News & Updates

This is a similar news report sent out a couple of days ago about the Orange County (CA) Grand Jury report. 

There is an interesting debate about the ‘expense’ of using of fire engines for medical first response (MFR).  Fire engines are staffed with firefighters typically based on a fire response deployment model (assembly of personnel for fighting a fire, etc.), which is why they typically have 3 to 4 firefighters on board).  In many departments, most of their response volume is EMS responses, with relatively few actual fires.  Some feel that using resources that are already on-duty and staffed for a fire response for MFR is very cost effective.  In essence, if the engine stopped going on medical calls, would you still retain those personnel for fire calls?  If yes, then the cost of the MFR is marginal.  Yes, the engine is expensive, but most fire engines are often replaced because they become outdated, not because they wear out due to things like high mileage.

Additionally, very few EMS calls are for time-life-sensitive emergencies, and therefore may not require an immediate MFR.  Life-threatening calls (cardiac arrest, severe trauma, severe difficulty breathing) represent only about 10% of EMS calls in most communities.  Perhaps it may be better to keep MFR resources available for the true life-threatening calls, as opposed to having them respond to call in which they will likely not have an impact on the patient’s outcome?  If a MFR unit is tied up on a non-life threatening call, they may not be available to respond to the cardiac arrest that comes in 3 blocks away.

Perhaps reserving MFR resources for the calls they are truly needed for would reduce wear and tear on the engines (and the streets), reduce firefighter fatigue, and help assure the MFR resources are available for the calls they will make a difference on?

And, as we know from numerous studies, HOT vehicle operations put providers, and the public, at significant risk of injury and death, and should only be used in cases where that mode of operation may make a difference in the patient’s outcome.

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Stop Sending Fire Trucks on Medical Calls, OC Grand Jury Report concludes

BY JESSE LA TOUR

MAY 31, 2022

https://fullertonobserver.com/2022/05/31/stop-sending-fire-trucks-on-medical-calls-oc-grand-jury-report-concludes/

A recently released Orange County Grand Jury report entitled “Where’s the Fire? Stop Sending Fire Trucks to Medical Calls” questions this widespread practice.

In Orange County, nearly 80% of all 911 calls to fire departments are for medical services. The report highlights potential problems with the deployment model of the Orange County Fire Authority (OCFA), which Fullerton is considering joining, as well as other city fire departments.

“Sending a 36,000 to 60,000-pound fire engine or aerial ladder truck down residential streets for strictly medical calls is not only dangerous and costly, but it also results in unnecessary wear and tear on our streets,” the report said.

The Grand Jury’s findings include:

• Despite use of a tiered dispatch system, Orange County Fire Authority deployment of resources for medical responses are the same for nearly all calls, resulting in unnecessary wear and tear on expensive fire-fighting equipment and public infrastructure.

• Ambulances or smaller squad vehicles are often the most appropriate response to medical calls and do not compromise the quality of medical care

• Over-deployment of firefighters for medical calls contributes to the current climate of firefighter fatigue.

• Code 3 response (lights and sirens) is over utilized by OCFA, unnecessarily putting the responders and public at risk.

The Grand Jury’s recommendations Include:

• All Orange County fire agencies utilize criteria-based dispatch protocols and send a single unit response [ambulance] to those incidents triaged as non-life threatening.

• OCFA should station a paramedic squad vehicle, which is more nimble and less costly to operate, in place of a second engine in stations with high volumes of medical calls.

The Grand Jury’s investigation “also revealed a breakdown in communication and trust between Orange County Emergency Medical Service (OCEMS) and Orange County Fire Chiefs, which includes Fire Chiefs of the Orange County Fire Authority (OCFA) and various city fire departments.”

The report commended the city of Placentia’s recent changes to their emergency medical response protocols after leaving OCFA, which have resulted in improved medical call response times.

To read the full report visit http://www.ocgrandjury.org.

Turf war brewing between OCFA and county over medical calls, grand jury says

Report slams use of extra personnel and expensive equipment to calls where they are not needed

By SCOTT SCHWEBKE

May 20, 2022

https://www.ocregister.com/2022/05/20/turf-war-brewing-between-ocfa-and-county-over-medical-calls-grand-jury-says/

Distrust and poor communications are fueling a heated turf war over medical responses involving Orange County’s Fire Authority, Fire Chiefs Association and Emergency Medical Services, a grand jury investigation has found.

“Although their mandated responsibilities are clear, there is a mutual reluctance to acknowledge their respective spheres of authority, in particular the critical role of Orange County Emergency Medical Services as an independent regulatory body,” the Orange County Grand Jury said in a 22-page report issued Friday, May 20.

The grand jury examined the efficiency of the Orange County Fire Authority and various municipal fire agencies in responding to emergency medical calls.

The grand jury recommend that fire departments implement a universal tiered response system to dispatch ambulances to most medical calls rather than deploying larger fire engines as a standard response.

‘Dangerous and costly’

“Current protocol requires sending multiple vehicles to the scene, which involves not only additional personnel but also expensive fire equipment,” the report says. “This is the case even when an ambulance or rescue squad vehicle could provide all the necessary medical supplies and personnel. Sending a 36,000- to 60,000-pound fire engine or aerial ladder truck down residential streets for strictly medical calls is not only dangerous and costly, but it also results in unnecessary wear and tear on our streets.”

The OCFA is reviewing the recommendations, spokesman Matt Olson said Friday. “We received the Orange County Grand Jury report and appreciate the work that went into it. We look forward to commenting further after a thorough review of the report and its recommendations,” he said.

The Orange County Health Care Agency, which manages the OCEMS, and the Orange County Fire Chiefs Association did not respond to requests for comment.

Appropriate level of response

The goal of a tiered dispatch system is to match the emergency with the appropriate level of response in terms of urgency, personnel and equipment.

As part of its investigation, the grand jury reviewed records, memorandums and other documents. It also interviewed OCFA and OCEMS officials, private ambulance company executives and firefighter union representatives.

The OCFA has 77 fire stations in Orange County and contracts its services to several cities. Municipalities with their own fire departments are Anaheim, Brea/Fullerton, Costa Mesa, Fountain Valley, Huntington Beach, Laguna Beach, Newport Beach, Orange and Placentia.

OCEMS has established a minimum requirement that one paramedic and one emergency medical technician respond to emergency medical calls. However, it is left up to the individual fire departments to determine how to deploy personnel and whether to exceed these minimum staff requirements, according to the grand jury report.

At the OCFA, regardless of the preliminary assessment of the medical emergency, a fire engine or truck staffed with four personnel — at least two of whom are paramedic/firefighters — are sent to the scene. A transport ambulance with two EMT trained attendants also is dispatched.

Ambulance use causing friction

The use of ambulances is causing friction between the OCES, the OCFA and the Orange County Fire Chiefs Association, the grand jury said.

The report noted that that Fire Chiefs Association wrote a seemingly contradictory letter to the OCEMS, describing the agency’s implementation of policy changes without prior notice or collaboration as “offensive.”

“This complaint was made despite the fire chiefs’ specific acknowledgment in the same letter that a joint advisory committee had been formed and had been discussing the issues,” the report says.

Despite the fire chiefs’ complaint about OCEMS overstepping its authority, the only example provided was an emergency action taken by OCEMS in 2021 when hospitals were backed up, causing long wait times for first responders.

In response, OCEMS introduced an emergency measure that allowed emergency medical technicians and paramedics to leave patients in the hands of the hospital on a portable cot, according to the grand jury.

“Although OCEMS could possibly have provided better notice to OCFA and the independent fire chiefs, the OCEMS appeared to be working in the best interest of all parties involved,” said the report. “This was a fact that was, at best, only begrudgingly acknowledged by a few OCFA union representatives and other fire agency personnel.”

Tensions have been exacerbated by the COVID-19 pandemic and the demand placed on ambulances, which have been struggling to respond to calls in a timely manner, prompting the OCFA to take matters into its own hands, the grand jury noted.

‘Code 3’ responses

In December 2021, the OCFA directed that all emergency medical services responses be classified as “Code 3” — requiring vehicles to use emergency lights and sirens — to speed up ambulance response times, according to the report.

“Code 3 responses have been shown to pose a significantly greater danger to the public and emergency personnel,” said the report. “The Orange County Grand Jury is concerned that this OCFA directive and the power struggles existing between the fire chiefs association and OCEMS may be viewed as self-serving rather than serving the best interests of the public.”

