Mercy Flights paramedic Trevor Waggoner recalls a diabetic patient who was constantly in and out of the emergency room.
"He was really struggling with knowing how to manage his diabetes and was having to call 911 probably at least three times a week, sometimes more often," Waggoner says. "Sometimes it was multiple times in a day that his blood sugar was getting very low — dangerously low."
The patient would lose consciousness, or if he was still alert, would become so combative with paramedics that police had to be called to help, Waggoner says.
At $1,200 per ambulance ride and $1,300 for a basic emergency room visit, the man's inability to control his blood sugar levels was also costly.
Nationwide, research shows chronic emergency room overuse makes up the fourth largest category of waste in the health care system.
Locally, patients who overuse emergency rooms make up 5 percent of Jackson Care Connect's members, but account for 50 percent of health care costs, according to the coordinated care organization that, along with AllCare Health, uses state and federal funding to manage the physical, mental and dental care of about one-third of county residents.
Recognizing the problem, Mercy Flights launched a new program in 2016 to send specially trained paramedics out on house calls to help prevent chronic emergency room use.
"They're in uniform and the public trusts paramedics to go into their house," says Mercy Flights CEO Doug Stewart, explaining the rationale for using paramedics. "Mercy Flights goes out every day to emergencies. We go into houses. We're trusted to have high integrity and professionalism. We're more comfortable in the field than in the hospital. We're used to total chaos and sorting through the chaos and figuring out what's needed. It was a perfect road for us to go down and it makes total sense."
Waggoner and Sabrina Ballew, who are called community paramedics or mobile integrated providers, began working with chronic emergency room users to figure out and treat their underlying problems.
For the diabetic patient who was a regular at local emergency rooms, they connected him with a specialist who outfitted him with a sensor that monitored his blood sugar every five minutes. After the patient showed he could do well with the sensor, he received an insulin pump, a small device that infuses insulin into the body day and night to regulate blood sugar.
"Since he's had that, he's been doing much better," Waggoner says. "He's starting to enjoy life more. It's just been a wonderful success for him."
The patient also changed his attitude about his own health.
"He's done a great job of taking ownership of his health," Waggoner says. "When we first started, he was blaming his providers. The turning point came when he started taking responsibility for his health."
Emergency room misuse
During his 30-year career in emergency medical services, Stewart has transported thousands of patients to emergency rooms.
"It's very obvious 40 to 50 percent of the people we were transporting didn't really need emergency services," he says. "However, they needed some kind of help. We were bringing them to the wrong kind of help."
Payment regulations for Medicare and Medicaid — government-funded health insurance for senior citizens, the disabled and low-income people — create an incentive for ambulance companies to whisk patients to emergency rooms, whether or not the situation is a true emergency. Ambulance companies don't get paid for responding to a call if they don't transport the patient, Stewart says.
Meanwhile, emergency rooms are required to assess all comers, regardless of their ability to pay, and provide any necessary treatment.
Mercy Flights, a nonprofit organization that provides ground and air emergency transport, heard of ambulance services in other parts of the country that were addressing the underlying problem of emergency room misuse and overuse. Stewart says programs that gave extra training to paramedics and sent them out on house calls were especially effective.
Mercy Flights launched its own house calls program, called the Emergency Department Avoidance Project, using a $220,485 grant from Jackson Care Connect.
"They were very on-board with us," Stewart says of Jackson Care Connect's enthusiasm for the pilot project. "They got where we were coming from. They believed we could make an impact."
Providence Medford Medical Center helped the organizations identify patients who were chronic emergency room users. In 2016, 62 patients who together had visited the emergency room 571 times in the prior year were enrolled.
"They had visited the emergency room an average of nine times a year. Some had 80 visits. Some had four or five," says Dr. Anne Alftine, Jackson Care Connect's director of clinical integration. "It was clear many of these folks need to be in a different setting. That's not the best way to spend health care dollars. The most expensive place to get care is in the emergency room of a hospital."
Data now in for 2016 shows the house calls program reduced emergency room costs by an estimated $448,100 and cut ambulance transport costs by an estimated $289,200 — for a total of $737,300.
With the $220,485 grant cost factored in, the program yielded estimated net savings of $516,815.
The patients in the program cut their overall emergency room use by 56 percent, surpassing Mercy Flights' original goal of a 50 percent reduction.
Stewart says the program not only cut costs, but improved the patients' overall health.
"We helped them get better, reduced health care costs to the system and created a healthier population," he says.
