Paramedic Jaclyn Kloecker has experienced her share of tension, turmoil, rising adrenaline and blaring sirens. She's been responding to 911 calls and rushing the sick or injured to emergency rooms for 15 years.
On a recent rainy morning, however, Kloecker wasn't responding to an emergency. Rather, she was on a calmer, quieter mission, performing medical screenings aimed at reducing the number of 911 calls that Christian Hospital’s Emergency Medical Service system handles.
The hospital’s approach, which Kloecker embraces wholeheartedly, is regarded by some as the future of EMS in an age when health care systems are under federal pressure to reduce costs, discourage overuse of medical services, and provide better patient outcomes.
Christian Hospital’s EMS system is addressing these issues in part by revamping the way it handles 911 calls. In addition to dispatching an ambulance to the site of a perceived emergency, the system requires that a specially trained EMS worker, such as Kloecker, go to the scene in a separate vehicle and learn more about the nature of the 911 call. These workers, which Christian calls advanced practice paramedics, or APPs, have additional medical training that allows them to make on-the-spot assessments of a patient's condition.
The APP decides whether 911 callers need emergency room care, or if they can get by with less intensive care for non-emergency problems. For example, the ER might not be needed for a patient who calls 911 after bumping too hard against a home appliance and hurting their arm. That’s unlikely to be life-threatening, even if the caller thinks otherwise.
In those circumstances, the APP can send the caller to what’s known as a hospital health resource center, which is located away from the ER, where treatment is likely to be provided by a primary care doctor. Alternately, the EMS team might urge such callers to seek care from their own primary care doctors. If the caller doesn’t have one, then the team helps the caller find an available physician from a list kept by the EMS workers.
Once EMS teams learned to look beyond the perceived emergency, ask more questions and determine that a life-threatening situation does not exist, they then seek other ways to help the callers. Here are examples of the kinds of non-emergency situations the team has confronted and resolved:
- One north county resident called 911 frequently whenever he would get hurt from falling. It turned out, he was falling because of a hole in the floor of his home. The EMS team solved the problem by using plywood to patch up the hole. The resident stopped calling 911.
- Another patient was having frequent seizures. The EMS team discovered the seizures were caused in part to his inability to swallow his medicine in capsule form. Team members taught him to break the capsule apart and consume the medicine by putting it in pudding or yogurt. Now that he does that, his seizures are regulated, according to EMS officials.
- Another common problem were the diabetics who called 911 when they felt ill. The team figured out that the patients were feeling ill because they didn't understanding how to properly monitor and control their sugar levels. EMS workers stepped in whenever they discovered that problem.
A change not based in benevolence alone
Christian Hospital's emergency system is one of the busiest in the state. When the hospital's EMS department analyzed the number and variety of emergency room visits they received in 2013, the team realized that about 55,000 of the 116,000 ER visits did not involve genuine emergencies.
Mining further into the data, EMS officials learned that 22 patients alone accounted for more than 600 ER visits since last August. It didn’t take long to do the math. If a combined EMS-ER visit costs around $500 or more, then non-emergency calls were adding needlessly to health care expenses and bills.
“When you have 55,000 people coming through the revolving door of the emergency room, we are not making a healthier community,” said Chris Cebollero, chief of emergency medical services at Christian.
“We are putting a Band Aid on it, and when the Band Aid falls off, we come in and get a new Band Aid. That’s not a healthy way to live. What we want to do now is focus on making [our patients] healthier and live a better life," he said.
Cebollero said many callers end up in the ER because they have no other options. He also stressed that it's not a matter of a person's financial status; middle class people are just as likely to overuse of 911 service as the poor.
“If you call the doctor’s office, what do you hear when you pick up the phone? The recording says if this is a true emergency, hang up and call 911,” Cebollero said.
But callers have a different opinion than medical providers of what constitute a genuine emergency, he said.
“To the 19 year old who just found out she is pregnant, that’s an emergency. She calls 911. We want to help [all patients] find the right place," Cebollero said.
The problem is in the health care system itself, not in the people it serves, he said. "We helped to create this monster that we are trying to fix now. We are now trying to be more proactive rather than reactive. Otherwise, they are just going to keep coming through the revolving door, those 55,000 patients.”
Putting a wrench in the revolving door
Christian Hospital's proactive measures are helping to change the over-reliance on emergency medicine for non-emergency situations, according to Cebollero. “Since we started the program we have navigated about 1,400 patients away from the emergency room when they did not need to go there. We’re talking about a program that’s been in place about 60 to 65 days. That has decreased the volume by about 9 percent in a short time.”
Shannon Watson, the community health supervisor for Christian’s EMS unit, mentioned one patient who had been readmitted seven times over a two month period between January and February.
“We started working with her in February. We met with her once a week, checked her weight, made sure she understood her medications, asked about her eating habits and checked her vital signs. We were there for her support, for whatever she needed. She went from being readmitted seven times to zero times,” Watson said.
She said Christian’s new approach to 911 is likely to spread statewide in keeping with the Affordable Care Act’s focus on effective care at lower cost.
“Right now, we bill fee for service. If you fall and you hurt your knee, we pick you up, take you to the hospital and we send a bill. If I am an insurance provider and I am billed the same amount for an injured knee as I am for a cardiac arrest, how does that make sense?" Watson said. "Eventually, we are going to start billing on the basis of patient satisfaction and the quality of care that you received.”
The house call
A recent house call that Jaclyn Kloecker, the advanced practice paramedic, made demonstrates how the system is trying to discourage overuse of 911. Klocker stopped at a patient's apartment in Black Jack with a black bag slung over her shoulder -- a bag about twice the size of those that doctors used to carry during home visits.
Kloecker was met at the door by Pauline Mathis-Snider, a 53-year-old diabetic who used to be transported to the emergency room two or three times a week. She gets around the apartment on a walker and must take insulin three times daily and once at night.
A few weeks before this visit, Mathis-Snider had slipped and fallen when taking a shower and had called 911 for help. During Kloecker’s follow-up visit, she brought Mathis-Snider a non-skid mat for her shower to help prevent falls. Kloecker also determined that Mathis-Davis would benefit from a motorized wheel chair to navigate her apartment building’s hallways and to reach the Older Adult Transportation Service (OATS) bus.
Klocker's black bag includes a large machine that she uses to check blood pressure, blood sugar and other vitals. She went about her routine much the same way a primary care physician might have, praising Mathis-Davis for following her doctor's orders and inquiring about any changes in areas such as weight and eating habits. Kloecker is among Christian paramedics who have undergone more than 16 months of additional training and still are involved in more training. Among other things, these paramedics are capable of checking ear, nose and throat issues that might be affecting a patient's well-being. What they learn can be passed on to the patient's primary care doctor.
Kloecker said she enjoys these home visits in addition to her work of responding to emergencies.
“The visits become personal because I get to know the patients and families, too," Kloecker said. "Before this visit, I was on the phone with the sister of another patient for 45 minutes, talking about things she thinks her brother needs. I try to get families involved in the care.”
In about 15 minutes or more, Kloecker finished her work and gave Mathis-Snider the good news that she can forget about calling 911 because her blood pressure and sugar level were normal. An elated Mathis-Snider smiled at Kloecker and said the results show that “it’s good to have a second mind working for you.”
She added that the regular visits are helping to stabilize her health conditions.
“It’s much better than going to the emergency room," Mathis-Snider said. "They give you a prescription, and you are back again in no time.”