation 5a
One specific solution, Recommendation 5a, warrants a close look. It read: "The Chief, in partnership with other District agencies and providers, shall develop and begin to implement, no later than March 31, 2008, an outreach program for patients with chronic needs."

The department's internal analysis revealed that just 20 addresses generated 10 percent of all EMS calls, and just 20 individuals accounted for 2.8 percent of all EMS transports. This was in a system with more than 120,000 EMS incidents and 75,000 transports a year.

The highest-volume individual system users were receiving more than 300 responses a year. Analysis of this patient population found strong correlations between high-volume 911 use and the conditions of homelessness, chronic public inebriation, addiction, mental illness, and lack of access to (or use of) primary and preventive care. We also found a high rate of mortality among this population, with several of the highest volume system users dying each year.

While the popular perception of the EMS "frequent flyer" is that of system abuser, our administration categorized these vulnerable individuals as system misusers — ones whose underlying needs could often be met more effectively through intervention and referral to more appropriate resources.

Hitting the streets
To reduce EMS system demand, and solve the complex needs of these patients we created the Street Calls program. Two non-emergency vehicles were placed into service soon after the report was published.

A physician's assistant or nurse practitioner, a paramedic and an EMT staffed each Street Calls vehicle. This team of three departmental members received additional cross-disciplinary training and established relationships with the District's safety net of mental health and social service agencies.

The Street Calls team identified the highest-risk, highest-volume system users and performed targeted interventions designed to move them out of the emergency medical system and into more appropriate and effective care.

The outcomes were amazing. Intervention and case management by the Street Calls team reduced the daily likelihood of 911 use for each patient by 54 percent. During the first five months of the program, the absolute number of 911 calls by the top 25 users was reduced by 375 calls.

A particularly poignant milestone was achieved two years into the program when the District's former top EMS system user (more than 300 transports per year) served as an articulate and moving keynote speaker at our annual EMS Week ceremony. Now compliant with his medication regimen, clean and sober, receiving preventive medical care, and in permanent housing, he thanked the Street Calls team for saving his life and helping him achieve stability and independence. 

Drop times
In tandem with the demand-reduction efforts of the Street Calls team, the department began centralized monitoring and management of hospital drop times — defined as the interval between when an ambulance arrives at the hospital and when it returns to availability.

These efforts had the practical effect of increasing total ambulance availability by the equivalent of 2.5 24-hour units at no additional cost to the city — a $3.5 million value.

In addition, active partnership with the hospitals improved patient distribution efficiencies across all facilities, reducing patient intake delays and emergency department overcrowding, and improving patient outcomes and customer satisfaction.

The program was tremendously successful. In fact, the entire EMS action plan process was quite a success, completing 39 of the 50 action items in the first three years of implementation. This success story has received extensive coverage in several national media outlets.

These two programs alone can bring pre-hospital service costs under control, which is something every department needs to consider in these uncertain fiscal times.

Until next time be safe out there!

About the author

Dennis L. Rubin is the principal partner in the fire protection consulting firm DL Rubin & Associates. The firm provides training, course development and independent review of policy and procedures for all types of fire and rescue agencies. In his more than 35 years in the fire service, Chief Rubin has served as a company officer, command-level officer and fire chief in several major cities including Dothan, Ala. Chief Rubin holds a bachelor's of science degree in fire administration, an associate's in applied science degree in fire science management, and he graduated from the National Fire Academy's Executive Fire Officers Program and the Naval Post Graduate School. Rubin has taught at several universities and colleges as well as at the National Fire Academy. He frequently speaks and lecturers at local, state, national and international events. Chief Rubin's textbooks Rube's Rules for Survival and Rube's Rules for Leadership are available at ChiefRubin.com. Chief Rubin recently published his third book D.C. Fire. You can follow Rube on Twitter at @ChiefRubin and contact him at Dennis.Rubin@FireRescue1.com You can follow him on Twitter at @ChiefRubin and contact him at Dennis.Rubin@FireRescue1.com.



Comments
The comments below are member-generated and do not necessarily reflect the opinions of FireRescue1.com or its staff. If you cannot see comments, try disabling privacy and ad blocking plugins in your browser. All comments must comply with our Member Commenting Policy.
A. Ken Krupnik A. Ken Krupnik Sunday, January 20, 2013 6:14:14 PM Congrats! Definitely some interesting concepts, and significant progress that other Fire/EMS providers can learn from. Ken Krupnik LAFD EMS Batt. Capt. (Ret.) & Singer/Songwriter of iTunes song "Paramedic Rescue 101"
Jimmy Bryant Jimmy Bryant Sunday, May 26, 2013 4:45:37 PM www.lights4love.org

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