By Sharon McDonough
For the past decade, most fire and EMS departments nationwide have realized an increased demand for response to low-level 911 calls where no emergent care is needed.
Here in Tucson, Arizona, we are taking a multi-tiered approach toward changing that trajectory.
In fiscal year 2019, the Tucson Fire Department (TFD) responded to just under 76,000 calls for EMS, a significant drop from our 2017 numbers of 83,000.
For several years prior, TFD had seen an average 6% increase in EMS call-load per year, a climb that was quickly becoming unsustainable.
Like many, our call load continued to increase while our budget remained stagnant.
With this disparity evident, we knew we had to get to root cause issues and better examine our public demand and how it aligned with our agency’s ability to respond.
An in-depth examination of our EMS incident data revealed that less than 40% of our responses to EMS incidents resulted in emergent on-scene interventions and/or an ALS-level transport to the hospital.
However, with worries of liability looming in a risk-adverse industry, the concept of a non-response, or even a reduced response, was taboo.
Meanwhile, response times to our time-dependent big four (cardiac arrests, heart attacks, strokes, trauma) were increasing, and our crews were suffering from burnout.
Fast forward three years, at the mid-point of a multi-year approach, and we are beginning to reap the fruits of our labor. Here’s how we’re doing it.
Rescue Tier: Non-transport, two-person resource
In 2015, TFD introduced the Rescue Tier, a small truck staffed with one firefighter/EMT and one firefighter/paramedic to respond to ALS “rule-out” types of incidents. Its introduction created efficiencies by matching resource allocation to the actual needs on a given incident while well covering the department’s liabilities.
For example, department data showed that of approximately 300 annual incidents where a caller reported a 40-something-year-old female who fainted, only one of them ended up needing life-saving interventions. But, we also know that a patient meeting that criteria must be provided a more extensive examination than an EMT is equipped and trained to provide. Cue the non-transport-capable single paramedic, two-person resource – fast, less expensive and more efficient.
TC-3: Tucson Collaborative Community Care
With the introduction of the Recue Tier, we began making steady progress toward appropriate resource allocation, and next needed to find better solutions for our city’s issue with “frequent fliers” – the underserved, vulnerable, disconnected members of the population that over-rely on public safety resources for basic healthcare and human needs.
In 2014, 50 of TFD’s frequent system users accounted for almost 1,400 calls to 911, with most culminating in an ambulance ride to a local emergency room. They call 911 reporting an emergency, we send Big Red, we provide an ambulance ride to an emergency department, they receive the most expensive care of the medical system and are released home with some paperwork telling them to follow up with a primary care doctor. Only they don’t, and the next day, 911 is called.
To address this issue, TFD began a late-2016 pilot for a program that would later become known as Tucson Collaborative Community Care, or TC-3. This program created efficiencies by building a bank of community resources and deploying “navigators” to connect the vulnerable high-frequency user to more appropriate long-term, non-emergent community resources, taking and keeping them out of the 911 cycle.
My initial direction to the team was simple: “Find the people where they are, find the community resources available to help them, and solve their problem – no matter what it is, don’t say no.”
The help provided by TC-3 is active rather than passive. Appointments are scheduled, contacts are made, paperwork is filled out and transportation is arranged. Some individuals find solution immediately, coming out of the 911 cycle as they are connected to long-term disease management, palliative care, hospice, home repairs, housing, pet solutions and dietary care, while others require on-going assistance and contact to keep them engaged and their needs managed.
With the reallocation of three uniformed staff and the collaboration of a large, ever-growing group of diverse community partners, the immediate impact of TC-3 was impressive, so much so, that it caught the attention of industry leaders, philanthropic and nonprofit organizations and insurance agency CEOs. Recently, TFD entered into a partnership with the TMC Foundation, which has provided a wealth of human and material resources to support and grow the program.
As a result of these efforts, 911 responses to our TC-3 clients have dramatically declined, with some completely removed from the 911 cycle, all showing improvement, and the vast majority reporting that their quality of life has improved. Further, our crews are feeling supported, with one department member stating, “TC-3 is the best thing that has ever happened to TFD.” Our reliability for time-critical incidents has improved, and our clients are finally able to get the right help for their often multi-faceted issues.
So what’s next in our battle against the trending demand vs. resources disparity? Here in Tucson, we plan to get SMART!
SMART: Social Medical Alternative Response Tier
SMART stands for Social Medical Alternative Response Tier, and the department is currently working toward its implementation.
