A mobile integrated healthcare approach can help people who call 911 due to mental health problems. These patients often wait in the ED for as long as 10 hours, waiting to be seen by psychiatric case worker.
The Los Angeles Fire Department (LAFD) started an advanced provider response unit (APRU) pilot program that helps people with nonmedical emergency problems, including those who land in the ED for mental health issues and problems related to alcohol use.
Before the LAFD started its APRU program, these patients would wait days for access to a mental health inpatient bed, says Stephen G. Sanko, MD, LAFD assistant medical director and assistant professor of clinical emergency medicine at the University of Southern California.
When the APRU handles these cases, the team can transport the patients to a mental health urgent care facility, providing patients with more timely care and decreasing their hospital admission rates. This frees up inpatient beds for other patients, Sanko says.
“We have both private and public options for a mental health facility,” he says. “We have Exodus Recovery, which contracts with the Los Angeles County Department of Health Services to provide crisis stabilization and run the sobering center downtown. We also have a Department of Mental Health urgent care site in the northern part of LA.”
Hospitals benefit from the mobile unit’s work because of more efficient EDs, shorter patient wait times, and fewer hospital beds occupied by mental health and alcohol-intoxicated patients, who are better served elsewhere.
“The benefit to payers is they’re paying fewer expenses for 911 transport and less for acute care, hospital-based services,” Sanko says. “Another benefit is there is improved navigation of patients to their preventive and primary care sites.”
During the initial phase of the program’s mission, the focus was on improving healthcare navigation of people who frequently call 911.
“We would perform a scheduled visit with high utilizers of 911 services,” Sanko says. “Some of these people would use the emergency department biweekly; in some cases, they’d visit the ED a hundred times a year.”
The scheduled visits involved performing a needs assessment and obtaining consent for social work services. When patients agreed, a social work team visited them and made sure they were enrolled in insurance, he says.
The mobile urgent care team helps people fill their prescriptions. Accessing a local pharmacy is a major problem for many people who repeatedly use 911 services.
“A number of patients need refills, but live in areas of the cities where they don’t have a lot of pharmacies,” Sanko explains. “They run out of their thyroid medication, insulin, or something else that is essential, and we’re able to meet those needs.”
The APRU also helps people who are dealing with minor trauma, such as a nosebleed, elbow pain, backache, or illness, but have called 911. For instance, some people with flu-like symptoms might call for emergency services, when all they need is a clinician to treat them. For those patients, a nurse practitioner can perform the same evaluation they would in the ED, Sanko says.
“The patients could go to the ED and wait for four to eight hours to be seen, and when they are seen there would be a lot of excessive testing done,” he says. “At the end of the day, they get a 30-second spiel by a clinician, telling them to follow up with their primary care provider and to take Tylenol.”
Instead, the mobile unit’s advanced practice provider can evaluate and treat the patient, spending a little time and helping the patient obtain medication. This can be accomplished without an ambulance ride and a long wait, Sanko adds.
Other cities could reproduce the LAFD’s mobile advanced practice model, especially if health systems collaborate with fire departments, emergency services, and payers. “It’s unclear who is ultimately going to pay for it, but the people who benefit the most from the program are the payers and the citizens,” Sanko says. “We are selecting patients who can be seen outside of an acute care hospital.”
“They have no deductibles or additional costs, and they are reaping the benefits of more timely linkage to social services and primary care,” he adds. “This allows us to keep the ambulances available in each neighborhood for the next critical emergency.”