SummaryThe City of San Diego's emergency medical services system
implemented a program to identify individuals who frequently
call 911 and arrange for them to receive relevant medical, social service, and other interventions that can reduce their future reliance on emergency services. This initiative, known as the Resource Access Program, uses sophisticated health information technology that immediately recognizes and notifies a program coordinator whenever a frequent user of emergency services calls 911. The coordinator, an experienced paramedic, then alerts a network
of community stakeholders (e.g.,
physicians, social workers, police officers, case managers, housing
providers) and works with them to implement measures to address the caller's immediate and underlying health and social needs. The program has significantly reduced emergency medical service transports for frequent 911 callers, leading to major cost savings.Moderate: The evidence consists primarily of pre- and post-implementation comparisons of the number and costs of emergency medical service encounters with frequent 911 callers.
Developing OrganizationsCity of San Diego Fire-Rescue Department, Division of EMS; Rural/Metro Ambulance Corporation
Date First Implemented2008
Vulnerable Populations > Medically or socially complex
Problem AddressedA small number of people with chronic health problems or drug and alcohol dependency typically account for a large proportion of 911 calls. Serving these individuals drives up costs for both emergency medical service (EMS) systems and local emergency departments (EDs) and can result in lower quality care for other EMS users. While connecting frequent callers to needed community-based services can reduce their future reliance on 911, most municipalities lack a coordinated system for identifying and treating these individuals.
Small number of frequent users: In many urban areas, a small number of individuals repeatedly call 911, often for nonemergent situations. Many of these frequent users are homeless or suffer from
various chronic medical conditions, including mental illness and alcohol/substance abuse.1 In 2008, the City of San Diego EMS transported 933 patients five
or more times, for a total of 3,347 transports. Collectively, these frequent users accounted for 11 percent of all paramedic transports in
- Major cost and health implications: In many instances, State and local laws require EMS responders to transport callers to an ED for evaluation. However, this evaluation typically does not address the underlying medical and social service needs of the frequent caller. In addition, conducting these evaluations diverts resources from—and potentially undermines the care provided to—nonfrequent callers experiencing true acute health crises.3 For the City of San Diego EMS in 2008, ambulance charges for the aforementioned group of 933 frequent callers totaled $6.4 million, $4.6 million of which was uncompensated care.2
- Inability to coordinate care for frequent callers: The health and social problems of individuals who frequently call 911 cannot be addressed unless these individuals can be quickly identified as frequent callers. Once frequent callers are identified, successfully addressing their underlying health problems typically requires the coordinated efforts of multiple community-based stakeholders that do not normally work together, including hospital and EMS leaders, primary care providers, law enforcement and court officials, behavioral health professionals, outreach teams serving the homeless, social workers, case managers, and housing providers. Achieving such coordination represents a major challenge.
Description of the Innovative ActivityThe City of San Diego's EMS system implemented a program to identify individuals who frequently call 911 and arrange for them to receive relevant medical, social service, and other interventions that can reduce their future reliance on emergency services. Known as the Resource Access Program (or "RAP"), this initiative uses sophisticated health information technology (IT) that immediately recognizes and notifies a program coordinator whenever a frequent user of emergency services calls 911. The RAP coordinator, an experienced paramedic, then alerts a network of community stakeholders (e.g., physicians, social workers, police officers, case managers, housing providers) and works with them to implement measures to address the caller's immediate and underlying health and social service needs. A detailed program description follows:
- Identification of frequent callers: An extensive IT system continuously monitors the electronic health records of the City of San Diego EMS system. RAP employs sophisticated software algorithms to prioritize individuals by frequency of use and nature of health condition. Using this information, the system generates a list of the most frequent 911 callers by week, month, or year. The list is continuously updated. These individuals typically have severe mental health issues (such as schizophrenia or bipolar disorder), physical problems (such as asthma, heart disease, or diabetes), or substance abuse problems, and many of them are homeless. In some cases, they have called 911 more than 100 times in the previous year for nonemergent situations, such as having feelings of anxiety or needing help changing clothes or traveling across the city.
Figure 1. EMS personnel enter patient information into the RAP system by using hand-held devices. Click the image to enlarge. Image courtesy of James Dunford. Used with permission.
