How to build fire-based community health care programs
The survival of fire-based EMS may rest upon delivering services before 911 is called; it's a tough proposition, but a doable one
By Sarah Calams
A year ago, a 64-year-old woman living in a Section 8 apartment complex in Oak Cliff, Texas was unable to drive from her apartment to a grocery store three blocks away without becoming short of breath and having to call 911.
After seeing her name pop up in a record search multiple times, a paramedic with Dallas-Fire Rescue knocked on her door to see how the department's mobile integrated health care services could help her. The medic quickly saw that the woman became short of breath very easily and appeared overweight.
He asked if she had seen a doctor, of which she said yes, and that the doctor recommended she start dialysis. The doctor, however, had never explained what dialysis was and the woman said she wasn't going to do it without knowing what it involved. The medic then gathered information about dialysis, sat at her kitchen table and explained in simple terms what renal failure was, what dialysis was and how it would help change her life.
She later started hemodialysis and through the course a few sessions 40 pounds of fluid was taken off her 100-pound frame. She later learned about peritoneal dialysis and does in-home treatments on her own.
She's now able to take her son, who suffered a traumatic brain injury a few years ago, to an adult daycare, drive 30 minutes to visit her sister and drive back home without having to call 911.
This success story, among many others, is why Assistant Chief Norman Seals got into the business of helping people 30 years ago.
In his presentation at the International Association of Fire Chief's Fire-Rescue Med conference in May, Chief Seals will examine how a mobile integrated health care program works, how to build a program that's sustainable, how to generate revenue to provide services and how to manage its data.
Chief Seals' seminar, "Creating Revenue from a Mobile Integrated Health Care Program," will be held May 24; the early registration discount is available until April 21.
Chief Seals, with the Dallas Fire-Rescue Department, has overseen the department's EMS bureau for the past three years, was a firefighter-paramedic from 1988 to 2000 and has been with the department for over 30 years.
The mobile integrated health care program, he said, is the most rewarding project he's ever been a part of.
How it works
The program uses patient-centered mobile resources in an out-of-hospital environment. It provides services such as advising patients, providing community paramedicine care, disease management, preventative care and post-discharge follow-ups.
"It's a fairly complex process with a lot of moving parts," Chief Seals said. "The program is about identifying individuals in the community that are in need of an extra measure of support and providing it to them. It's designed to identify and fill gaps that exist in the modern health care system."
The system identifies the patients who are in need, looks at what their needs are and links them to community-based resources to improve their level of independence, understanding of their own needs and help them better manage their own health care.
"We do all of this through education, health care navigation and patient advocacy concepts," Chief Seals said.
The program identifies potential enrollees by examining the department's frequent-user data and by field or hospital referrals.
"We look at our high-frequency utilizers over a 90-day period, and we do an evaluation fairly frequently," Chief Seals said. "We reach out to them and try to get them enrolled in the program to get some help. We take field referrals, and our hospital contracts also refer to us based upon their patients' records."
When patients enroll, the department does a full patient assessment that looks at everything from living conditions, family support, health status and more. From there, the department builds out a set of goals and actions items.
As the goals are met over a span of several months, crews educate patients on things such as how to make and get to doctor appointments. Sometimes patients will even request that medics go with them to appointments.
"That has been hugely successful because a lot of times these patients are somewhat intimidated by the physician and won't tell them the whole story," Chief Seals said. "So the medic gives the doctor the full story and helps the physician be able to better treat the patient."
The department has a set of criteria they use to determine if a patient should be "graduated" based on if the patient's goals are met and defined, and if the department sees a reduction in 911 use as a result of their efforts.
"The medics will go out and hand them a certificate and do a little celebration in the patient's home," Chief Seals said. "And we'll monitor them for a year to make sure the program worked."
For Dallas Fire-Rescue, there have been many lessons learned along the way to make sure their program works for the long term.
Building a sustainable program
The first step a department should take when trying to start a mobile integrated health care program, according to Chief Seals, is to become highly educated on the concept.
"There are a number of conferences and even a book about the program by Matt Zavadsky at MedStar provides a roadmap on how to do this," Chief Seals said. "When we started having the conversation in Dallas almost four years ago, there wasn't a lot of resources available. At conferences where this was a major topic of conversation, I spent a lot of time in between sessions and at dinners picking people's brains on how they were doing this."
Another way for a department to become educated is to visit other programs.
"On a fairly routine basis, we have people emailing us asking questions about the program or coming to visit, doing ride-alongs or sitting down in some of our meetings," Chief Seals said.
The first step — the education component — is to understand what the program is and its nuances. Once a department becomes knowledgeable, the next step is a performing a community-needs assessment.
"That is a fairly complex process but it identifies where the gaps are, what patients are falling through the cracks that need the program's assistance and then finding out what resources are available," Chief Seals said.
When the program first started in Dallas, Chief Seals said he had no idea how many groups in the city were trained, equipped, passionate, funded and ready to help.
"We networked with a lot of those groups — we have 40 or 50 agencies that we work with routinely," Chief Seals said. "And we make referrals between them and help our patients access their systems so their needs can be met.
