Community Paramedic

Saving lives, saving money

Wednesday, October 19, 2016

911. It’s an easy number to remember—deliberately so!—and, like a light switch, it always works.

Emergency dispatch is always there, but a lot of times—a lot of times—people will call it for non-emergencies. That gets expensive.

In 2014, the City of Bellingham began an experiment to help connect frequent utilizers of 911 services for non-emergent medical needs to more appropriate services. The benefit of the program was conceived as twofold—citizens are connected to medical and social services that better meet their needs, and it creates capacity for the fire department to more quickly respond to true emergencies.

The Community Paramedic program serves citizens dealing with complex medical issues including substance abuse, mental illness and complications related to aging, disability, fall-risk and homelessness by assessing their needs and coordinating their care with appropriate community resources. The program is modeled after a number in place throughout the country.

The program has worked, and worked in a big way to free up paramedics and bend the curve on rising costs of providing quality medical services. That’s why, as officials began to craft a levy for countywide emergency medical services (EMS), they included a provision to extend the community paramedic program across the entire system as a line item in the proposed EMS budget.

“The fire department has a call volume that is pretty high, and what we wanted to do is bring that down and focus on life-threatening, time-critical emergencies versus everything else we’re asked to do that isn’t emergent,” Community Paramedic Jeff Brubaker explained. Brubaker is a captain with Bellingham Fire Department. “One of the huge things that comes up is people who call 911 a lot.

“There’s one guy who in the course of last year called 911 100 times. That’s a hundred responses for one person. You take the top five people, and that could be 200 responses.”

Brubaker estimated the Bellingham Fire Department received about 15,000 calls last year, with approximately 12,000 of those requiring paramedic response.

“Of the top 50 people who use the system, they account for about 15 percent of all of those calls—hundreds of calls. In many cases they were not emergent,” Brubaker said. “We can’t ignore those. So if you can respond to those calls in a different way, you open up capacity to not have to expand the fire department, or build new firehouses. It is cheaper to put one guy, like me, on to that, rather than hire three firefighters and buy a fire engine and staff a firehouse that you have to build. And all those capital expenses associated with that.”

“The communities of Bellingham and Whatcom County support social and health resources for many kinds of crises,” Bellingham Paramedic Rob Stevenson reported to Bellingham City Council at the launch of the program in 2014. “Many 911 callers do not require time-critical medical interventions, but their needs are real nevertheless. Homelessness, chronic behavioral health conditions, failing mobility and other social welfare crises challenge the scope and capacity of the emergency medical system.”

Many times, the response ends in an unnecessary trip to the hospital emergency room, a costly response to common and non-life-threatening situations.

That one guy who called 100 times? He was phoning in his age.

“He is 99 years old,” Brubaker laughed. “He is going to be 100 in about a month. He’s a super-interesting guy, very lucid, but he is nearing the end of his life. He was in a facility, but he had a cellphone. He would call us—100 times—because he thought he was dying, which technically he was. When you’re 99 years old, you’re not too far off the mark, statistically, in believing your life may be nearing its end.

“We worked with him and his family. He didn’t want advice from someone half his age, telling him what to do. We made a plan to get him a different phone plan, so he could call his friends and family, but was restricted from calling 911. That way he would go through his care providers, the staff at his care facility, for his needs—which is appropriate. Versus him just calling us from his bed.

“It’s an easy number to call,“ Brubaker said. “They’ve ingrained that since we were children.

“But that reduced half a percent of our call volume, just doing that.”

Efficiently delivering emergency medical services while controlling costs is at the heart of Whatcom County Proposition 2016-1, the EMS levy. Service calls are growing at about 5 percent each year, based on population growth and the demographics of an aging generation. Changes in federal medical reimbursement and a reduction in state revenues mean funds available for EMS are insufficient to maintain future levels of service. A dedicated property tax levy was constructed to provide emergency medical services at $0.29 per $1,000 of assessed property valuation to maintain EMS at its current level and meet future demand. The levy sunsets in six years. As a property tax measure, it requires a higher bar—60 percent must approve the levy for passage.

It’s a big ask for a county that intensely dislikes taxes, but integral to the success of EMS are cost-control measures to reduce call loads and demands on service.

And yet it’s really in the county that the benefits of the EMS levy will be most keenly realized, primarily the result of helping to stabilize the system across multiple fire districts and reduce response time for those requiring transport to a hospital or care facility. Despite this, it is also in the county the levy is likeliest to fail the required number of voters.

“People don’t think they’re going to need a service, they’re not so willing to pay for it,” Brubaker admitted. “But they will. It is statistically true that at some point in their life, they will need it. They, or somebody they know, will need it.”

Much of the efficiency of an EMS program comes from the stability of its funding sources, which allows improved long-range planning of facilities and personnel, supporters of the levy say. Booyed entirely by sales tax, that funding rises and falls with the economy. In a sense, rejection of the levy will not save money, it will simply shift costs through inefficiency. And for emergency situations, inefficiency can translate to death.

In remote areas of the county, call response times can be critical; and units that are responding to non-emergent calls can be delayed in responding to real emergencies.
“When someone like our 99-year-old friend calls 911, he is going to get a minimum response of three people, and that is only if dispatch determines his condition low acuity,” Brubaker explained.“But he’s 99, and he is going to sound short of breath, so they usually send five—an engine company and a paramedic unit. That’s the time of five employees, two apparatus out of two different stations for this one call. That’s a lot of resources.”

That has downstream effects, Brubaker said.

“Now imagine there’s a true emergency. Well, guess what? Those employees can’t respond. They’re busy. The person with the true emergency, their response time is increased. And if another call comes in? Those responses are also delayed.

“It is a cascading effect,” Brubaker said.

“By sending in one guy—me, in an SUV—that’s way cheaper than sending five guys in two apparatus. The cost savings are astronomical.”

The program savings can allow fire departments to put off hiring more paramedics, Brubaker said.

“To staff one paramedic unit is about $1.6 million a year,“ Brubaker estimated. “If you’re able to put that off for three years, that’s $1.6 million times three. And that doesn’t even include the engine company, which can be north of $2 million. You want to put that off, as long as you can.”

In the year the community paramedic program was established, more than 100 people called 911 more than six times. In the year following implementation of the program, that number was down to 80.

If the levy passes, the community paramedic program, which is currently funded solely by the City of Bellingham, has capacity for expansion to the county.

“I could then help take care of some of the fire districts’ call loads, reduce them,” Brubaker said. He estimated his county effort would be different, with fewer responses to issues of homelessness, perhaps more in assisting the elderly with medications and mobility issues.

“The lion’s share of people who want social support services come into town, because that’s where the services are,” he said. “The agencies and health services are based out of Bellingham. My sense is there is a more complex medical response needed for the county.

“I think the taxpayers accept the fire department going on life-threatening, time-critical emergent calls, and they’re willing to pay for that,” Brubaker said. “Where I think they get frustrated is the wrong resource applied to the wrong thing. Our goal is to reduce those calls.”

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