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Finding adaptive solutions: Birmingham C.A.R.E.S. treats ‘frequent fliers’

Birmingham community paramedicine program identifies individuals with needs in order to reduce unnecessary future calls taxing the system


Lt. Ben Thompson (right) sits with a former C.A.R.E.S. patient and current friend of the program, Curtis Falconer.


It’s a universal problem among fire and emergency services departments. There are people in the community who disproportionately and often unnecessarily use the 911 system, tying up emergency equipment and crews, endangering the public due to unnecessary emergency response, and driving down morale for first responders.

We had a name for them on my department: frequent fliers. We also came up with names for individuals in this group, such as the woman we called “The Nightmare on Elm Street,” referring to her address and the fact that she usually called after midnight for some trivial reason. It was easy to objectify these people.

We accepted these calls as part of our job, and handled them with courtesy and professionalism, but for many years, no one was doing anything to address the root cause of the problem.

It’s like the old story about the good Samaritans who see babies floating down the river and jump in to save them. Hour after hour, they heave one baby after another to safety on the shore, but never pause to ask: Why are there babies floating down the river?

In Birmingham, Alabama, a city of 212,000 with 32 fire stations and 19 medical transport units, someone finally asked why – and then did something about it.

Birmingham’s frequent flier problem

In 2016, 20% of all 911 calls were responses to fewer than 2,000 people in Birmingham. That year, one man was transported 79 different times by firefighters on medical units. Call volume city-wide was increasing 5% every year.

Ben Thompson, a lieutenant with the department with less than 10 years on the job (and also a columnist), wrote a memo of concern about the problem to department leadership. And you know what can happen if you write a memo. The next thing he knew, he was in charge of the department’s new program, Birmingham Fire and Rescue Service C.A.R.E.S., which stands for Community Assistance, Referrals, and Education Services.

The program, which Lt. Thompson said was inspired by similar efforts in other cities, is designed to identify and follow up with individuals within the service community who make excessive calls to 911 for any reason. Firefighters in the field refer people they see on emergency calls, and those working exclusively for the C.A.R.E.S. program then follow up with those individuals and attempt to help with the issues that are driving their perceived need to call 911.

For example, Thompson told a story of a man with diabetes who repeatedly called 911 at night for symptoms of insulin shock. The man would call week after week for years, until one day the crew went out to his home during the day, just to talk to him.

The man, who had usually been drinking when the crews responded to 911 calls for him, was sober and welcoming the day they arrived. Their conversation that day quickly revealed that the man did not know that insulin lowered his blood sugar. He thought it was simply “diabetes medicine,” and when he felt sick due to low blood sugar, he took more insulin, thus making the problem worse. No one had ever made sure he knew how to monitor his blood sugar. Once he had the information and support he needed, he became healthier and the 911 calls stopped.

That’s how the C.A.R.E.S. program works – identifying individuals with needs and taking the time to try to fill those needs. Sometimes the needs are great and even insurmountable, and Thompson admitted that the program has had limited success with the city’s homeless population. But for others, who may be just lost in the system or confused about some aspect of their healthcare, the program has had some dramatic results.


Grant money helped purchase a new vehicle for the C.A.R.E.S. program.


Crew satisfaction

The program is designed to help the residents of Birmingham, but it has also helped members of the fire department.

Thompson reports that the crews on the street are very happy with the program. Until recently, firefighters had no one to call to ask for follow up with people they see. Now Thompson and his team follow up from every referral: “Even if we’re not able to solve the problem, just by us checking up on the person on behalf of the concerned firefighters and then sending the crew an email about what we did, the crews are extremely grateful. They feel like they actually did something to help.”

Funding sources

Birmingham Fire C.A.R.E.S. is funded through normal budget allotments, and one grant has been written for a vehicle purchase. That means that the program runs with minimal resources, just Thompson and one other full-time firefighter assigned to it, with help from department members on temporary light duty, as well as an intern from the local university.

An additional funding source: Birmingham Fire C.A.R.E.S. contracts with other entities, including a large healthcare organization, to provide in-home follow up for people in need. People seen in this capacity may be frequent 911 callers, or just people who are at high risk in their homes. These outside organizations pay the fire department for this service. According to Thompson, Birmingham Fire is the only department in the state to access outside funding in this capacity.

Adaptive solutions

Getting Birmingham Fire C.A.R.E.S. up and running has been challenging at times, both logistically and financially, but Thompson says the department is committed to the services they provide through the program.

As for the future, Thompson said: “I think everybody’s going to be doing this. We have to, as EMS providers. We can’t sustain this growth in call volume that all fire departments are experiencing across the country. We have to propose some sort of adaptive solution. We can’t just throw trucks and people at it. We have to really fix the problem.”

Take your department in the direction you want. Get expert advice on how to effectively lead your fire department. 20-year veteran Linda Willing writes “Leading the Team,” a FireRescue1 column about fire department leadership.
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