- Rapid identification of frequent callers, triggering notification of program coordinator: An ambulance or fire engine with at least one paramedic and one or more emergency medical technicians (EMTs) responds to every 911 call. Upon arrival, these personnel begin inputting information provided by the patient or those at the scene into a hand-held wireless computer, as shown in Figure 1. This information includes the patient's name, date of birth, chief complaint, and relevant health issues. As the information is entered, a computer software tool (Street Sense) linked to the regional health information exchange (San Diego Connect) uses algorithms to identify whether the patient is a frequent caller, highlighting key issues such as history of substance abuse, psychiatric problems, and in-home falls. If the patient has been previously identified as a frequent user by the RAP coordinator, Street Sense automatically pages her and, in some cases, other members of the patient's care team. The RAP coordinator may then meet the patient in the ED to assist the emergency physician in determining an appropriate followup plan or, less commonly, respond directly to the scene of the incident.
- Contact with community-based support services: Depending on the situation, the RAP coordinator may contact one or more people from a network of community-based partners who are familiar with the frequent caller or in a position to influence his or her future behavior. A few examples of how community partners are brought into the process and subsequently support the patient appear below:
- Chronic health problems: If the patient has a chronic mental or physical health condition that is not being properly addressed, the coordinator calls the primary care provider and any mental health professionals who have treated the patient. This step ensures that these individuals know that one of their patients is calling 911 repeatedly and can take steps to reduce future calls (e.g., adjusting or changing psychoactive medication, treating a painful physical problem, or talking to the patient about when it is appropriate to call 911).
- Substance abuse: If the individual is intoxicated or has a history of arrests for chronic public intoxication, the system can simultaneously contact the RAP coordinator and a police officer who has previously agreed to serve as the person's case manager. The RAP Coordinator works closely with the San Diego Police Department Serial Inebriate Program (SIP), which addresses individuals convicted of repeated public intoxication by offering them the choice of incarceration or completion of a court-ordered substance abuse program. With client consent, the SIP officer receives a Street Sense alert whenever the EMS system encounters a client. The officer can go directly to the ED to determine whether the individual will return to jail (for a violation of the terms of probation) or re-enter the treatment program.
- Social problems: Because social factors commonly contribute to frequent 911 calls, the RAP coordinator calls representatives of the local social service system who can help address these issues. For example, a social worker can often help the person access health benefits and other financial aid and may be able to help resolve conflicts with family members. In addition, representatives of housing agencies and volunteers can help a homeless person find temporary shelter or subsidized housing.
- Ongoing support by coordinator and community-based providers: The RAP coordinator works on an
ongoing basis to build relationships with frequent callers and help them address their problems. To that end, the coordinator contacts each individual identified as a frequent user by phone
or in person, explaining her role as an EMS employee responsible for
helping people coordinate health and social
service needs. As part of this process, the coordinator investigates the factors underlying the individual's excessive use of
acute care resources for nonemergent situations, including lack of
transportation, social support, and health literacy. The coordinator then works with the community-based network of partners to connect these individuals to the services they need. As necessary, the coordinator conducts house calls with the
San Diego Homeless Outreach Team, which consists of a
police officer, psychiatric clinician, and county eligibility
worker. Together, the coordinator and team educate frequent callers about appropriate use of EMS, connect them with needed community resources, and make followup calls and inperson contacts to remind them about appropriate use of the EMS system.
- Patient alerts to community-based providers: Members of the community-based support network can subscribe to receive patient-specific information alerts delivered as e-mails, text messages, or pages. For example, an alert can be sent to notify the case manager of an individual with a drinking problem who calls 911 after a relapse, thus ensuring that the case manager promptly becomes aware of the patient's change in status.
- Ongoing analysis and identification of trends: The RAP coordinator uses the IT system to analyze data and identify meaningful trends that might inform program-related changes. For example, the system can provide information on subgroups of 911 callers, such as those who call only from pay phones, have substance abuse problems, or live in a particular neighborhood. This information can be used to identify emerging needs and mobilize community resources to meet them.
Context of the InnovationThe City of San Diego EMS serves a population of 1.3 million people living in a 362-square-mile area. The city contracts with Rural/Metro Ambulance Corporation to handle more than 100,000 calls to 911 each year. RAP grew out of an earlier initiative, SIP, in which EMS leaders work with police officers, court officials, and housing advocates to offer housing for chronically homeless alcoholics in lieu of incarceration. Launched in 2000, SIP substantially reduced EMS, ED, and hospital inpatient costs.4 Encouraged by these results and aware that a significant number of frequent 911 callers are not homeless or battling substance abuse problems, EMS leaders decided to create a broader program to serve a larger proportion of frequent 911 callers.
ResultsThe program has significantly reduced EMS transports for frequent 911 callers, leading to major cost savings.
Moderate: The evidence consists primarily of pre- and post-implementation comparisons of the number and costs of emergency medical service encounters with frequent 911 callers.