The report recommends that the OCFA immediately stop the practice of requesting Code 3 responses on all non-life-threatening calls. “Code 3 response is over-utilized by OCFA, unnecessarily putting the responders and public at risk,” the grand jury said.

The grand jury also recommended:

By 2024, all Orange County fire agencies utilize criteria-based dispatch protocols and send a single unit response to those incidents triaged as non-life-threatening. Additionally, the OCFA should station a paramedic squad vehicle, which is more nimble and less costly to operate, in place of a second engine in stations with high volumes of medical calls.

That OCEMS should recognize how certain policy changes may pose operational challenges to emergency responders in the field, and fire leadership should recognize and respect the independent oversight authority and expertise of OCEMS.

Departments with publicly owned ambulances should allow OCEMS to inspect their ambulances for compliance with state emergency medical services guidelines and adopt OCEMS recommendations.

“Despite fire departments throughout Orange County having evolved into emergency medical departments, most have not updated their emergency response protocols accordingly, but have simply absorbed emergency medical responses into their existing fire response models,” the grand jury concluded.

A day on the job at MedStar: What’s it like to be a paramedic or 911 dispatcher?

BY JESSIKA HARKAY

MAY 23, 2022

https://www.star-telegram.com/news/local/article261635822.html

For first responders at MedStar, no day is ever the same, and not every day is high-intensity. But there’s one thing that remains the same day in and day out when they clock in for their 12-hour shifts — maybe they’ll help save or change a life that day — and that alone is enough to make them love what they do.

The Metropolitan Area EMS Authority, also known as MedStar, serves millions of people in Tarrant County across 15 cities. The ambulance service responds to upwards of 155,000 calls per year with its 65 emergency vehicles, 550-person staff and an efficient operations system that other ambulance service providers from 46 states and five countries have come to Fort Worth to pick up tips from.

Matt Zavadsky, a spokesperson for MedStar, said that though there’s a shortage or even a “crisis in true EMS” staffing nationwide, in Fort Worth “we’ve had a waiting list for the most part.”

Last year, NBC reported that a mix of low wages and the pandemic has contributed to a shortage of EMS workers in the U.S. and Texas. In 2020, almost a third of the workforce left after less than a year and 11% left within the first three months, according to a national AAA survey of 258 EMS organizations. In Texas, by mid-August, only 27 percent of licensed EMS workers had submitted a patient care record for 2021, meaning more than 70 percent didn’t work on an ambulance in the first eight months of the year, NBC reported, citing the Texas Department of State Health Services. “People want to come here, which is a blessing, but that’s also because of our reputation, the way we do things,” Zavadsky said. “Our field EMTs and field paramedics don’t need to stock their trucks, they don’t need to push their trucks, where in most systems you have to do that. People know that’s how we operate, plus we do a lot of cool, innovative programs.”

With flexible deployment methods, in-house logistics to keep ambulances stocked with emergency materials and a community paramedic program, MedStar is an example of how EMS is evolving as a “young field” and finding new ways to not only stay efficient in helping those in need in times of emergency, but also to provide preventative care. But the ambulance company wouldn’t be the same without the people who make operations run smoothly, including its dispatchers, EMTs, paramedics and field supervisors. As National EMS Week came to an end last week, some local first responders shared their stories.

DISPATCH

Jamey Clark sits in a dark room off of the lobby of the MedStar headquarters in Fort Worth. In front of her, seven computer screens filled with data, maps and incoming 911 calls reflect off her eyes and black headset as she types rapidly. “MedStar, this is Jamey, how can I help you?” she says before the typing takes off again.

Clark never imagined she would be a dispatcher. She woke up one day out of high school and thought being an EMT would be fun. She enrolled in classes to receive her certification, and once she graduated, found out she was pregnant. A year later, at 22, Clark was ready to begin her career. The first job that opened up was for a dispatcher, and seven years later, she’s still there.

“It was definitely a switch than what I was used to with my typical daytime-type job. The hours are much more demanding, there’s a lot more time spent away from home but (my daughter) throughout the years has always been very supportive and really proud of what I do,” Clark said.

“She used to call the ambulances, ‘Mommy’s trucks.’ So she would see one driving down the road, and she’d be like, ‘Mommy’s truck, Mommy’s truck!’” Clark’s now 8-year-old daughter isn’t the only one who has pride in her mother’s profession.

Clark said there are many moments that make her job rewarding, especially recalling a time she helped a grandmother deliver her grandchild over the phone.  “[MedStar] actually organized a meeting so I could meet the mom and the baby, and that was a really sweet coming together,” Clark said, noting that in a MedStar hallway, a Star-Telegram article is framed on the wall with a picture of her and the baby. “Her name is Carter, and her family gave me a plaque picture they made, painted with her baby feet prints on there, and I have it up on the wall in my house,” Clark said.

But like most first responder professions, there’s also an important balance with difficult situations and being able to compartmentalize. Clark remembered a call when a man said his wife had fallen and was bleeding, and after being on the phone for several minutes as she dispatched an ambulance, she realized there was more to the story.

“He just kept telling me, ‘My son is standing there like nothing’s wrong,’ and I was like, ‘Red flag. Weird, weird, weird, something is off about this. He’s not being completely forthcoming with me,’” Clark said. “I could hear the patient in the background, she was distressed and having difficulty breathing …

I was giving (the husband) instructions on how to control the bleeding and he kept telling me there’s so much blood and he didn’t know where it was coming from.”

Clark said that she had to deviate from protocol and tell the man to wipe all the blood away to find the wound, and while he did that, she said the woman’s voice in the background grew more and more faint, and the man finally admitted a knife was on the table.

The son had stabbed the woman over 50 times, police later concluded, Clark said. “I heard her ask her husband, ‘Why did you wait?’ And he said, ‘I’m sorry I didn’t think it was this bad,’ so I think there was a history of domestic violence between the son and the mother,” Clark said. “She then told her husband ‘I love you,’ and it was like 10 seconds of silence and all of the sudden the police department busted in.”

Clark said that call stuck with her for years, not because of the nature of the call, but the final words of the woman. “It just goes to show that no matter what the situation is, no matter what has happened or has transpired, people take those moments of care, with concern and love, truly, to the end,” Clark said. “It changes how you look at certain aspects of life in general.”

Clark said she’s had to learn not to emotionally invest in her work, which can be difficult being in a non-visual environment where sometimes the event sounds much worse over the phone than what it actually is. “It comes with practice, and it comes with time, learning how to disconnect from some of those things so that you can function professionally,” Clark said.

“It’s not every day that you get something like that, but you never know when it’s going to happen. And when it does, you need to be able to keep yourself calm and to perform in the aspect that you need to make sure that you’ve gotten help where it needs to go. …

Then take care of yourself on the backend.” When asked something she’d like the public to know about her job, Clark said that though she often has to repeat information, which can be frustrating to those under distress, it’s to ensure the right care. “We need to make sure that the address that we’re sending the units to is correct, and make sure that we understand what’s going on at the scene because we work in a non-visual environment,” Clark said.

“And we use the details that the caller provides to us to navigate that call, triage that call and provide instructions before the first responders get there.”

AMBULANCE CREW

Chandler Ashley and Matt Willens, two paramedics with MedStar, spent a recent Tuesday preparing for a press conference announcing new technology that could save lives. That afternoon was a testament to what both men said they love about their careers — the day never repeats twice.

For Willens, who serves as a clinical practice coordinator, he always knew he was going to end up in emergency services. Originally from New York, he spent his childhood watching his neighbor, who was a paramedic. “I heard the stories that he was telling me, and how he changed patient outcomes daily and no day was ever the same, and that really was something that I wanted to be involved in,” Willens said.

“Once I was an EMT and I went on my first call, I really saw how the paramedics at that time were interacting with not only the patient but the patient’s family, and how that interaction can have a change on that patient outcome in the long run.” For Ashley, though he has family that had EMT training, his interest in the field came in college, while he was studying to be a band teacher. He grew up playing the saxophone and loved music, but it didn’t take long until he realized some passions are better left as hobbies instead of careers.

“I actually went to college in a really small town out in Commerce and the dorm hall I stayed in, oddly enough, had this just massive parking lot, and being a small town, there’s not a lot of hospitals out there,” Ashley said.

