a countys experience dan lynch, ems director central california ems agency
TRANSCRIPT
HOW TO STOP 9-1-1 ABUSE
A County’s Experience
Dan Lynch, EMS DirectorCentral California EMS Agency
1. Understand the importance of identifying frequent users in the EMS system
2. Acknowledge the impact and cost that frequent users have on the EMS system
3. Recognize tools and methods to reduce ambulance use by frequent users
4. Recognize challenges of dealing with frequent users in your system
OBJECTIVES
I am Not an Expert
in Ambulance Abuse
I don’t have all of the answers – I have a lot of opinions.
I know about Fresno County.
Solutions will be different from County to County◦ There are other programs in the State.
FULL DISCLOSURE
Central California
Agricultural Center of the World
Pop 976,000
Pre-hospital Calls
2012 – 165,916
FRESNO COUNTY
“Ignorance is Bliss”
“What you don’t know won’t hurt you”
WRONG!!
THE VALUE OF NOT KNOWING
Hearing chatter from the field◦ Calls from ambulance crews and hospitals
“Two guys using the ambulance”
DISCOVERING THE PROBLEM
2010 – 471 transports 2010 – 329 transports
“Cesar” “Lonzel”
LOOKING AT THE DATA◦ (aka: UH OH!)
“Fresno, we have a problem!”
DISCOVERYFrequency
of Use People %Once 49478 75.9%2-3 11438 17.5%4-5 2351 3.6%
6-10 1392 2.1%11-20 399
Less than 1%
21-30 9731-40 3041-50 1151-75 18
76-100 6101-150 3
185 1196 1329 1471 1
Pre-hospital calls only
DENIAL ANGER BARGAINING
DEPRESSION
ACCEPTANCE
5 STAGES of GRIEF
There is No Way this data
is correct
Who do they think they
are!?!
GRRRR!
…or we can put you on a
bus to Nevada for
FREE
How can this be
happening?
This is a
nightmare
Identified “Target Audience”
Created a list of “Top 50” Abusers
DISCOVERY
Impact of “Top 50” Abusers
4,367 responses
Cost: $3,895,364
(year 2012 data)
DISCOVERY
DISCOVERY
HomelessMental Health
Substance AbuseMedical Disability
Pain Meds
46% 50%
84%
24%
20%
FREQUENT USERS1. Identify the
abuser.
2. Look at the underlying problem.
DISCOVERY
IHSS 80%
Goal:Help them out of the system
NOT shut them out of the system
Denying service is the last resort
HOW DO WE SOLVE THIS?
Odd Jobs
Create a Multi-Disciplinary Task Force
“The Group”
Create Policy for EMS Personnel At some point, we will have to deny service
SOLUTIONS
Topic: Frequent
User
EMS
Mental Health
Social Services
Homeless Services
Hospitals Social
Services
Law Enforcement
Multi-Disciplinary Task Force◦ No interest from other participants◦ Excuses....
News Media Intervention◦ Exposed the crisis and abuse◦ Public and political outcry
Multi-Disciplinary Task Force◦ Back on track
SOLUTIONS – Set Back
The ProcessIdentified Frequent User
Are they in the “System”?
Determine Responsible
Agency
Mental Health
Social Services
Homeless Services
Engage person
Follow-up
Yes
Can they be referred?
(or refuse)
Yes
Law Enforcement
EMS Agency Abuse Policy
No
Keep “The Group” advised
of abusers
Engage person
No
EMS ABUSE POLICYIdentified Frequent User
(not in system or refusing services)
*Letter – 1st Notice
*Letter – 2nd Notice
*Letter – 3rd (final) Notice
EMS Medical Director Order of Suspension of
Ambulance Services
30 days
30 days
10 days
*Hand-delivered or Certified Mail
Letters include reference information on where to obtain care or services.
Group Notified
Group Notified
Group Notified
Group Notified
Defines an Abuser◦ Twelve or more responses within a 90-day period
The count does not include calls for 5150 transports.
Provides a description of the process◦ 1st, 2nd, 3rd Notice and Suspension Order
Provides an appeals process◦ Appeal panel
Direction for Field Personnel
EMS ABUSE POLICY
CCEMSA Policy #570
Field Direction
EMS ABUSE POLICY
V. AMBULANCE PROVIDER RESPONSIBILITY
A. Upon contact with an EMS abuser, who is specifically determined to be an abuser by the EMS MedicalDirector, the ambulance personnel will make an initial scene assessment upon arriving on scene.
1. If the patient is not ambulatory, cannot sit unassisted, meets 5150 criteria, meets trauma centercriteria, or the paramedic recognizes a medical condition that requires immediate medical treatment, normal policies and procedures for patient assessment, treatment and transport shall be initiated. The EMS Medical Director may modify these criteria on a case-by-case basis.
2. If the patient does not meet the above criteria, the EMS crew will advise the individual of thefollowing:
“You have been identified as abusing the ambulance system. The EMS Medical Director hassuspended ambulance transport for you. You need to consider alternative transportation. If you
feel this is in error, you can contact the EMS Agency at (559) 600-3387. We are not transporting you to the hospital.”