"That's probably one of the more important parts of the process. As an EMS provider, we don't have the knowledge or expertise to do a lot of the things that need to be done. But we can certainly learn who the people are that can help and act as that bridge between the patient and those providers."
That being said, mobile integrated health care programs at Dallas Fire-Rescue and elsewhere have had their fair share of skeptics within the fire service.
Making the transition
The fire service has a long history of being tradition-bound, which is great in a lot of ways.
But a lot of fire service agencies, like Dallas Fire-Rescue, have been in the EMS business for more than 40 years.
"In a lot of ways, we have better equipment and science-based protocols, but outside of that we're still doing things the way we did when we started this game 40 years ago," Chief Seals said. "There has been some hesitance in the fire service to embrace the changes that are coming from health care reform. Sometimes it's hard to crawl out of that box and try something new."
For Chief Seals, he's seen how tough it is for programs like this to get acceptance among firefighters and officers.
"The reality is: we have to change. It's going to be mandatory or we'll cease to exist as EMS providers and someone else will step up to provide that service," he said. "This program allows us to really help individuals in a way that can dramatically alter their life."
Crews on Dallas Fire-Rescue's program, according to Chief Seals, sign up to be a part of the program — no one is forced into it.
"It's like any other job — it has its days and sometimes seems like more headaches than it's worth," he said. "But overall, it seems to be very rewarding for our crews and we sometimes take a moment to talk about our success stories just to remind ourselves of where we've been and what we've accomplished."
And even though the program has celebrated many successes, Chief Seals and his team have encountered many roadblocks along the way.
The biggest obstacle Dallas Fire-Rescue has encountered has been navigating the legal and contract side of the mobile integrated health care program.
"This is such a new direction for EMS agencies and municipal attorneys are more generalists than they are specialists," Chief Seals said. "So getting them to understand the current EMS law here in Texas and how this is beneficial has been an interesting challenge. But so far, we've been able to manage that."
Trying to work through the legal side, Chief Seals said, delayed the growth of the program. On the flip side, data collection and analysis has also been difficult for the department.
"If you look at the technology that is available today, there's nothing out there that's designed for what we do," Chief Seals said. "We have contracted with a data company that is going to build us a data management system that is unlike anything else on the market."
That system should be rolling out in the next two to three months.
"There's also a lot of data sharing obstacles with HIPAA," Chief Seals said. "It's difficult to determine if we take one of our high-frequency patients, for example, and we know that we transported them 100 times in the last year and reduced that to 25 times. But we don't know if they're still going to the hospital outside of that."
Chief Seals said they can ask, but are relying on the patient to give accurate information. And they have no way of pulling information from the hospitals to see if those patients are going to the hospital by means other than a Dallas ambulance.
To compound that, there are 26 hospitals in Dallas and it's really hard to get them to agree to share information, he said. "Hopefully the HIE processes will get a little more robust in the future and allow us to access that information."
Making mobile integrated health care programs successful also depend heavily on contracting with nearby hospitals. This can sometimes also be a roadblock as fire officials often have to learn how to access the executives at hospitals and how to speak their language.
"I've gone through a learning process to understand what hospitals' issues are, what problems they're facing in terms of changing payment structures and their changing environment to help them understand how our program can help them by filling some gaps they have in their current system" Chief Seals said.
Agencies or departments, he said, will have to learn the health care world so they can help hospital officials better understand why the partnership can be beneficial to both sides.
"The contacting process takes a while, and our hospitals partners, once we helped them understand how we can be beneficial to them and how that relationship works, have been very supportive," he said.
Chief Seals the power of the patch plays a big part in the success of mobile integrated health care programs in a fire-based EMS world.
"These patients have been failed by the health care system over and over," he said. "They go to the ER and get dismissed a lot. Yet when we walk in the door, they still trust the patch. And that has been very important in this process — that we can gain their trust very quickly. It's the relational part of it. They see us, trust us, appreciate us and know that we're doing what's in the best interest."
Dallas Fire-Rescue contracted with two hospital partners in September and is in the process of contracting with four others. They're also working on five hospice contracts.
These partnerships have snowballed as departments within the partner hospitals are observing what is happening and contacting the fire department with requests to get involved.
"It has been encouraging and opens up the door for us," Chief Seals said. "I really believe that in another year or two, this will be a really large program here in Dallas and we'll be heading in the direction of seeing 300-plus patients a week."
And with more patients comes the need to generate revenue to keep programs this going. Up until September, the program at Dallas Fire-Rescue didn't generate revenue. It was funded out of the city budget — tax dollars.
And using tax money means having city administrators completely sold on the program's value.
"The city manager has bought into it strongly enough that the program is funding to date," Chief Seals said. "And that has not been cheap, but the mandate to me from the city manager is that you make the program pay for itself as soon as you can."
In Dallas, that means working toward having the hospital under contract funding the entire operation.
And since the program is marketed mostly through word of mouth, medics are hitting the streets, knocking on doors and asking who they need to talk to in order to get the program noticed and funded.
For Chief Seals, the program will always be about helping individuals.
"It's the most important part," he said. "Everything builds off that — just helping those people who need that help in a very real way.
And that's why he started in the fire and EMS business 30 years ago — to help people in their time of need like the woman in Oak Cliff. And mobile integrated health care is just a different way of doing that.