“So they landed the helicopters out there all the time, and there was one day we had three or four EMTs out there and I ended up going and talking to them while they were waiting for a patient. I was picking their brain on what things were, what they did and stuff like that.” It piqued his interest, which led to Ashley speaking with his uncle who was a firefighter, and from there, “it just kind of spiraled.”

Both men said that although they’ve been in the field for years, Willens since 1996, and Ashley since about 2016, they still consistently learn something new. “People in ambulances — EMTs, paramedics — they’re some of the most highly-trained people out there.

We have to be prepared for whatever type of emergency we go on,” Willens said. “We don’t specialize in, just say, cardiac or OBGYN … it’s not just, you take one class and you’re done. People in this field are constantly learning and constantly bettering themselves to take care of the patients. We’re always learning because we have to be masters at so many things because we never know what’s going to be thrown at us.”

Ashley added that he hopes patients can re-frame their thinking of what an ambulance crew does and can do. “If we can stay and stabilize on scene and use the medications we have to start those IVs and secure the airways, that person is going to show up at the hospital with all the nitty gritty done, and the doctors can really start to delve into why did this happen? What are we going to do to fix this long term?” Ashley said. “And typically that almost always has a better outcome than if we just summon the ambulance and drive like people think we do.”

FIELD SUPERVISOR

George Church began working in EMS after having friends who volunteered at local fire departments and would come back with interesting stories. “Back in those days I didn’t really know what I was going to do or where I was going to go. So many kids that I remember growing up with didn’t have much planned out back then,” Church said. “I was working for a custom cabinet shop, making pretty decent money at that time, and I thought that I would always do that, but it wasn’t very exciting.

That’s why the lure of volunteering as an EMT was there.” He thought it would be a temporary thing, just for fun, and now it’s been 30 years. It starts as an EMT basic, where you can move up into an EMT paramedic and from there, the options open. Some become field training officers, others become critical care paramedics and the branches continue until you can become a supervisor like Church, who is one of eight at MedStar.

He spends his time in his own truck, watching a tablet that has a map with where ambulances are dispatched, fixing any scheduling or personnel problems and rushing to scenes when another paramedic is needed.

After spending a short lifetime as a first responder, he’s seen a little of everything, including his profession mixing into his personal life, for better and for worse. “It really has influenced me quite a bit. In the early years, I think I didn’t have the coping mechanisms that I have now. While I don’t blame my career for any failed relationships, I could see where at that young age, not having the coping skills that I have now, made it hard to balance the two [worlds],” Church said.

“Since that time I’ve learned the hard way to balance that.” Part of that was working long hours, sometimes being desensitized to little things like cuts and bruises and sometimes feeling there were things he couldn’t speak about to people who weren’t in the field and wouldn’t understand. “After two divorces, I’m in a relationship with someone that really, truly, understands what I do and why I do it. She was a paramedic at one time and worked for the Denton County Emergency Management, where it’s not exactly what I do, but with a lot of similarities,” Church said.

But there were also good moments, he said. Similar to Clark, he helped deliver a baby, but this one was in person. His name is even on the child’s birth certificate, he laughed. And somewhere along the way, Church’s love for his work transferred to his 28-year-old son, who is an EMT in Austin. “I didn’t think he would follow my footsteps. I really didn’t think he would,” Church said. “He wanted to do something different, looked into and is really enjoying it. I’m really proud of him.”

Windham County’s EMS saga, even with a surprise resignation, may be just starting

By Kevin O'Connor

May 23, 2022

https://vtdigger.org/2022/05/23/windham-countys-ems-saga-even-with-a-surprise-resignation-may-be-just-starting/

When leaders of more than a dozen towns met at Windham County’s largest emergency medical services provider last Thursday, they wrestled with the ramifications of a sudden plan by Brattleboro — its hub community for nearly 60 years — to pull out of the district.

Then the Brattleboro town manager behind the surprise withdrawal gave his two weeks’ notice Friday, just a month before his municipality is set to depart with a full third of the provider’s funding.

Many area residents, critical of the lack of notice and public debate over the ambulance change, are wondering if a last-minute reconciliation will be the end of the story. But based on the latest actions of both sides, it’s more likely southeastern Vermont’s EMS saga is just beginning.

Brattleboro is still scheduled to leave the private nonprofit Rescue Inc. on June 30, having just approved a one-year contract with Golden Cross Ambulance of Claremont, New Hampshire, until the town can complete a feasibility study on whether the municipal fire department should take over local EMS calls.

Rescue, for its part, has told its remaining 14 member communities it won’t cut care or raise rates for the coming year, but will consider whether to charge Brattleboro if it requests mutual aid as of July 1.

“Is it reasonable to dissolve a 56-year relationship without any discussion and then ask us to provide the backup coverage you need?” Rescue Chief of Operations Drew Hazelton said of Brattleboro.

Brattleboro residents approved a 2022-23 municipal budget in March that included a $285,600 ambulance service assessment figure sought by Rescue. They weren’t told that Town Manager Yoshi Manale, who started less than three months earlier, had reopened talks his predecessor had completed and other municipal officials had confirmed in a January operational letter of agreement.

Manale won’t elaborate on what was said at a private February meeting between the two sides other than to note he and Rescue “have different recollections” and “I’m not going to continue a back and forth.”

But Rescue’s chief of operations, the head of its board of trustees and Brattleboro’s resident representative all contend that Manale asked for drastic changes in a longtime connection that former Town Manager Peter Elwell supported publicly before his December retirement.

“The system is working,” Elwell told Rescue at the end of its most recent annual meeting, aired and archived on Brattleboro Community TV.

Manale, however, told the provider it either would have to work under the oversight of the municipal fire department, even though Rescue is a private nonprofit, or provide services to the town at no cost, all three EMS representatives assert.

“We declined to accept either scenario,” said Kathy Hege, president of Rescue’s board of trustees, “and unanimously rejected the proposal.”

Manale also verbally asked for data on the private nonprofit’s administrative costs and Brattleboro insurance compensation, both sides confirm, although he never followed up with those authorized to release such data to learn it isn’t broken down by community, but instead reported as a unified district.

Manale went on to issue a press release last month, saying Rescue had written him to report it wouldn’t serve the town as of July 1, even though the EMS provider’s actual letter noted it simply couldn’t agree to offer free care but was open to talking about continuing paid work.

The resulting news, coming just weeks after a Town Meeting report that featured Rescue’s future plans and just months before the end of the current contract, has sparked criticism everywhere from social media to selectboard meetings to the Statehouse, where retiring Democratic Windham County Sen. Jeanette White called it “one of the worst decisions ever made.”

Critics of Brattleboro’s plan have stressed they support both Rescue and the fire department, but simply can’t understand why the town is dropping its current EMS provider before completing a feasibility study to see if it makes sense to invest in an in-house model.

“The Town of Brattleboro’s unilateral withdrawal from Rescue Inc. is the destruction of an integrated system of personnel, equipment, communication and services,” Putney resident Howard Fairman wrote in the latest edition of The Commons weekly newspaper, “disdaining and imperiling residents of and visitors to 14 lesser towns while looking out for number one.”

At a meeting Thursday, Rescue outlined its district finances — available on its IRS form 990 for tax-exempt organizations — to show how its collaborative structure allowed Windham County towns to pool their resources to provide specialized staff, equipment and services that none could pay for on their own.

Vermont has a higher-than-average number of people covered by federal Medicare health insurance for older adults or Medicaid for anyone with low incomes, statistics show. But Medicare pays only 80% of a bill, while Medicaid pays only about 64%.

“Every patient we see with Medicare or Medicaid is being reimbursed at least 20% less than the cost of delivery,” Hazelton said.

That requires Rescue to charge each member town an additional per-person assessment — in Brattleboro’s case, $285,600 for the coming year to cover its population of 12,184 — to meet expenses after receiving what private and public insurers pay for reimbursement.

Manale, however, has estimated Brattleboro could reap up to $700,000 in revenue if its fire department took over local EMS calls — a claim several experts have dismissed and no other local or state leader has supported.

Manale said his figures anticipated the receipt of a federal Staffing for Adequate Fire and Emergency Response (SAFER) grant used at his past job as an administrator in Trenton, New Jersey. But a check there shows that city couldn’t rely on such funds, leading to threats of layoffs.

