By Jeff Poole
In an effort to reduce 911 calls for non-emergency situations, while caring for a segment of the population that uses the emergency services as its primary care physician, the Orange County Board of Supervisors recently approved a pilot paramedicine program for the county fire and EMS department.
The $150,000 approved for the program is part of the recent allocation of nearly $7.2 million in federal American Rescue Plan Act funds to support local government in the wake of the COVID-19 pandemic.
The funds, also known as the Coronavirus State and Local Fiscal Recovery Funds, are part of $350 billion in emergency federal funds to fill revenue shortfalls, offset negative economic impacts, support essential workers and make investments in water, sewer or broadband infrastructure.
The county received the first allocation ($3,598,361) in June and is expected to receive the balance in June 2022. The entire $7,185,813 allocation must be spent on eligible items by Dec. 31, 2024.
At its Aug. 24 meeting, the board of supervisors quickly approved a spending plan for $3.8 million (see last week’s Review or www.orangenews.com) while thoroughly debating a plan for the $3.3 million balance.
The community paramedicine program was one of three proposed health and wellness projects, including public safety resiliency and in-house paramedic training programs.
In her presentation to the board, Orange County Human Resources Director Jenny Carpenter said, “The pilot community paramedicine program is intended to reduce the amount of 911 calls that are not emergency related and to care for the demographic that uses 911 and emergency rooms as their primary care physician. By visiting this population on a two-week rotational basis, we should anticipate a decrease in calls that are non-emergent.”
The program also would assist in reducing non-emergency illnesses from reaching already overtaxed emergency rooms, she said. The county’s fire and EMS department would utilize its patient care Records system to identify frequent users of the 911 system as a start to determine those who are the most frequent, non-emergency callers.
“This program will help reduce the strain on the four medic units currently staffed within the county by assisting patients with non-emergency needs using partnerships with local health department and primary care providers,” she said.
Orange County Fire and EMS Chief Nathan Mort said the idea of community paramedicine was developed in Texas in the 1990s.
“They noticed a disproportionate amount of the population was using 911 and emergency rooms as their primary care physicians, which was backing up the 911 system for non-emergency calls and the ER health care systems,” he said. “What we’re envisioning is one paramedic and one social worker who will take our frequent call list and schedule visits to these individuals every two weeks. By scheduling these visits, we can almost guarantee we’ll reduce the number of 911 calls coming from the house.”
Once the program is established, he said, the department could work with the local health department and free clinic for a list of other patients beyond the most frequent 911 callers.
“The goal is to get people used to a primary care relationship rather than using 911 and the emergency room as their primary care doctor,” he said.
A lot of the success of the program will be rooted in educating those the program is designed to serve. He gave an example of visiting a diabetic whose blood sugar is low again. “Let’s talk about it and what steps you can do to manage your situation,” he said.
In considering the proposal, supervisors expressed concerns about ongoing costs, as well as those who may take advantage of the system, and whether or not the county fire and EMS department was delving too far into the medical field.
“It may start out initially as consultation services, but this is teetering on the edge of providing medical care,” District 2 Supervisor Jim White said. “You start writing prescriptions, taking blood pressure, counseling, giving advice about diet or exercise, we’re suddenly in the medical arena and I don’t know that we’re prepared for that.”
“We’re already in the medical profession,” District 4 Supervisor and board chair Jim Crozier responded. “Our people are providing services and working under the license of a doctor.”
White said the difference is emergency care as opposed to ongoing care.
“This is something that would be used and a great resource for people who need it and within 10 years be a budget line item at least 10 times of what we’re starting out with,” District 1 Supervisor Mark Johnson said. “As word spreads, people are going to take advantage of it. It won’t be repeat callers. If we insist it’s repeat callers, people can arrange that very easily. You’re going to have people who say, ‘They came out to see my Mama, you should have them come see your Dad. They can write prescriptions and everything.’ You’re going to have to tell people no, which government isn’t particularly good at, or we’re going to have to fund it at ever-increasing levels.”
Johnson cited the current county fire and EMS program and its growth over the last 20 years.
“It sounds like a great thing, but this is an eyes-wide-open situation. It costs money and we’ll see higher costs and demand,” he said.
“If the program was framed such that one of its objectives was that the system is supported through existing revenue sources, that’s a different story,” White added.
District 5 Supervisor Lee Frame asked if there would be opportunity for the county to be reimbursed for paramedicine services through Medicaid, Medicare or private insurance.
Mort said there would be.
“The goal of community paramedicine is not to become the primary care provider to the county,” Mort said. “The goal is a stopgap. We’re going to help those people in the short-term and try to get them to a primary care provider long-term.”
White asked if the program would be driven by social services with a counseling element or would be more medically focused?
“In a lot of the cases Chief Mort is referring to, our social workers are involved, for adult protective services,” said Crystal Hale, Orange County Director of Social Services. “We’re doing a lot of extra footwork he didn’t delve into in his presentation. Our staff are going out to help folks get the care they need, evaluate them for self-neglect and potentially start seeking some sort of action to bring them into care in most extreme cases.”
“It starts off as a medical aspect,” Mort said. “We’re getting called, but we’re just not getting called for something an ambulance needs to be called for.”
White said he’d like to see the program better defined.
“I’m concerned about opening this up and taking the frequent caller list and offering them new opportunities,” he said. “That doesn’t seem quite as thought-through as we need to. I’d hate for this to get to the point it gets out of control and we either have to stop it or expand it to an order of magnitude—neither of which is a good answer. I’d rather see this evolve a few steps at a time and see where we can be the most help to the people who most need it.”
Board members debated the length of the pilot program and the period of data needed to determine its success or failure, discussing a one-, two- or three-year trial.
Ultimately, Frame moved to create the program as a one-year pilot program, at a cost of $150,000 for two positions—a paramedic and social worker.
The board voted 4-1 in favor of the program with Johnson dissenting.