SMART addresses the resources vs. demand issue at its starting point, the 911 call center. Once implemented, it will ensure that our 911 call-takers continue to fast track life-threatening calls for service, but will also allow them to slow down and more accurately resource calls best served with a less emergent or non-public safety resource. In short, SMART will utilize a tiered approach to increase efficiency, minimize risk and leverage public/private partnerships. Emergent calls will continue to get a short call process and immediate dispatch of public safety resources, including fire, EMS and law enforcement as needed. Less emergent calls will be further screened to prioritize accuracy in what we send, over quick processing.
To date, we have utilized incident outcome data to identify non-emergent call-types that bog down the system, with little or no need for immediate intervention by public safety resources. Through the efforts of our TC-3 team, we have also identified and collated reliable community resources that stand ready to absorb and manage the non-emergent needs of our public. Last year, we added two crisis call-takers to our 911 communications center, allowing immediate vetting of calls that present as mental health in nature. We continue to work with our 911 and local law enforcement partners to develop standardized caller-questioning to appropriately sort high-frequency/low-risk call types that may be able to be moved from the timed 911 process into a “deeper dive” queue of questioning, freeing up emergency call-taker lines.
The SMART call-taker duties and training will require a level of expertise on community resources, including agency ability, user qualification requirements, limitations and hours of operation. We are also beginning to identify and tag frequent callers within our 911 centers’ computer-aided dispatch system. This tag causes the TC-3 team to be immediately notified when a frequent user is hitting the system, allowing the team to re-engage with them as needed. Our plan is that it will one day allow the SMART call-taker to view instruction from the TC-3 team on how to best mitigate the individual issue at hand, with the possibility of no or limited need for response.
In addition, because we know that callers often paint a confusing picture of what is going on at a given scene, discussions are beginning with our local public safety partners on the development of a SMART Response Unit (SRU). In this concept, the SRU would be staffed with an EMT and a law enforcement officer or official to mitigate the high-frequency/low-risk call types that, despite extensive questioning, provide inadequate information to allow appropriate and safe outsourcing. This SRU staffing model would allow the EMT to immediately render aid and call for additional resources as needed, while law enforcement personnel would be immediately available to manage any safety or law enforcement issues, or call upon an in-service unit to manage more complex scenarios. Depending on system design, in limited circumstance, the SMART team may be able to provide non-emergent transport.
This preliminary concept also includes having the team take a proactive approach to preventing 911 calls by connecting the vulnerable population to community resources, similar to the work of TC-3. As with all good programs, standardized data will need to be gathered prior to the implementation of SMART and evaluated throughout, with adjustments made along the way to ensure appropriate mitigation of 911 requests for service and minimized risk to our City.
There is much work to be done to get SMART up and rolling, partnerships to be identified, protocols to be written, business agreements to be drafted, logistics to be managed and, at the top of the list, a public to be educated.
Time for proactive approaches to the new normal
With over-reliance on 911 resources becoming epidemic, we must collectively create public safety announcements, education, branding and literature to educate the public about alternative options to calling 911, for use proactively and reactively. We need to provide website and non-emergency phone line access to information on how to file low-acuity police reports, how to manage an expected death or a minor auto accident, how to help someone suffering with a mental health concern, or how to get connected to the non-public safety resources most suited to the issue. A fire truck responding to someone who needs a ride or ran out of their medication or needs a new oxygen cylinder connected is just plain wasteful.
Fire and EMS agencies are the most trusted and relied upon entities in our communities, affording us the unique ability to facilitate and coordinate a new approach to a growing issue. As the demand of our communities’ change, we must find collaborative, innovative, cost-effective ways to meet these demands, no matter how non-traditional they may seem.
Doing more with less is not the answer; it’s harming our people. Continuing to be the end-all-be-all agency is not sustainable, as we can’t afford to keep throwing more fire trucks at a growing problem. We must instead create a strong, connected, community network of appropriate agencies ready and able to assist in assuring 911 system reliability and fiscal responsibility. Otherwise, we will merely be left to manage overhaul operations and pick up the ashes.
About the Author
Sharon McDonough is the deputy chief over the EMS Division for the Tucson (Arizona) Fire Department. McDonough was hired by TFD in 1990, progressing through the ranks of firefighter, paramedic, captain, battalion chief and deputy chief, and recently served a two-year appointment as interim operations assistant chief. During her 15-year tenure as chief officer, she has managed fire operations, medical administration, safety and the 911 communications center, developing and implementing innovative solutions to long-standing and trending industry issues.