In 2017, for example, Trenton was set to let go of 64 of its firefighters when it didn’t receive the federal money. The city of 83,387 people ultimately averted staff cuts by reducing overtime. That, in turn, dropped the number of professionals working at each of its seven stations at any time down to three.

“It’s a safety concession — federal standards recommend four,” the news website NJ.com reported.

Manale has acknowledged that, for all his charges against Rescue and confidence about a town EMS takeover, his estimates may not hold up to independent review.

“If it does say, hypothetically, this doesn’t financially make sense and the model doesn’t work here, we would go out to a bid and ask providers — including Rescue,” Manale told the Selectboard at its meeting on April 19.

Since then, the Selectboard has signed a nearly $40,000 contract for the Wyoming-based consulting firm AP Triton to study the costs, staffing needs and related challenges of the municipal fire department taking over EMS responsibilities.

A recent AP Triton study for the Vermont town of Williston, which made national news after a firefighter shortage left its station empty for almost an hour, required the community to increase its fire and EMS budget by 42% this year to pay for the nine additional employees recommended in the report.

Hats off to the FDCARES program developers, and all those who have ventured into the MIH/CP waters, proving the value of “EMS” in much different ways!

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A Different Kind Of First Responder

Brian Rinker

MAY 2022

https://www.healthaffairs.org/doi/10.1377/hlthaff.2022.00363

Abstract

A Washington State fire department dispatches nurses and social workers to address the underlying health and social needs of repeat 911 callers.

Dana Bray remembered September 8, 2019, as the unforgettable day her seizures began. It started with what she thought was a bad reaction to a medication that left her unconscious and not breathing on her condo floor in Renton, a Seattle suburb in King County, Washington. Her downstairs neighbor found her purple and almost dead. The neighbor called 911, and Bray was admitted to the intensive care unit for ten days.

Later, Bray, 65, was diagnosed with functional neurological disorder, a broad category of motion disorders caused by problems with how the brain functions.¹ (After speaking with the author for this article, Bray died in March 2022.)

After that first near-death experience, Bray’s neurological problems affected her ability to move around—she had to relearn how to walk, and getting around required a walker or wheelchair. More troubling, though, were the continued seizures, which snuck up without warning, randomly and frequently. Bray would go stiff, start shaking, and then fall.

“The worst part about it was that I had no control where I fell,” Bray said.

During the next two years, Bray estimated that she had fallen close to 150 times from the seizures. Sometimes she collapsed three times in a single day. There was hardly a spot in her modest condo where she hadn’t fallen and hurt herself. There was the time she knocked her chin on the nightstand, or when she rolled under the dresser, violently shaking, and got stuck; she also dislocated her ankle, severed a finger, and had countless blue and purple bruises all over her body. She must have called 911 at least once a month over the years, she said. On a particularly rough week, she remembered dialing 911 four days in a row.

Had Bray lived in some other community across the United States, each of those of 911 calls likely would have resulted in a maximalist response: paramedics, ambulance with lights ablaze, and maybe even a million-dollar ladder truck from the local fire station. Fortunately, Bray said, her community is served by a fire department that instead sent a nonemergency unit known as FDCARES, which stands for Fire Department Community Assistance, Referrals, and Education Services.

FDCARES is a specialized unit in which registered nurses and social workers work alongside firefighters to address the underlying causes contributing to repeat callers like Bray. It was created by Puget Sound Regional Fire Authority and is available in the southern region of King County.

For Bray, from their first contact in 2019 until her death, FDCARES became a mainstay in her life. During that time, FDCARES connected her with a fall prevention program that installed grab bars and a shower seat in her bathroom. The unit stopped by her condo so many times, whether to drop off a new walker or a wheelchair or just to check in, that Bray considered one of the nurses a good friend.

“I didn’t call and ask them to come see me, they just came and knocked on my door, you know, out of kindness,” she said. That meant a lot to Bray, who lived alone and didn’t have family nearby. “It was nice to have somebody with professional medical training visit me, and it was nice to know that somebody cared about me,” she said.

‘Costly And Overcrowded’

Bray was what emergency service professionals refer to as a 911 high utilizer—a small subset of the population that uses a large portion of fire department, police, and emergency department resources. Every community has them. Many high utilizers have complex medical and psychosocial needs and call 911 for nonmedical emergencies. Cities and health systems across the country are incentivized to address these so-called high or “super” utilizers to divert them from costly and overcrowded emergency departments, drive down health costs, and free up limited resources for people experiencing true medical emergencies.

Shifting trends during the past decades toward value-based and whole-person care—addressing an individual’s health, behavioral, and social services needs in concert—have led to a growing number of efforts nationwide to reduce hospital readmissions, divert nonemergency cases away from emergency departments, and provide resources to tackle any environmental conditions that may affect a person’s health. Although hospitals and accountable care organizations have a keen interest in coordinating care to improve health and wellness for high utilizers, some lack the resources and staff to meet this tough subset of patients.²

Mobile integrated health programs such as FDCARES are well suited and strategically better positioned than hospitals or physician groups to provide care and social services to people in the community. These mobile health programs, also called community paramedicine, harness local emergency services, which have the existing infrastructure to respond to community members’ needs. One 2014 survey³ identified well over 100 EMS agencies in thirty-three states that are implementing some version of a mobile integrated model, with dozens more agencies in the process of launching their own units.

With the COVID-19 pandemic, experts say that mobile integrated health units are now more important than ever before, as they have skill sets, resources, and infrastructure to quickly pivot and be flexible. When the pandemic hit and hospital systems were overwhelmed, the area’s public hospital district, UW Medicine Valley Medical Center, and the King County public health agency called on FDCARES to run community COVID-19 testing and vaccination efforts.

FDCARES, however, is unlike other mobile integrated health units, as it is one of the only fire departments in the country to hire nurses and social workers to work alongside firefighters.

‘The Potential’

The concept for FDCARES dates back to 2010 and was born out of the recognition that the King County fire departments were spending a lot of money, resources, and time to respond to repeat 911 callers.

In general, fire departments assume the brunt of high utilizers’ impact, responding to upward of 80 percent of 911 calls for medical services. Of those calls, about 40 percent are considered nonemergencies, such as falls, complications arising from chronic health conditions, mental health episodes, and intoxication.

For Puget Sound Regional Fire Authority, which serves several cities in southern King County, departmental estimates indicate that slightly more than 1 percent of the community accounts for roughly 40 percent of 911 calls.

As envisioned, FDCARES not only helps people navigate the complicated world of health and mental health care but also connects them to social services, such as food banks, rental assistance, fall prevention, therapy, and substance use treatment. The idea is that by addressing the root causes of super utilizers’ super utilization, the program will save fire departments, hospitals, and taxpayers tons of money.

Has that vision been fulfilled? As the public health field has learned, it’s hard to quantify prevention. However, a 2017 evaluation⁴ estimated that FDCARES had the potential for annual savings of $600,000 for the fire department, as well as $1 million a year for the area’s health care system, and that it could reduce emergency department visits by up to 200 a year.

In the eyes of many regional officials, the program has been such a success that it has expanded to the nearby Renton Regional Fire Authority. At this time, FDCARES covers seven King County cities and receives roughly 2,600 calls a year. The program has continued to evolve since it formally launched in 2015 and is on track to grow bigger and take on more responsibilities.

“I expect over the next fifteen to twenty years, mobile integrated health and…FDCARES-type units will be as common as fire suppression is at a fire station,” said Puget Sound Regional Fire Authority Deputy Chief Aaron Tyerman, who oversees FDCARES’s strategic direction.

‘It Doesn’t End There’

The standard fire department model is straightforward. A 911 call for medical assistance comes in, and dispatch triggers a rapid response deployment of fire department emergency medical technicians (EMTs) and paramedics, who arrive on scene in four to seven minutes. The job of the first responders is to quickly assess the situation, deliver appropriate interventions, and then transport anyone who needs it to a hospital emergency department.

But with close to half of all calls being nonemergency, said Captain Matthew Madlem, from Puget Sound, ten years ago they were essentially “sending very expensive ladder trucks to go help people who have just simply fallen.”

A big chunk of 911 calls, according to Madlem, were from those who had fallen, in fact, and these callers didn’t need the emergency department, they needed someone to figure out why they were falling all the time. Perhaps it was a medication problem, an adverse consequence of a chronic health condition, intoxication, or a mental health issue. Yet back then the fire department, similar to many emergency medical services agencies, didn’t have a process for closing the loop on care or managing continuity of care for patients they saw repeatedly, Madlem noted.