Significantly fewer EMS transports: In a pilot study conducted in 2008 and 2009 that featured the coordinator working with the network of community stakeholders (but not the sophisticated IT system), the number of EMS encounters among frequent callers—51 individuals with 10 or more EMS transports in the past year—fell by roughly 38 percent (from 736 to 459) in the 16 months after program implementation, compared with the 15-month period before implementation.2 Recent internal program records suggest the addition of the Street Sense IT system has led to continued progress in reducing 911 calls from frequent callers. For example, the top 20 most frequent callers from 2011 made an estimated 1,200 fewer calls during 2012.
- Lower costs: In the pilot study described above, EMS charges fell by 32 percent (from $689,743 to $468,394) as a result of the decline in encounters.2 Fewer encounters also translated into a 40-percent drop in the number of hours spent by EMS workers caring for the 51 frequent callers, and a 47-percent reduction in the number of miles traveled by emergency vehicles in response to calls from them.2 Based on internal program data from 2012 and 2013, program leaders conservatively estimate that RAP generates net savings (i.e., after accounting for program costs) of approximately $700,000 a year.
Planning and Development ProcessKey steps included the following:
- Expanding network and hiring coordinator: In 2007 and early 2008, leaders of the San Diego SIP began enlarging their network of community stakeholders to expand the program's reach. In addition, they hired an experienced paramedic to coordinate RAP on a full-time basis.
- Launching low-tech version of program: RAP launched in April 2008 without the health IT component of the program. Instead, the program largely relied on personal communication among program participants. Under this approach, the medical director of San Diego EMS received phone calls from EMS and ED workers who recognized frequent 911 callers from previous encounters. After reviewing these callers' prehospital medical records and confirming that they were frequent callers, the medical director contacted the RAP coordinator, who developed plans for assisting these callers. While successful, this approach was quite labor intensive and also made it difficult to recognize changes in the population of frequent callers over time. Program leaders recognized that use of health IT could help them better meet their goals.
- Obtaining grants to implement high-tech version: In 2010, the San Diego region received a $15 million Beacon Community grant from the Office of the National Coordinator for Health Information Technology to demonstrate the value of health information exchange between the region's hospitals, clinics, medical groups, and EMS providers. With input from RAP leaders, software developers created the EMS Hub, which serves as the gateway for regional EMS data into the health information exchange. They created novel applications to make it easy to identify frequent callers and access and probe relevant data. In 2011, the Alliance Healthcare Foundation awarded a $1 million innovation grant
to begin creating a community information exchange to enable real-time,
bidirectional links between RAP and key social service partners. In 2012, a local software developer (InfoTech Systems Management, which was initially involved with RAP through the Beacon Community grant) worked with the RAP coordinator to develop Street Sense.
- Planning for future expansion: RAP leaders are working with city officials and other stakeholders to expand the program's reach beyond the most frequent 911 callers by linking additional partners to the health information exchange. Under a proposed Community Paramedicine pilot proposal, RAP aims to expand the scope of practice and training of additional RAP paramedics to better address these patients’ complex needs by means other than transport to EDs. RAP also hopes to address a broader set of frequent callers who face disproportionate health burdens. For example, an expanded RAP could automatically notify primary care providers when patients with asthma or diabetes call 911 and allow these physicians to access details of the patient's EMS- and ED-based treatment. In the future, Street Sense may also be programmed to identify patients at risk for 30-day hospital readmissions and alert case managers so they can coordinate necessary urgent care. Such an expansion requires development of new software and consent protocols consistent with the Health Insurance Portability and Accountability Act.
Resources Used and Skills Needed
- Staffing: RAP has two full-time employees, the program coordinator and a paramedic, who are employed by Rural/Metro Ambulance. All other participants (e.g., the medical director of San Diego EMS, EMS and ED workers, police officers, physicians, social workers) contribute their efforts voluntarily or as part of their regular job responsibilities.
- Costs: Major program expenses include the RAP coordinator's salary and benefits, a monthly fee ($2,000) to maintain and upgrade the IT system, and the monthly cost of using a large wireless network.
Funding SourcesOffice of the National Coordinator for Health Information Technology; Alliance Healthcare Foundation
Tools and Other ResourcesInformation about InfoTech Systems Management (which played a key role in creating the software tool that RAP uses) is available at: http://www.infotechsm.com/StreetSense.html.
