Reducing Nonemergency Use of Emergency Systems

All of Washington’s fire agencies operating programs do so under the authority of state law RCW 35.21.930, which established community assistance referral and education services programs. These programs are also known by other terms, including mobile integrated health, community paramedicine and co-response.

CARES programs have few state requirements for those fire agencies that choose to establish such a program. (Fire agencies are never required to develop one.) The program must measure both any reduction of repeat 911 calls and avoidable ER visits. Beyond that, the law also suggests the program identify community members using emergency systems for nonemergency needs and refer them to more appropriate resources, offering agencies great flexibility to develop a program tailored to community needs.

The results of our survey of fire agencies and interviews with eight programs show community needs drive the types of services a program provides. Most programs work with people who repeatedly call 911, connecting them with services, such as behavioral health services, home health care providers, or others who can help with issues like housing and transportation. Programs also often visit people in their homes to help reduce their risk of falls or to check in with them after being discharged from a hospital. Other programs specialize in case management to help coordinate care for people with complex needs, or in overdose response mitigation to help prevent overdoses in people with substance use disorder. Some programs focus on responding to patients experiencing a behavioral health crisis.

To do these types of work, program staff often include social workers, emergency medical technicians (EMTs), paramedics, nurses and other types of professionals. About half of the programs we surveyed relied on multiple funding sources, most often from a combination of local government funds and grants.

The audit report contains brief profiles of eight CARES programs.

We surveyed 178 fire agencies without a CARES program. Nearly half (47%) of them agreed with the statement “This community needs a program,” while one-fifth said it did not. However, a much smaller percentage of respondents – just 12% – thought their agency would start a program within the next three to five years. More than half (57%) said it was unlikely they would do so. Notably, one-third of respondents were neutral on both questions.

To determine which counties are most burdened by nonemergency use of emergency systems, and therefore might benefit from CARES programs, we considered three indicators:

• Rates of avoidable ER usage, meaning the percentage of ER visits that could have been avoided based on the diagnoses patients received there.
• Rates of nonemergency 911 EMS calls.
• Primary Care Health Professional Shortage Areas scores, which identify a shortage of primary care providers. State and federal programs use these scores to determine eligibility for some programs.

Six counties were in the top 10 for at least two of these indicators: Adams, Asotin, Kitsap, Mason, Skamania and Wahkiakum. While the other counties have at least one active CARES program, Adams and Wahkiakum do not. The results suggest these counties might benefit from establishing new programs.

Fire agencies described barriers to starting or maintaining CARES programs. Insufficient funding forms the most critical barrier to starting a program. Funding is also a challenge for existing programs: nearly three-quarters of programs surveyed said they were at risk of having insufficient funding in the next five years.

Staffing is another barrier. Professional shortages and unfamiliarity with this emerging, interdisciplinary field make it difficult to find personnel. Furthermore, many rural fire agencies are volunteer-based, making it even harder to establish and maintain needed programs. Lack of guidance and local support deterred some fire agencies from starting needed programs. And due to an absence of statewide expectations, community paramedics are limited in the services they can provide.

State law requires programs to track two metrics: reductions in 911 calls and in ER visits. While CARES programs tracked a variety of performance measures, only half fully met state requirements. Program directors’ reasons for not tracking the required metrics included being unaware of the requirement, not knowing how to track the information, and programs maturing to the point that early referrals preempted patterns of repeat 911 calls. These reasons suggest a lack of centralized coordination at the state level, as no one is responsible for ensuring all programs are aware of required tracking or providing technical assistance to do so. Furthermore, no one is advocating for possible changes to legal requirements.

Programs used a variety of other measures to track their performance, often to comply with grant requirements. However, the time and effort spent complying with grant requirements took time away from helping patients. Upcoming changes to a national database for emergency medical services should make it easier to systematically measure CARES program success.

Cost savings opportunities

Numerous studies have demonstrated CARES programs can produce improved patient outcomes in their communities. The Centers for Disease Control and Prevention (CDC) reported these programs can reduce barriers to needed health care, such as transportation and scheduling issues. The CDC also reported that these programs serve as an essential resource for several populations that have high rates of chronic diseases but limited access to critical care resources.

The audit found that CARES programs can generate substantial savings for private insurance companies, Medicaid and hospitals by reducing avoidable ambulance trips, ER visits and hospital readmissions. However, in doing so, fire agencies absorb costs that would otherwise have been borne by hospitals and insurers.

For example, community paramedics may spend hours with a patient, even visiting them multiple times over the course of a few months, to ensure the patient is connected with behavioral health and housing services. Without the program, the fire agency could just repeatedly transport that patient to an ER, leaving hospitals and insurers to incur costs while the patient’s needs go unmet. As such, insurers and hospitals could partner with CARES programs, supporting them with a portion of the savings they generate.

We recommended the Legislature amend state law to develop ways to reimburse services provided by CARES programs, pending the results of a study by the Office of the Insurance Commissioner. We also recommended it take steps to address a lack of centralized coordination and regulatory barriers for CARES programs by convening a workgroup or advisory committee.

To address other challenges fire agencies face when starting a CARES program, or trying to strengthen an existing program, we made recommendations to the University of Washington School of Social Work, the Washington State Association of Fire Chiefs, the International Association of Fire Fighters, the Washington State Hospital Association and existing CARES programs.