“Firefighters are trained to do a lot of things, from fighting fires to river rescues, confined space rescues, hazardous material responses, basic life support for people that have medical issues,” Madlem explained, “but we’re not trained to be social workers, and we’re not trained in transition care management or care coordination.”

In fact, the department’s past approach to recording data was so arcane, it couldn’t even identify high utilizers. The first thing they had to do when implementing FDCARES was create a database that could identify repeat callers. The database also uses predictive analytics, a technique commonly called hot spotting, to identify areas and callers at higher risk for complex medical and psychosocial needs.

Today, under the FDCARES model, when someone calls 911, dispatch uses updated criteria-based dispatch guidelines developed in house by King County Emergency Medical Services to identify nonemergency callers; in those cases, it’s the FDCARES unit that goes to the scene. Because the call is not an emergency, FDCARES has twenty-five minutes to get there, instead of only a few minutes. Nor does it need a large fire engine or state-of-the-art ladder truck.

Instead, the firefighter and nurse duo drive a red pickup truck with “FD CARES” written on the side of the truck, which carries fall prevention equipment and lift devices. Altogether, their truck costs a fraction of the price of purchasing and maintaining a fully equipped fire engine. Once there, the responders can spend a much longer time working with the person to figure out what is going on and how they can help.

But it doesn’t end there. The unit also proactively checks up on patients to make sure their needs are being met and whether the initial assistance is helping them navigate health care. This may include bringing a wheelchair or walker over, as they did in Bray’s case, or connecting them with a social worker.

In 2015 the Puget Sound Regional Fire Authority launched FDCARES as an eighteen-month pilot program, hiring a social worker and three registered nurses. Reaching that point alone was a considerable lift for the department and local officials, as fire departments are funded with tax dollars and don’t have very much flexibility.

To make sure FDCARES didn’t step on any toes, the program enlisted support from the Washington State Nurses Association and was able to obtain medical oversight from the medical director of the UW Valley Medical emergency department, Cameron Buck, who helped define the scope of practices.

The partnerships supported the fire department’s case that it was in the community’s best interest to spend its tax dollars on nurses and a social worker. The buzz around FDCARES spread across the state and inspired the state legislature to pass a bill5 in 2013 allowing fire departments to hire nurses, social workers, and other nonfire personnel.

‘Worth The Risk’

Back in November 2015, Sara Hardin was one of the first nurses hired. Hardin’s family thought it was odd that she left a stable job in the intensive care unit (ICU), taking a hefty pay cut, to join an experimental pilot program with the fire department. But for Hardin it was worth the risk. She said that it was “heartbreaking” to see the same people admitted to the ICU over and over again and not being able to prevent it.

“Trying to offer a solution was really appealing,” she said about joining FDCARES.

When FDCARES first went into action, the team got some pushback. The nurses didn’t exactly fit in at first. Initially, they weren’t a part of the firefighters’ union, which left them feeling that they were not on equal footing. Plus, they didn’t accrue any vacation or sick time, Hardin recalled.

Some fire crews were concerned the nurses might replace firefighters, and their integration at the station went against decades of tradition. The county’s paramedic squad also complained, worried that the fire department was encroaching on their medical domain. When it eventually became clear that the nurses handled only nonemergency and high-utilizer calls, Madlem said, they agreed that FDCARES would make everyone’s jobs easier. Over time, the nurses blended in. Two years later the union accepted Hardin and her nurse colleagues into their ranks, further cementing their role as a core service of the fire department. Today, if the department canceled the FDCARES program, Hardin said, there would be an uproar.

The other big challenge was getting nurses prepared to work in the station and up to speed on all the firehouse lingo and culture, as well as training them on the radio, computers, and operational procedures. Training them was Madlem’s job. Basically, the gist was “how to exist in the fire department culture as somebody who’s not a firefighter,” he said.

Much of the learning is picked up over time by living with the crews, whether it’s working twenty-four- or forty-eight-hour shifts. They learn words such as “beanery,” firefighter talk for the living room, where there is always a pot of coffee ready, and “spike the bag,” meaning to start an intravenous drip. Then there are the little things, such as bringing doughnuts, making coffee, and racing to always be the first to answer the telephone.

Hardin was surprised by just how much time the firefighters spend together, especially all of the group meals—wake up; drink coffee in the “beanery;” and eat breakfast, lunch, and dinner together. When bedtime arrived, they were all walking around with toothbrushes in hand. It was like a big family, Hardin said. And similar to what happens in big families, there was a lot of joshing around and poking fun at each other.

“You have to be able to take a joke,” Hardin cautioned. “The fire department jokes a lot.”

‘Culture Shock’

When Daniel Henriquez joined FDCARES, he didn’t know what he was getting himself into. Henriquez, similar to Hardin, was an ICU nurse. But he had longed to work in the community, helping vulnerable and marginalized people get better. In his decade of ICU experience, he had seen how often poorly managed chronic health conditions, such as hypertension, ended with preventable tragedies, such as a stroke or heart attack.

In addition, coming from health care, Henriquez said, entering the fire department was a complete culture shock. Many firefighters have military or law enforcement backgrounds, and the fire department is structured with ranks similar to a military chain of command.

Henriquez was roughly three months in with FDCARES when he went out on a 911 call that ended with him finally feeling like part of the team. It’s an unpleasant and terribly sad story, but it does have a happy ending.

Henriquez and his firefighter partner got a call requesting help for a man who had been living in his car for several months. Approaching the vehicle, they were hit with a smell that Henriquez likened to the inside of a septic tank. The man told them to go and wouldn’t get out of the car, but after some cajoling, he rolled down the window.

Henriquez started talking with the person—really talking, he said—and in that moment, “we were level, human-to-human,” he said.

That’s when the man started bawling. He told them he had lost his job, been divorced, and was forced to live in his car, which was parked in front of his old home. He’d run out of money and gas. At some point, about six months prior, he lost the will to get out of the car. Henriquez looked inside the car and saw feces and urine piled all the way up to the man’s knees. Hoping to shield his legs from the mess, the man had wrapped plastic garbage bags around them, but the ties on the bags cut deep into the skin and muscle, all the way down to the bone; maggots covered the wounds.

“If we try to move this patient out of here, his legs might fall off, and he will just bleed out and die,” Henriquez thought at the time.

But they had to move him. They cut his clothes off and pulled him through the window and put him on a stretcher. His vital signs were OK, surprisingly. Paramedics transported the man to the hospital, and miraculously, they were able to save his legs.

“Thank God for the maggots,” Henriquez said, noting their antimicrobial effects. “He had no infection whatsoever—those maggots saved his life.”

Several months later the man walked into the fire station and left a message thanking the firefighter and Henriquez for taking care of him. He was grateful that they didn’t make fun of him, choosing compassion instead. Henriquez later heard that the man got an apartment and began volunteering at a homeless resource center.

‘It’s Evolving’

Last year the fire chief asked Henriquez what he wanted for the FDCARES program. If you could have anything, the chief inquired, what would it be? “The first thing I said,” Henriquez recalled, was, “I need my partner to be a social worker instead of a firefighter.”

During the four previous years, Henriquez had felt as if something was missing. Many of the calls he went on, although dispatch had classified them as nonemergency, still resulted in the patient being transported to the emergency department. When that happens, FDCARES units don’t have much of a role to play. Henriquez said that these calls are best handled by EMTs. In his view, having to spend all that time dealing with medical emergency calls prevented him and the other crews from doing the upstream work that FDCARES was created to do in the first place.

Part of the challenge is that the county’s emergency dispatch service has a tough time understanding the severity of a call in that moment, said Nancy Valencia, FDCARES’s lone social worker. The call may come across as not that intense, but once first responders are on the scene, the patient may still need emergency medical care.

Valencia, an army reservist, was deployed last year, and in her absence FDCARES turned to UW Valley Medical Center’s health facilitators to cover her social work duties, which did not entail going out on calls. With the pandemic strengthening their long-standing relationship, FDCARES is increasingly becoming UW Valley Medical Center’s boots on the ground in the community. The two organizations are currently ironing out the details on a project in which FDCARES will perform follow-up medical visits and welfare checks on patients recently released from the hospital.