Sit-up/stand/walk = No Transport
RESULTS
1 3 5 7 9 11
13
15
17
19
21
23
25
27
29
31
33
35
37
39
41
43
45
47
49
51
1 3 5 7 9 11
13
15
17
19
21
23
25
27
29
31
33
35
37
39
41
43
45
47
49
51
0
20
40
60
80
100
120
140
January 1, 2011 to December 31, 2012
EMS ABUSE PROCESS IMPLEMENTED - March 2012
Nu
mb
er
of
Re
spo
nse
s
Weeks
Dept Engaged 8 16%1st notice 7 14%2nd notice 4 8%3rd notice 3 6%Suspended 1 2%Dead 5 10%Active 22 44%
50 100%
RESULTS
1991 calls / year
Savings: $1,771,990
“Top 50” from 2008 to 2013
2011 – Out of Control
2013 Goal of 1140
RESULTS
2008 2009 2010 2011 2012 20130
500
1000
1500
2000
2500
3000
3500
4000
4500
747
1152
2180
4367
2596
1140
WATCH THE BACK DOOR!
Others will be entering the system – not in the “top 50”
◦ Person # 1 – 113 responses (Dec 19 and Mar 1)◦ Person # 2 – 101 responses (Jan 4 to Mar 31)◦ Person # 3 – 50 responses (Jan 2013)◦ Person # 4 – 170 responses in 2012
◦ Watch List of 22 people – “Nip it in the bud!” Need to feel immediate resistance.
*** WARNING ***
Law Enforcement
Keeping other agencies / departments involved◦ Do not overwhelm◦ Keep number of abusers manageable
Consistency◦ Keep engaged with abuser
If you give them slack, they will take it.◦ Everyone is treated the same
◦ Interesting reactions◦ Small Fire Dept
◦ Physician Group
Challenges
43 y/o male Substance abuser – alcohol
Heavy user of the system:
Defiant – “I can use the ambulance whenever I want”
Case Study #1 – “Cesar”
2008 2009 2010 2011 2012 2013
27 179 471 710 247 33
Case Study #1 – “Cesar”
Janu
ary
2011
Febr
uary
201
1
Mar
ch 2
011
April 20
11
May
201
1
June
201
1
July
201
1
Augus
t 201
1
Sept
embe
r 201
1
Oct
ober
201
1
Novem
ber 2
011
Decem
ber 2
011
Janu
ary
2012
Febr
uary
201
2
Mar
ch 2
012
April 20
12
May
201
2
June
201
2
July
201
2
Augus
t 201
2
Sept
embe
r 201
2
Oct
ober
201
2
Novem
ber 2
012
Decem
ber 2
012
Janu
ary
2013
Febr
uary
201
3
0
10
20
30
40
50
60
70
80
90
ResponseTransport
Suspension of Transport- April 6, 2012
Nu
mb
er
of
Re
spo
nse
s
Case Study #1 – “Cesar”
Janu
ary
2011
Febr
uary
201
1
Mar
ch 2
011
April 20
11
May
201
1
June
201
1
July
201
1
Augus
t 201
1
Sept
embe
r 201
1
Oct
ober
201
1
Novem
ber 2
011
Decem
ber 2
011
Janu
ary
2012
Febr
uary
201
2
Mar
ch 2
012
April 20
12
May
201
2
June
201
2
July
201
2
Augus
t 201
2
Sept
embe
r 201
2
Oct
ober
201
2
Novem
ber 2
012
Decem
ber 2
012
Janu
ary
2013
Febr
uary
201
3
Mar
ch 2
013
April 20
13
0
10
20
30
40
50
60
70
80
90
ResponsesTransports
YIKES!!
Nu
mb
er
of
Re
spo
nse
s
Case Study #2 – “Richard”
31 y/o male Substance abuser – alcohol & drugs
Heavy user of the system:
2008 2009 2010 2011 2012 2013
6 6 1 24 170 5
Case Study #2 – “Richard”
0 3 6 9 12 15 18 21 24 27 30 33 36 39 42 45 48 51 2 5 8 11 14 17 20 23 26 29 32 35 38 41 44 47 50 1 4 7 100
2
4
6
8
10
12
Response Transport
Firs
t N
oti
ce
Seco
nd N
oti
ce
Thir
d N
oti
ce
Susp
ensi
on O
rder
Homeless Services Engaged Mental Health Engaged
Nu
mb
er
of
Re
spo
nse
s
Admit you have a problem.
Find out who your abusers are.
Get help from the people that can do something.◦ Also look at other programs in other counties.
Create a process to engage.
Stay consistent and constant.
Keep EMS field personnel advised. (IMPORTANT!!)
The Short Version
Dan Lynch
Phone: (559) 600-3387
Email: [email protected]
Abuse Policy: EMS Policy #570Website: ccemsa.org
Email me for samples of notices or suspension orders
CONTACT INFORMATION