EXECUTIVE SUMMARY

Firefighter paramedic programs, designed to help community members stay healthy and safe, are cropping up around the country as community case management needs rise.

  • One example is Focus Hilliard, a program in Ohio that helps residents through referrals for health and safety assistance.
  • In California, the Los Angeles Fire Department brings mobile community healthcare to residents who call 911 but do not require ED care.
  • Firefighter paramedics have built trust in the community through generations of offering help during crises.

A burgeoning new area for community case management involves fire departments and emergency medical services (EMS).

In a growing number of towns across the country, EMS paramedics and firefighter paramedics are visiting people experiencing issues with health access and social determinants of health. The goal is to help them access better primary care or help in the community and prevent using ambulances for problems that are not truly emergencies.

“One of our biggest frustrations is when we get called out to a house and there is an issue that doesn’t require a trip to the hospital,” says Chris Grile, battalion chief of Norwich Township Fire Department in Hilliard, OH. “As a 911 provider, we don’t have any other option than taking this person to the emergency room and hoping it works out,” Grile adds.

This new field of paramedicine provides another option. Paramedics can help these people through proactive visits and assistance. They also gain community members’ trust, built up over generations of helping citizens when they are in crisis.

“It’s the new horizon of EMS,” Grile says. “It’s so new in Ohio that no one has a firm definition of what this is.”

Five years ago, the fire department started a case management-style program called Focus Hilliard. It was partly in response to the need for dealing with the increasing number of 911 calls for nonemergency problems. It also helps keep firefighter paramedics active in an era of declining fire calls, Grile says.

“We do a good job of reducing fires through the fire codes,” he explains. “Now, we’re reducing risk in our community by making paramedicine visits and keeping people healthy at home and not in the hospital.”

Firefighter paramedics visit patients in nonemergency settings, providing support and assistance. A study of the program showed that it resulted in a 44% relative reduction in 30-day ED visits, and a 28.4% relative reduction in 30-day readmissions.1

Paramedicine is an exciting new area of care delivery, says Stephen G. Sanko, MD, assistant professor of clinical emergency medicine at the University of Southern California, and assistant medical director of the Los Angeles Fire Department (LAFD).

The LAFD fields 1.1 million calls per year. The department developed a mobile community healthcare model, led by advanced practice providers, to bring case management-style services to people who live in the city’s healthcare deserts, Sanko says. (See story about LAFD’s program in this issue.)

“There is significant inequity to access to primary and preventive care in the City of Los Angeles,” Sanko says. “In the neighborhood of Westwood, where Ronald Reagan Medical Center is located, there are 1,100 healthcare providers per 100,000 population; in South Los Angeles, there are 20 healthcare providers per 100,000 population.”

People in healthcare deserts cannot access primary care providers, dentists, optometrists, or dermatologists, he adds. “These are basic needs that can be addressed in these medical areas by an advanced practice provider,” Sanko explains.

In Ohio, Norwich Township Fire Department is leading the way in paramedicine. An example involves an elementary school teacher whose major stroke left her unable to speak, upending her life. She now lives in an assisted living facility.

“We visit her about every third day as her life becomes more and more challenged with additional medical events,” says Nathan Jennings, firefighter paramedic with Norwich Township.

The woman’s grown daughter lives out of state and travels for work, so the firefighter paramedic visits are reassuring and helpful, he notes. “Our visits give the woman something to look forward to,” Jennings says.

People like the former teacher just need someone to check in on them to make sure they are doing well and to provide some companionship. “We’re just doing life with them, and we stay with them for as long as it takes,” Jennings explains. “We take time between 911 calls.”

The firefighter paramedics often help people living in unsafe housing. “We’ve been engaged in quite a few healthcare issues surrounding hoarding and homes collapsing and falling apart,” Jennings says. “We are invited into their homes because folks are worried they’ll lose the things most important to them. They welcome us to discuss the next steps.”