This summer Henriquez will get what he asked for: FDCARES has adjusted its model again. A nurse will team up with a social worker and go on calls only after a firefighter has determined them to be true nonemergency events. The department has a potential grant for $185,000 pending from the One Medic Foundation. If approved, the grant will go toward hiring three more social workers. As to an evaluation plan, Henriquez said that they don’t have one now. They are studying outcomes, such as how many patients get connected to resources, but with the pandemic and staffing shortages, they have struggled to keep up on these efforts.

“We’ve been doing this for basically seven years, and it’s evolving,” Valencia said. “We’re continuing to try to meet the patients where we need to meet them and do that in the most efficient and effective way we can for our community.”

Henriquez envisioned that working for FDCARES would be similar to providing home health care. Instead of the health care happening in the hospital, he’d address patients’ day-to-day health issues in their homes. It turned out to be kind of like home health care, but on steroids.

FDCARES units are dispatched to multiple 911 calls each day—for example, responding to an intoxicated person experiencing homelessness, or an elderly person who has fallen—and they proactively follow up with past callers, helping them navigate the health care system and ensuring that they have been connected to the right resources, from medical equipment to rental assistance, and even assisting family caregivers struggling to care for a loved one.

NOTES

• 1.       Mayo Clinic. Functional neurologic disorder/conversion disorder [Internet]. Rochester (MN): Mayo Clinic; [cited 2022 Apr 8]. Available from: https://www.mayoclinic.org/diseases-conditions/conversion-disorder/symptoms-causes/syc-20355197 Google Scholar
• 2.       Peikes D, Chen A, Schore J, Brown R. Effects of care coordination on hospitalization, quality of care, and health care expenditures among Medicare beneficiaries: 15 randomized trials. JAMA. 2009;301(6):603–18. Crossref, Medline, Google Scholar
• 3.       National Association of Emergency Medical Technicians. Mobile Integrated Healthcare and Community Paramedicine (MIH-CP) 2nd national survey [Internet]. Clinton (MS): NAEMT; 2018 [cited 2022 Mar 22]. Available from: https://www.naemt.org/docs/default-source/2017-publication-docs/mih-cp-survey-2018-04-12-2018-web-links-1.pdf Google Scholar
• 4.       CGI Group Inc. FD CARES innovative analytics project [Internet]. Montreal: CGI; 2017 [cited 2022 Mar 22]. Available from: https://www.cgi.com/sites/default/files/casestudies/cgi-case-study-fd-cares-prescriptive-analytics.pdf Google Scholar
• 5.       SB 5145-2013-14: Allowing fire departments to develop a community assistance referral and education services program [Internet]. Olympia (WA): Washington State Legislature; 2013 [cited 2022 Mar 22]. Available from: https://apps.leg.wa.gov/billsummary/?BillNumber=5145&Year=2013&Initiative=false Google Scholar

Excellent article! 

The 2^nd linked study in the 4^th to last paragraph has a fantastic compendium of all the research studies published around the world about MIH/CP programs (most of them from countries outside the U.S.), but GREAT info!

The article references the benefits of EMS systems doing safety checks on scenes and referring patients for other follow-ups.  MedStar has been blessed to work with several Universities on HRSA and DOJ funded studies doing exactly that for things like fall risk assessments, elderly neglect and abuse and opioid overdose risks.  We strongly recommend agencies seek out those types of partnerships as a value-added role in your local community.

Tip of the hat to MedStar’s Chris Cunningham for finding this article!

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Beyond emergencies: Researchers rethink the role of paramedics in the health system

April 26, 2022

Alisa Kim

https://www.utoronto.ca/news/beyond-emergencies-researchers-rethink-role-paramedics-health-system

As a paramedic, University of Toronto alumnus Amir Allana routinely responds to a wide range of calls – from people suffering a heart attack or stroke to those experiencing mental health issues and addiction.

“On a given day, I might go from acute trauma to someone who’s 70 and has just had a fall but is otherwise uninjured,” says Allana, who recently defended his master’s thesis in the health services research program offered by the Dalla Lana School of Public Health’s Institute of Health Policy, Management and Evaluation (IHPME).

“The next call might be for someone who’s in a shelter system who has a number of chronic conditions that have gotten worse, or who just needs somewhere to go. You’re trying to navigate to what extent is this a health issue versus a social issue? Is this an addictions issue? You’re switching gears all the time, and a lot of it is case-finding, triage and navigation of the health system,”

In fact, Allana says that traditional medical emergencies account for only a small fraction of the cases he sees.

“It’s difficult for newer paramedics who spend all their schooling thinking about trauma and cardiac arrest, only to realize, ‘Oh, that’s just 10 per cent of what I do,’” he says. “Not enough education or cultural pieces are in place to tell them, ‘Actually, your role for the most part is diagnostics and care navigation. Your role is an extension of health services because you’re mobile in the community.’”

Allana and his co-supervisor, Andrew Pinto, an associate professor at the Dalla Lana School of Public Health and a family physician at St. Michael’s Hospital, recently published a paper in Healthcare Policy, that explores how paramedics can address social determinants of health more effectively.

Care could be improved, they argue, by equipping paramedics with tools for better social and environmental assessments. For example, questionnaires could be used to help paramedics assess patients for risks associated with housing, income and food insecurity. Paramedics could also address social factors linked to health by working directly with community-based organizations such as legal aid, shelters, detox centres, food banks and employment agencies.

Allana says such an approach would require a shift in paramedic education, culture and governance.

His research also looks at integrated care and how paramedics can extend primary and preventive care in home and community settings.

Allana says the pandemic has exposed the vulnerability of the health system and provides an opportunity to think about how to restructure it in a way that leverages local agencies and services to improve outcomes.

“There are approaches to care that can be provided in the community, but require a rethink of the role of primary care, community-based nursing and mobile care teams – including paramedics and mental health services – to address people’s needs in a way that doesn’t rely just on doctors and nurses in a hospital,” he says.

In a study published in the International Journal of Integrated Care, Allana looked at 108 programs around the world that use paramedics in various care pathways in the community. He found paramedics bridged gaps in care by working across silos that exist between hospitals, social services, primary care and public health. For instance, paramedics in some jurisdictions work with primary care teams to address flare-ups of chronic diseases such as heart failure (when the heart is too weak to meet the body’s pumping needs) and chronic obstructive pulmonary disorder (a lung disease that causes breathing problems) by going into the community to address needs both reactively and proactively.

“Even something simple like weight monitoring for people with congestive heart failure can catch deterioration early,” says Allana. “Systems can be put in place by family health teams and paramedics to follow care plans and adjust medications. There’s something in the middle of purely scheduled primary care and highly acute unscheduled emergency care – there’s a big gap in the middle that no one fills, and a lot of new [paramedicine] programs are filling that.”

Allana says that, ultimately, a more expansive view of the profession is needed and that investing in the capacity of paramedics to provide urgent and preventive care will strengthen the health system for everyone.

“The use of emergency departments and hospital services has outstripped population growth for several decades and that’s going to continue to happen. The reason for that is you’re not providing appropriate care options in the community. We don’t have capacity in the acute care system to appropriately care for people. If you invest in prevention and care co-ordination, it’ll pay off in the long term and curb the need for additional emergency coverage over time.”

This may be something for us to keep an eye on? 

We’ve noticed denials from some MA programs for services covered by FFS Medicare, including some ambulance services coverage authorized under COVID-19 waivers…

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Medicare Advantage debate rekindled by report on coverage denials

Tina Reed

Caitlin Owens

4/29/22

https://www.axios.com/medicare-advantage-debate-rekindled-by-report-on-coverage-denials-c76d3d57-df26-41be-8d7e-e8d1a5911514.html

Thursday's federal watchdog report accusing Medicare Advantage of denying too many services that should have been paid for under Medicare coverage rules is inflaming Washington's debate over whether the program is helping seniors or simply padding insurers' pockets.

Why it matters: Medicare Advantage enrollment has ballooned in recent years, making the question of its value — both in terms of quality and cost — increasingly important.

Driving the news: The report from the HHS Office of the Inspector General says it found "widespread and persistent problems" of inappropriate denials of services and payment requests that met Medicare coverage rules.

