June 03--A "community paramedic" program intended to reduce overuse of ambulances by chronic 911 callers has been dropped by the new city administration, but the state hopes to start a similar effort.
The Honolulu Emergency Services Department, led at the time by Dr. James Ireland, created a community paramedic team in November after research revealed that the top 10 callers to 911 had taken an average of 52 ambulance rides per year. One logged 142 trips in the year before he died.
The plan was for two community paramedics to visit the top 50 callers, who were on track to make 1,600 emergency calls that year, and try to determine the underlying causes of their problems and steer them to more appropriate care.
Seventy percent of those patients had chronic medical problems, which left untended can lead to emergency situations. About a third were homeless and a third were mentally ill.
Costs quickly get out of hand when patients rely on 911 as their main means of getting medical care, especially when what they really need is access to medicines or substance abuse treatment.
An ambulance ride costs roughly $800, and emergency room visits also run about $800 on average, according to the Emergency Medical Services Division of the city Emergency Services Department. Abuse of 911 also ties up valuable resources vital for actual emergencies.
The community paramedic program, a collaboration with social services and homeless providers, barely had a chance to get underway when it was suspended after Mayor Kirk Caldwell took office Jan. 2. Mark Rigg, who replaced Ireland as director of the Emergency Services Department, told the Star-Advertiser last week that it would not be revived.
"It wasn't our area of expertise, nor did we have the resources," said Rigg, who has been a paramedic for 25 years. "Our resources are primarily used to respond to 911 calls in the city."
He added, "I think the state is going to be able to put together the program the way it should be run. It's a very worthwhile program. Statistics have shown nationally that it decreased the number of times these callers call 911."
Dr. Linda Rosen, chief of the Emergency Medical Services and Injury Prevention branch of the state Department of Health, said the state is eager to pursue the idea but does not have a timetable for it.
"We're very interested in it," Rosen said Friday. "It has been done in other areas of the country and Canada. We think it has a lot of potential in Hawaii, but we're still in the early stages. We don't have a specific project in mind right now."
The state contracts with the counties and private agencies to provide ambulance service. Its electronic record system gives it the information needed to identify frequent users, and the state could start with a pilot project, Rosen said.
"Whether it is federal funding or even state funding, I'm confident we could take those early steps and demonstrate that it is valuable," she said. "If you can save money on top of better outcomes and patient satisfaction, that's the holy grail."
"We're not trying to be a new provider of a new service," she added. "What's important is using what EMS already does well in partnership with others to give the right kind of care at the right place at the right time."
Niels Tangherlini, a paramedic captain with the San Francisco Fire Department, helped launch a community paramedic program there in 2004, when frequent callers were costing on average $56,000 each per year. Within a few years of the creation of the Homeless Outreach and Medical Emergency Team, that cost had been cut to $23,000 and the number of frequent callers cut in half, he said.
The San Francisco program ran for five years before it was put on hold amid budget cuts and a change of administration, he said. Tangherlini is now trying to get studies published to validate its results and obtain grant funding.
Tangherlini has consulted with cities including Washington, D.C., and San Diego on their programs, and helped write a curriculum that is available free to any university through the International Roundtable on Community Paramedics.
Community paramedics are effective as "engagement specialists," he said, because people trust them and are likely to respond to their guidance.
"Many of these people are reliant on EMS as it is already," Tangherlini said. "They view it with respect. ... You can trade on this idea of being an official and use that as a tool to engage folks.
"The community paramedic should never try to replace a case manager, therapist or public health nurse. Their role is not to do the long-term care. But to get the patient involved in those other services, hands down, the community paramedic will do a better job."
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