San Diego Community Paramedicine
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1 San Diego Community Paramedicine Jim Dunford, MD City of San Diego EMS Medical Director Emeritus Professor, Emergency Medicine UCSD School of Medicine
2 San Diego County 3.2 million popln. 4,526 sq miles World s busiest border Signif. military presence 28 ALS agencies 1000 paramedics 19 hospitals 115 clinics 9,000 physicians 2
3 8 th largest U.S. city 1.3 million population >100,000 ambulance responses > 80,000 transports City of San Diego
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5 < 6 min < 15 min Emergent 84% Urgent 10% Other 6% < 12 min < 30 min
6 San Diego Fire Communications Center Tri-Tech CAD
7 Medical Priority Dispatch System
8 San Diego Fire-EMS Dispatch , , ,000 80,000 60,000 40,000 medical response fire response 20,
9 First Watch CAD Surveillance
10 Hospital Hospital Hospital Hospital Hospital Hospital Hospital Hospital Hospital 1 million EHR EMS Hospital Hospital Hospital Hospital Hospital Hospital Hospital Hospital Hospital
11 The homeless alcoholic Detox Street Street Hospital Jail Street
12 Homeless Inebriates 18 months 417 ED visits $1,476,000
13 Serial Inebriate Program San Diego Police Department City of San Diego EMS San Diego Sheriff s Department San Diego Superior Court San Diego City Attorney Public Defender San Diego County HHSA Volunteers of America Mental Health Systems, Inc. St. Vincent de Paul Village
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15 U.S. Interagency Council on Homelessness we ve unearthed evidencebased research that allows us to make policy and provide investment in these projects. Philip Mangano White House Homeless Czar
16 Serial Inebriate Program (SIP) Avg. charges/mo: clients who accepted tx 0-10,000-20,000-30,000 - $73,552/mo -40,000-50,000-60,000 EMS ED In-pt. Dunford JV et al. Ann Emerg Med. 2006;47(4):
17 Serial Inebriate Program (SIP) Avg. charges/mo: accepted vs. declined 1000% 800% 953% 600% 400% 200% EMS ED In-pt. 0% -200% accept decline Dunford JV et al. Ann Emerg Med. 2006;47(4):
18 Name Any Chronic Disease EMS
19 In 2013, 130 San Diegans (. 04% popln) generated 5000 (5.4%) 911 calls
20 Frequent User Impact on San Diego EMS n = 37,820 transports Other < 3 transports transports (82.7%) Frequent User >3 transports 1130 people 6529 transports (17.2%) High User 4-9 transports 1000 people 4480 transports (11.8%) Super User > 10 transports 130 people 2049 transports (5.4%) City of San Diego EMS TAPCHART 4/27/11 10/27/11
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24 Resource Access Program (RAP) Case manages frequent EMS users Connects with existing resources Forges new connections RAP Coordinator (paramedic)
25 211 San Diego AIS Downtown Partnership HOT SIP IHOT P25 ED Case Managers Jail Case workers Multicultural Clinic PATH Family Health Centers Public Defender erap Volunteers of America Veterans Village Rural/Metro Project 25 San Diego Fire Catholic Charities HHS Behavioral Health Alpha Project Episcopal Services St. Vincent de Paul Salvation Army SD Sheriff Social Workers Rescue Mission PERT
26 Resource Access Program (RAP) EMS RAP Coordinator SDPD HHS PERT
27 Effect of RAP UCSD Hillcrest (51 clients) Total charges declined by $314, Pre-RAP Post-RAP ED visits Admits LOS Tadros AS, Castillo EM, Chan TC, Patel E, Watts K, Jensen AM, Dunford JV. Prehosp Emerg Care 2012 Oct;16(4):541-7
28 San Diego Health Connect (HIE) Funded by ARRA HITECH Act as a Beacon Community $15M (3 yr) grant to UC San Diego Dept. of Emergency Medicine Transitioned to self-sustaining independent organization Hospitals Home health Nursing homes Labs Physician practices Public health Pharmacies Community health centers EMS Patients & caregivers Schools Behavioral health 28