For instance, the family of a person referred to the program expressed concerns about the loved one living in a house that was in poor condition. The firefighter paramedics helped the family coordinate with an extended care facility, where the family member was convinced to move, he notes. “That’s a different place for firefighters to be, but we strike that as a win,” Jennings says.

In another case, the program worked with a man whose house was in deplorable condition, Grile says. “It didn’t have properly functioning electricity, plumbing, or water,” Grile adds. “From the referral, we had to go in and build a relationship with him, proving to him that we weren’t there to kick him out of his house.”

The firefighters could not even get rid of his 50-plus propane cylinders without his permission because of state legal protections for homeowners. “That shows the importance of building relationships,” Grile says. “We met with the man multiple times, and built that relationship.”

The man had enough money to clear away the brush and bring the electricity up to code. It took about three months, but once the homeowner trusted the firefighter paramedics, he got rid of the propane cylinders and installed a large propane tank outside.

“We had to prove to him that our goal was to keep him there, in his home,” Grile explains. “Then, we were able to let him stay in a much safer manner.”

Cases like these show how a person’s health and safety will continue to be compromised until someone helps get to the root cause of the problem, says Heith Good, firefighter paramedic at Norwich Township.

“The man was hopeless and had a fear,” Good says. “We have several hundred examples of cases like that one, where patients have frequent healthcare issues.”

Build Trust in the Community

The Focus Hilliard program builds trust with residents, helping them receive the housing support, mental health resources, and preventive care they need to stay healthy and safe. “We try to be a resource to link patients with the right help,” Good says.

A local hospital recognized the case management benefits of the paramedicine program and formed a collaboration with Norwich Township Fire Department. Before the collaboration, OhioHealth Doctors Hospital would see frequent ED users. Often, these were people who would call 911 in Norwich Township and be taken to the ED, regardless of whether they were experiencing an emergency, says Joe Geskey, DO, MBA, MS-PopH, vice president of medical affairs at OhioHealth Doctors Hospital.

The hospital and the Norwich fire department began a study in 2017 to determine why some people returned so frequently to the ED. Geskey accompanied firefighter paramedics to their nonemergency visits to at-risk members of the community to get an idea of what the population was facing in their daily lives.

“I met one individual who was relocated from her housing because it was, essentially, unlivable; she was a hoarder,” Geskey says. “She also was a diabetic, had musculoskeletal pain, and fell frequently.”

The woman also took narcotic painkillers intermittently, which contributed to her falling. She often called EMS to be taken to the hospital. “Clinicians would evaluate her, sometimes with imaging studies, and sometimes with pain relief treatment — depending on what the condition was — and then they’d send her back home,” Geskey says.

The woman’s home contained a dilapidated couch that contributed to her back problems. Focus Hilliard helped her buy a new bed and a safer place to live. Since then, she has become more adherent to her diabetes medication, and her back pain went away. She also no longer needs narcotics. This ended her falling and ED visits, Geskey says.

“This kind of thinking highlights to me that medical care is not always related to medicine,” he says. “It’s related to taking a more holistic approach to where people live, and the background of their circumstances in which they live.”

Communities, taking cues from case management principles, can incorporate that kind of thinking into a treatment plan for a patient, Geskey says. “As the result of a minor intervention like this, hospitals can save thousands of dollars,” he adds.

An important reason why paramedicine programs work is because people trust firefighters and paramedics, Geskey says. “They’ve gone to every community in need and did their jobs professionally,” he explains. “They were always available when somebody made a phone call.” Firefighter paramedics are always on the job and accessible to the public, Good says.

“We have a phone that rings at all hours, seven days a week,” Good says. “There are a lot of people who are not afraid to call us if they have a question.”

REFERENCE

  1. Geskey JM, Grile C, Jennings N, et al. Use of postdischarge emergency medical services to reduce hospital readmissions: Does it work and is it economically feasible? Popul Health Manag 2019; Oct 7. doi: 10.1089/pop.2019.0125. [Epub ahead of print].