Getting Started with This Innovation
- Identify community champions: An EMS system interested in
creating this type of program should start by identifying members of the community
who are also affected and frustrated by frequent 911 callers, such as a police officer who repeatedly responds to calls from a small group
of people or an ED director who constantly deals with individuals who
visit the ED one or more times each week. These individuals often become program champions who play a vital role in building a larger network of community-based resources to address the underlying health and social problems faced by frequent callers.
- Focus on stakeholder concerns: When building the network,
program developers should share with potential stakeholders data that show how frequent callers negatively affect their
domains, thus making them more likely to commit time and resources to the
program. For example, hospital administrators will likely be interested in data about how often these individuals come to the ED or get admitted to the hospital, while a fire chief will be more interested in the impact that frequent 911 calls have on firefighter response times and service hours. Similarly, a police chief will be
concerned about officers spending an inordinate amount of time
dealing with a small group of individuals,
while an EMS supervisor may be interested in the impact that frequent callers have on response/travel time and the morale of paramedics.
- Start small, potentially with low-tech version: If available resources are constrained, developers can start by
focusing on the 5 or 10 people who most frequently call 911 or on frequent callers at one ED. In addition, the program can be launched without sophisticated health IT. All that is really needed is a small group of like-minded individuals who agree to work together on the issue.
- Adapt existing technology: A number of software companies have
developed software tools to identify and
track frequent 911 callers. An EMS system interested in creating a
program similar to RAP would benefit from adapting existing technology to
meet its needs, rather than attempting to create such a system.
Sustaining This Innovation
- Expect setbacks: Working with frequent 911 callers, many of whom have complex psychosocial issues and are averse to treatment, requires great patience and perseverance. It is not uncommon for an individual to stop calling 911 for a short period of time after an intervention, only to resume calling after circumstances change (e.g., a formerly homeless person loses his residence, a recovering substance abuser relapses). Program leaders should recognize and accept that such setbacks will inevitably occur. The approach should be to test different strategies with these individuals over time, in hopes of identifying those that yield long-term benefits.
- Consider expansion to other populations: This type of data-driven program has the potential to benefit a much larger group of individuals, including those with chronic health problems (e.g., diabetes, heart failure) or at high risk for ED visits and readmissions (e.g., nursing home residents with a history of falls). To determine the best opportunities for expansion, work with community health leaders to identify health problems that lead to the most 911 calls and then develop programs and services to better serve individuals with these problems.
Contact the InnovatorJames Dunford, MD, FACEP
EMS Medical Director
City of San Diego
Emeritus Professor of Emergency Medicine
UCSD School of Medicine
1010 Second Avenue, Suite 300
San Diego, CA 92101
Anne Marie Jensen, PM
San Diego RAP Coordinator
Rural/Metro Ambulance Company
1010 Second Avenue, Suite 300
San Diego, CA 92101
Innovator DisclosuresIn addition to the sources listed in the Funding Sources section, Dr. Dunford and Ms. Jensen reported being members of the steering committee of the newly formed San Diego
Community Information Exchange, which received a $1 million grant from the Alliance Healthcare Foundation that will be used in part to support broader implementation of RAP. Ms. Jensen also reported being listed as an inventor on a patent application for some of the electronic surveillance features integrated into the RAP IT system.
References/Related ArticlesJensen AM, Dunford J. Putting the 'RAP' in 'rapport.' JEMS. 2013;38(1):38-41. Available at: http://www.jems.com/article/technology/san-diego-s-erap-system-redirects-freque.
Tadros AS, Castillo EM, Chan TC, et al. Effects of an emergency medical services-based resource access program (RAP) on frequent users of health services. Prehosp Emerg Care. 2012;16(4):541-7. [PubMed]
Dunford JV, Castillo E, Chan TC, et al. Impact of the San Diego Serial Inebriate Program (SIP) on use of emergency medical resources. Ann Emerg Med. 2006;47(4):328-36. [PubMed]
Lucas RH, Sanford SM. An analysis of frequent users of emergency care at an urban university hospital. Ann Emerg Med. 1998;32(5):563–8. [PubMed]
Tadros AS, Castillo EM, Chan TC, et al. Effects of an emergency medical services-based resource access
program (RAP) on frequent users of health services. Prehosp Emerg Care.
Salit SA, Kuhn EM, Hartz AJ, et al. Hospitalization costs
associated with homelessness in New York City. N Engl J Med.
Dunford JV, Castillo E, Chan TC, et al. Impact of the San Diego Serial
Inebriate Program (SIP) on use of emergency medical resources. Ann Emerg
Med. 2006;47(4):328-36. [PubMed]
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Original publication: June 04, 2014.
Original publication indicates the date the profile was first posted to the Innovations Exchange.
Last updated: June 04, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.