• Auditors found 15 Medicare Advantage organizations denied 12,273 previously authorized requests for medical care during the first week of June 2019.
• Putting that into context, the Medicare Advantage plans would have denied 84,812 beneficiary requests for services that met Medicare coverage rules that year.

Between the lines: Medicare Advantage has proved highly lucrative for insurers, turning Medicare into more of a private marketplace as enrollment swells.

• Private insurers like Humana and UnitedHealth Group that administer Medicare Advantage plans can expect a 5% average increase in federal payments next year — half a percentage point above what the Biden administration proposed in February.
• Humana recorded a $930 million first-quarter profit and projected its Medicare Advantage rolls will grow by 150,000 to 200,000 this year, according to Modern Healthcare.
• More than 28 million seniors and people with disabilities were enrolled in a private Medicare Advantage plan at the beginning of this year, an 8.8% increase from the same time in 2021.

Yes, but: Not everyone thinks the program's success is a good thing — particularly for taxpayers.

• Whistleblowers have accused Medicare Advantage plans of inflating how sick their members are in order to bump up federal payments, Bloomberg recently reported.
• A recent report from the Medicare Payment Advisory Commission concluded that plans collected $12 billion more caring for seniors in 2020 than it would have cost in traditional Medicare.

The other side: "The OIG report validates that the vast majority of Medicare Advantage prior authorization requests are approved, and that the vast majority of denials that the OIG reviewed were appropriate," said Kristine Grow, a spokesperson for America's Health Insurance Plans, adding Medicare administrators noted plan performance is improving.

What we're watching: The program generally isn't an attractive political target given its popularity with seniors and, for Republicans, its embrace of private-sector coverage.

• Policymakers often turn a blind eye to exorbitant health care costs in response to health industry lobbying.
• But denial of services could make the program an easier target for critics.
• Democratic Reps. Katie Porter, Rosa DeLauro and Jan Schakowsky and Sen. Elizabeth Warren are pressing the Biden administration to put payments to Medicare Advantage plans on a par with traditional Medicare and increase transparency in the program.
• Reps. Suzan DelBene, Mike Kelly, Ami Bera and Larry Bucshon seized on the inspector general's findings to call for reforms to the program.

The bottom line: Medicare Advantage is unquestionably getting bigger. Thursday's report once again raised the question of whether that's a good thing.

An international challenge – Fundamental changes are need to how EMS is delivered….

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Data shows ambulance unavailability getting worse in Winnipeg

In January, there were 28 hours where zero ambulances were available, according to City of Winnipeg figures

Sarah Petz · CBC News

Apr 20, 2022

https://www.cbc.ca/news/canada/manitoba/winnipeg-ambulance-unavailability-1.6425663

There were 28 hours in January when there were zero ambulances available in the City of Winnipeg to respond to emergencies, according to data obtained by the Manitoba NDP. 

That's four times longer than it was two years before in December 2019, which at the time was the longest monthly total in four years. 

It also wasn't even the worst month for ambulance unavailability in Winnipeg in the last year.

Figures from the City of Winnipeg show that in August 2021, there were nearly 31 hours where there were no ambulances available to respond to calls. 

That works out to about 59.69 non-consecutive minutes per day, a City of Winnipeg spokesperson confirmed. 

The data, obtained through a freedom of information request, was tabled in question period Wednesday by NDP Health Critic Uzoma Asagwara. 

It also shows that in the same month, there were 588 instances where there were no EMS units available to respond to calls for service. 

"The problems were known long before the pandemic, and the government did absolutely nothing to resolve it," Asagwara said. 

Paramedics exhausted

The figures for January also show that nearly two-thirds of the time that month the ambulances were in degraded mode — meaning there were six or fewer ambulances available for service.

Six is the base number the Winnipeg Fire Paramedic Service uses to determine whether they can meet target response times.

After working through the pandemic, paramedics are burned out, and numbers reflect that, said Ryan Woiden, a longtime paramedic who is the president of the paramedic union, Manitoba Government and General Employees' Union Local 911.

"The days of trying to pick up the over time when the staffing levels are low, they're becoming fewer and far between because of the exhaustion," he said.

Back in December 2019, Woiden told CBC News he had never seen it so busy for paramedics. 

The fact that it's gotten even worse reflects that the entire system needs to be revamped, he said. 

"Truly I think that you end up seeing those numbers increase because there hasn't been any major changes to the way we do business," he said. 

"I'm not sitting here saying that we need ten more ambulances and 100 more paramedics. What I'm saying is, what if we were to think outside the box and do things a little bit differently?"

Population growth, increased call volumes and call complexity, longer wait times for transferring patients, and the ongoing impact of the COVID-19 pandemic have put additional pressures on the city's transport ambulance availability, a spokesperson for the City of Winnipeg said via email.

However, the Winnipeg Fire Paramedic Service and Shared Health are implementing measures to reduce strain on the system, such as serving lower acuity patients through the community paramedic when safe to do so, and establishing transfer of care procedures to minimize the time ambulances remain at a hospital, said Michelle Lancaster, communications officer for the Winnipeg Fire Paramedic Service.

Health Minister Audrey Gordon said she hadn't seen the data yet, but will review it. 

She added that her government's most recent budget includes money to hire 35 more paramedics across the province.

In addition, the City of Winnipeg and Shared Health are currently working on a new deal over funding for ambulances and paramedics, she said. 

"And it's my job to listen to Manitobans and ensure that, as part of the discussions around development of that agreement, we're looking at these concerns," she said.

A timely blog post, as some agencies are still facing this challenge – perhaps some kernels that folks can use?

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Improving Flow: Addressing the Complexities of Emergency Department Overcrowding

By Patricia Rutherford | Monday, April 11, 2022

http://www.ihi.org/communities/blogs/improving-flow-addressing-the-complexities-of-emergency-department-overcrowding

When patients have to wait for long periods in overcrowded emergency departments (EDs), it’s not just an inconvenience. Evidence shows that ED crowding leads to significant patient harm, resulting from delays in treatment and increases in preventable harm. A systematic review in 2022 concluded that ED crowding was associated with higher mortality in 45 percent of the studies, worse quality of care in 75 percent, and a worse perception of care in 100 percent.

ED Crowding Has Multiple Sources

The problem of ED crowding is widely recognized. Too often, however, ED crowding is seen in isolation — as a matter of simply making ED operations more efficient. To be sure, there are ways that ED staff can improve their operations to ease crowding, but there are limits to how much those efforts can accomplish. Efficient, high-quality ED care is also dependent on factors outside the control of the ED — such as lack of sufficient and timely primary care and mental health services as well as timely availability of post-acute care services. To solve the problem of ED crowding and delays in admitting patients to the hospital, improvements in community-wide and hospital-wide patient flow are needed.

Indeed, the situation is reminiscent of the metaphor about the people who are all looking at a different part of an elephant. The one who sees a tusk thinks it’s a spear, the one who sees the tail thinks it’s a rope, and so on. Something analogous occurs when clinicians and staff only see flow problems from their perspective in the ED and within other units or departments throughout the hospital. While the ED staff see long delays in admitting patients, the clinical staff on medical and surgical units see unnecessary bed days and long delays in discharging patients to homes and community-based care settings. To improve patient flow in the ED, we need to look at the whole “elephant” — the whole system that impacts hospital-wide patient flow.

Efficiency Improvements in the ED

There is certainly some potential for improvement in the ED itself. For example:

• Separate flows in the ED (based on acuity) with dedicated clinical teams for each flow. Many EDs that have implemented these lean principles have significantly improved efficiencies and decreased the length of stay for patients discharged from the ED and for patients being admitted to the hospital.
• Create a separate protocol-driven unit for short-stay patients with relatively straightforward diagnoses. These units are intended for patients who may not be sick enough to warrant a hospital admission but are not well enough to be discharged immediately. A 2013 article found that, compared to patients under observation elsewhere in the hospital, patients in dedicated observation units with defined protocols had 23 to 38 percent shorter length-of-stay, and their likelihood of subsequent inpatient admission was 17 to 44 percent lower.

In addition, clinical teams in the ED can partner with community providers of care to shape demand for ED visits.

• Provide end-of-life care in accordance with patients’ wishes. This step often prevents admissions to intensive care units.  
• Utilize case managers. These team members can facilitate discharges to home and arrange home care and timely follow-up care after discharge from the ED.
• Support patients with low-acuity needs in community-based care settings. Extend the hours of primary care offices and offer more virtual office visits for primary care, specialists, and mental health care.