29 SD CONNECT (Regional HIE) Hospitals Public Health EMS Hub Clinics EMS Health Systems Medical Groups
30 EMS Hub
31 Hospitals EMS Hub monitoring Medical Groups Clinics EMS Hub StreetSense ALERT!
32 StreetSense RAP clients Notify case manager
33 EMS Alert
34 INFOTECH Systems, Inc. San Diego FCC CAD
35 Hottest spots StreetSense - InfoTech Systems, Inc. and San Diego Fire Communications CAD
36 Hot-spotting
37 Most frequent callers StreetSense - InfoTech Systems, Inc. and San Diego Fire Communications CAD
38 Most frequent homeless users StreetSense - InfoTech Systems, Inc. and San Diego Fire Communications CAD
39 Most frequent behavioral/psychiatric StreetSense - InfoTech Systems, Inc. and San Diego Fire Communications CAD
40 Most frequent in-home difficulties StreetSense - InfoTech Systems, Inc. and San Diego Fire Communications CAD
41 Financial tracking StreetSense - InfoTech Systems, Inc. and San Diego Fire Communications CAD
42 Project 25
43 Project 25: year 1 $12,000,000 $10,000,000 $8,000,000 $6,000,000 $4,000,000 $2,000,000 $- N = 35 clients Δ = -$7,716, Psych response team Homeless shelter Crisis house Public defender Jail days Arrests In-pt (acute & psych) ED Ambulance
44 EMS to 211 referral ü Food ü Childcare ü Utility ü Finance ü Healthcare navigation ü Housing/shelter ü Early education ü Mental health
45 Community Paramedicine Pilot Project
46 Community Paramedic Roles Transport to alternate, non-ed locations Treat and release/treat and refer Assist frequent 911 callers Follow-up patients at risk of readmission Support patients w complex conditions Partner w community health workers to provide preventive care
47 LOI July 18, 2013 Solicited interest of LEMSAs State EMSA submits application to Office of Statewide Planning and Development (OSHPD) Health Workforce Pilot Projects up to 24 months Provides statutory waivers Data to inform State on need for change in statute and regulation
48 Potential CP Roles Transport to alternate, non-ed locations Treat and release/treat and refer Assist frequent 911 callers/ed visitors to access primary care and social services Provide f/u for discharged patients at risk of return to ED or readmission Support px with complex conditions, DM, asthma, HF Partner with community health workers/ PCP to provide preventive care
49 State Advisory Committee Review and oversee individual sites Representatives from EMSA and each project site (LEMSA, providers, healthcare systems)
50 Medical Control LEMSA Medical director or designee acts as PI Local Project Steering Committee LEMSA MD, LEMSA administrator, medical director and administrator from participating healthcare systems and EMS provider agencies
51 PM Eligibility 4 years experience A.A. or > preferred Recommended by medical director of agency or LEMSA
52 Training Standardized core content (didactic and clinical) h Local training re project parameters, organization P&P, clinical experience Approved by Local Project Steering Committee Successful completion of exam LEMSA accreditation > EMSA notification and documentation in central registry
53 Outcome Objectives Increased access to care Improved efficiency of healthcare delivery Decreased hospital readmissions Decrease in low acuity ambulance transports Decrease in low acuity ED visits Cost savings Healthcare utilization patterns Patient satisfaction Primary care/health system satisfaction
54 Funding Local CHCF to support state program manager, independent evaluator, training programs and stipend for site data collection
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56 Project # Lead Agency LEMSA Pilot Concepts EMS Providers CP001 UCLA Center for Pre Los Angeles Alternate Destination Santa Monica, Glendale & Pasadena Fire Dept s Hospital Care CP002 CP003 UCLA Center for Pre Hospital Care Orange County Fire Chief s Assoc Los Angeles Orange County Post Hospital Discharge Follow Up (CHF) Alternate Destination CP004 Butte County EMS S-SV EMS Post Hospital Discharge Follow Up CP005 CP006 Ventura County EMS Agency Ventura County EMS Agency Ventura Ventura & Santa Barbara Directly Observed Treatment of TB Hospice Support Burbank & Glendale Fire Dept s Fountain Valley, Huntington Beach & Newport Beach Fire Dept s Butte County EMS, Inc AMR Ventura, Gold Coast Ambulance & LifeLine Ambulance AMR Ventura & Santa Barbara CP007 Alameda County EMS Agency Alameda County Post Hospital Discharge & Frequent 911 Callers Alameda City & Hayward Fire Dept s CP008 San Bernardino County Fire Dept San Bernardino County Post Hospital Discharge Follow Up San Bernardino County Fire Dept CP009 Carlsbad Fire Dept San Diego Alternate Destination Carlsbad Fire Dept CP010 City of San Diego San Diego Frequent 911 Callers San Diego City Fire Dept & Rural Metro Corp CP011 San Joaquin County EMS Agency San Joaquin County Post Hospital Discharge Follow Up AMR San Joaquin County CP012 Mountain Valley EMS Stanislaus County Alternate Destination Mental Health CP013 Medic Ambulance Solano County Post Hospital Discharge Follow Up AMR Stanislaus County Medic Ambulance
57 Enhanced Resource Access Program (ERAP)
58 Frequent User Impact on San Diego EMS n = 37,820 transports Other < 3 transports transports (82.7%) Frequent User >3 transports 1130 people 6529 transports (17.2%) High User 4-9 transports 1000 people 4480 transports (11.8%) Super User > 10 transports 130 people 2049 transports (5.4%) City of San Diego EMS TAPCHART 4/27/11 10/27/11
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60 Questions?
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