With the positive results from 2016 in hand, Jackson Care Connect awarded Mercy Flights $170,898 to continue the project this year and also launch a new Transitions of Care program. Paramedics meet with selected patients who are being discharged from the hospital and help with follow-up care. The goal is to cut hospital readmission rates.
The help patients really need
Paramedic Kalah Hilliker has received additional training so she can join Waggoner and Ballew this year for the house calls program.
"It's hard to see people's problems and not be able to do anything about it," Hilliker says of her prior work as a regular paramedic. "This program allows us to go to their homes, see their medications, educate them and prevent them from using the emergency room for everyday health needs."
Waggoner and Ballew say they also joined the program so they could help with the root causes of emergency room misuse.
Their training runs the gamut, from managing chronic disease and interacting with diverse patients to understanding how traumatic events like childhood abuse and neglect influence people's behavior.
Rather than use an ambulance, which might alarm patients or neighbors, they drive around in an SUV loaded with medication, supplies and equipment.
Ballew says a woman who became disabled didn't have the resources for a wheelchair ramp to get in and out of her home. Her husband had to quit his job to care for her. The paramedics connected her with Mountain Christian Fellowship, which provided supplies and manpower to build wheelchair ramps for the front and back of her home.
The woman has since died, but in the last months of her life she was able to get out of her house for trips to Portland and the coast, Ballew says.
Stewart says some people can't afford their medication, so paramedics find programs to help cover the costs.
"A lot of times, people will say they're supposed to be taking medication, but they can't afford it and haven't taken it for two weeks," he says. "That alone can put them back in the emergency department."
Stewart says the paramedics often act like medical detectives.
One woman with chronic obstructive pulmonary disease, which impairs a person's ability to breathe, was going to the emergency room two or three times each week for shortness of breath. The woman has a home nebulizer, a machine that turns liquid medicine into a mist patients inhale to improve their breathing.
"The paramedics said, 'Let's see your nebulizer.' They found mold in the nebulizer," Stewart says. "She wasn't using or cleaning it properly. She was nebulizing mold into her lungs, which was causing her to go to the emergency department. Now she doesn't go to the emergency department."
Waggoner says drug and alcohol abuse plays a role in about half of the cases they see.
One 65-year-old man had been dependent on opiates, commonly used to treat pain, and benzodiazepine (anti-anxiety) drugs for 40 years. When his surgeon stopped writing him prescriptions, the man began visiting the emergency room to satisfy his dependency on the narcotics. At one point, he threatened to kill himself if he did not get the drugs.
Working with doctors and a U.S. Department of Veterans Affairs representative, the paramedics were able to connect the patient to the VA and have him start a narcotics tapering plan.
A 33-year-old woman who was homeless and an alcoholic was cycling in and out of the emergency room for alcohol intoxication and because she was being assaulted. When she asked for help, a paramedic, insurance and Addictions Recovery Center specialists and hospital personnel teamed up to help her get through a local detox program and then start a one-year residential treatment program.
"One year of residential treatment is absolutely cheaper versus constant emergency room use," Alftine says.
While the paramedics spend much of their time making house calls, they also make appointments with their homeless patients or track them down.
"We meet them where they're at — whether that's at home, a park, St. Vincent de Paul or homeless camps," Ballew says. "We're always on the lookout for each other's patients. For some high-need patients, we tag-team them."
The paramedics occasionally accompany their patients to doctors' appointments.
"Sometimes patients don't feel like they have an advocate," Stewart says. "The paramedics go and help the patient communicate better with the doctor. The doctor sees they are taking their health more seriously."
Leslie Tevrell, manager of mobile integrated health care for Mercy Flights, says patients need more education about managing their own health and when it's appropriate to visit the emergency room versus a primary care doctor or urgent care clinic. The public also needs more information about accessing services such as drug and alcohol treatment and mental health care.
"People don't know how to access the resources that are available. They only know about the emergency room," Tevrell says. "The 911 system has been good at training people to call 911 for help, but we don't do a good job training people how to take care of themselves."
He says the paramedics are the keys to the success of the Emergency Department Avoidance Project.
"They are passionate about connecting with patients, building rapport, figuring out what they need and connecting them with resources," Tevrell says.
Ballew says the program is not only improving the lives of patients, it has the power to transform the way ambulance services operate.
"This is the future of emergency medical services," she says. "We can't just load and go anymore. We should treat the whole patient. It's our job. It's time to grow and change."
Reach staff reporter Vickie Aldous at 541-776-4486 or firstname.lastname@example.org. Follow her at www.twitter.com/VickieAldous.