Addressing Common Bottlenecks in the Hospital

Often, beds are not available in the hospital, leaving patients to wait for inexcusably long periods in the ED. A commentary in NEJM Catalyst suggests the problem is, in fact, getting worse.

Common bottlenecks and system constraints include:

• Discharge delays — Difficulty finding the right settings and needed services for patients who are otherwise ready to be discharged from the hospital causes delays. Address this bottleneck by focusing on efficient discharge planning and collaborations with family caregivers and community providers of care. In other words, focus on the “back door” in addition to the “front door” of the hospital.
• Unnecessary bed days — Unnecessary bed days occur when patients remain in the hospital for extra days or weeks after they are medically ready for discharge. Comprehensive assessments for post-acute care needs, interdisciplinary planning with a patient and their family, and decision-making can all take time and extend a patient’s stay. In addition, the lack of availability of post-acute facility beds and home care services often leads to long-term hospital occupancy. Inpatient units lose functional capacity as patients await placement in post-discharge health care settings (rehabilitation centers, skilled nursing facilities, or nursing homes).
• Uneven elective surgical scheduling — It is common for surgeons to schedule elective surgery in an uneven manner throughout the week, which can contribute significantly to hospital-wide flow problems. Efforts to “smooth” the flow of elective surgical patients throughout the week can have multiple benefits: more predictable flows of patients from the operating room to intensive care units and other inpatient units, less competition between ED and elective admissions, and more predictable and appropriate nurse staffing on units.

A NEJM Catalyst article identified essential steps to mitigate crowding in the ED, including acknowledging it as a serious problem and threat to patient safety, and urging visible, committed leadership buy-in as an essential part of the solution.

It is crucial to address hospital-wide patient flow, not just to pursue isolated improvement projects that may not have an impact on timely patient progression throughout the hospital. In addition, community-wide efforts to create timely access to care can prevent overutilization of ED services and lengthy hospital admissions. We need to see the “whole elephant” to address both system-wide hospital flow issues and the availability of community-based health care services which impact overutilization in hospitals.

The Pandemic Exacerbates the 'Paramedic Paradox' in Rural America

Katheryn Houghton Kaiser Health News

April 07, 2022

https://khn.org/news/article/rural-paramedic-pandemic-shortage-montana/

Even after she's clocked out, Sarah Lewin keeps a Ford Explorer outfitted with medical gear parked outside her house. As one of just four paramedics covering five counties across vast, sprawling eastern Montana, she knows a call that someone had a heart attack, was in a serious car crash, or needs life support and is 100-plus miles away from the nearest hospital can come at any time.

"I've had as much as 100 hours of overtime in a two-week period," said Lewin, the battalion chief for the Miles City Fire and Rescue department. "Other people have had more."

Paramedics are often the most highly skilled medical providers on emergency response crews, and their presence can make a lifesaving difference in rural areas where health services are scarce. Paramedics are trained to administer specialized care from the field, such as placing a breathing tube in a blocked airway or decompressing a collapsed lung. Such procedures are beyond the training of emergency medical technicians.

But paramedics are hard to come by, and a long-standing workforce shortage has been exacerbated by turnover and resignations related to pandemic burnout.

Larger departments are trying to attract paramedics by boosting pay and offering hefty signing bonuses. But small teams in underserved counties across the U.S. don't have the budgets to compete. Instead, some rural crews are trying to train existing emergency responders for the roles, with mixed results.

Miles City is among the few communities in rural eastern Montana to have paramedic-level services, but the department doesn't have enough paramedics to offer that care 24/7, which is why medics like Lewin take calls on their time off. The team received a federal grant so four staffers could become paramedics, but it could fill only two slots. Some prospects turned down the training because they couldn't balance the intense program with their day jobs. Others didn't want the added workload that comes with being a paramedic.

"If you're the only paramedic on, you end up taking more calls," Lewin said.

What's happening in Miles City is also happening nationwide. People who work in emergency medical care have long had a name for the problem: the paramedic paradox.

"The patients who need the paramedics the most are in the more rural areas," said Dia Gainor, executive director of the National Association of State EMS Officials. But paramedics tend to gravitate to dense urban areas where response times are faster, the drives to hospitals are shorter, and the health systems are more advanced.

"Nationally, throw a dart at the map, the odds are that any rural area is struggling with staffing, with revenue, with access to training and education," Gainor said. "The list goes on."

The Michigan Association of Ambulance Services has dubbed the paramedic and EMT shortage "a full-blown emergency" and called on the state legislature this year to spend $20 million to cover the costs of recruiting and training 1,000 new paramedics and EMTs.

At the beginning of this year, Colorado reactivated its crisis standard of care for short-staffed emergency medical service crews experiencing mounting demand for ambulances during a surge in covid cases. The shortage is such a problem that in Denver a medical center and high school teamed up to offer courses through a paramedic school to pique students' interest.

In Montana, 691 licensed paramedics treat patients in emergency settings, said Jon Ebelt, a spokesperson for the Montana Department of Public Health and Human Services. More than half are in the state's five most-populous counties — Yellowstone, Gallatin, Missoula, Flathead, and Cascade — covering a combined 11% of the state's 147,000 square miles. Meanwhile, 21 of Montana's 56 counties don't have a single licensed EMS paramedic.

The Pandemic Exacerbates the "Paramedic Paradox" in Rural America

Andy Gienapp, deputy executive director of the National Association of State EMS Officials, said a major problem is funding. The federal Medicaid and Medicare reimbursements for emergency care often fall short of the cost of operating an ambulance service. Most local teams rely on a patchwork of volunteers and staffers, and the most isolated places often survive on volunteers alone, without the funding to hire a highly skilled paramedic.

If those rural groups do find or train paramedics in-house, they're often poached by larger stations. "Paramedics get siphoned off because as soon as they have those skills, they're marketable," Gienapp said.

Gienapp wants to see more states deem emergency care an essential service so its existence is guaranteed and tax dollars chip in. So far, only about a dozen states have done so.

But action at the state level doesn't always guarantee the budgets EMS workers say they need. Last year, Utah lawmakers passed a law requiring municipalities and counties to ensure at least a "minimum level" of ambulance services. But legislators didn't appropriate any money to go with the law, leaving the added cost — estimated to be up to $41 per resident each year — for local governments to figure out.

Andy Smith, a paramedic and executive director of the Grand County Emergency Medical Services in Moab, Utah, said at least one town that his crew serves doesn't contribute to the department's costs. The team's territory includes 6,000 miles of roads and trails, and Smith said it's a constant struggle to find and retain the staffers to cover that ground.

Smith said his team is lucky — it has several paramedics, in part because the nearby national park draws interest and the ambulance service has helped staffers pay for paramedic certification. But even those perks haven't attracted enough candidates, and he knows some of those who do come will be lured away. He recently saw a paramedic job in nearby Colorado starting at $70,000, a salary he said he can't match.

"The public has this expectation that if something happens, we always have an ambulance available, we're there in a couple of minutes, and we have the highest-trained people," Smith said. "The reality is that's not always the case when the money is rare and it's hard to find and retain people."

Despite the staffing and budget crunches, state leaders often believe emergency crews can fill gaps in basic health care in rural areas. Montana is among the states trying to expand EMS work to nonemergency and preventive care, such as having medical technicians meet patients in their homes for wound treatment.

A private ambulance provider in Montana's Powder River County agreed to provide those community services in 2019. But the owner has since retired, and the company closed. The county picked up emergency services last year, and County Commissioner Lee Randall said that providing basic health care is on the back burner. The top priority is hiring a paramedic.

Advancing the care that EMT crews can do without paramedics is possible. Montana's EMS system manager, Shari Graham, said the state has created certifications for basic EMTs to provide some higher levels of care, such as starting an IV line. The state has also increased training in rural communities so volunteers can avoid traveling for it. But those steps still leave gaps in advanced life support.

"Realistically, you're just not going to have paramedics in those rural areas where there's no income available," Graham said.

Back in Miles City, Lewin said her department may get an extension to train additional paramedics next year. But she's not sure she'll be able to fill the spots. She has a few new EMT hires, but they won't be ready for paramedic certification by then.

"I don't have any people interested," Lewin said. For now, she'll keep that emergency care rig in her driveway, ready to go.