Steve was a “frequent flyer”, to say the least. He called EMS services 96 times in 2011 and was on track to exceed this number in 2012.
Steve, like so many others in the community, used 911 to compensate for enormous gaps in his care. Where he clearly needed a skilled facility placement, he limped along with the five daily hours of caregiver assistance the Department of Rehabilitation Services allowed him. Relatively young but mentally ill and confined to a wheelchair, Steve was not equipped to spend 19 hours alone each day.
Steve refused all attempts to place him in a skilled nursing environment because institutional life would require adherence to routines and limits imposed by others, and would compel him to make uncomfortable changes. He wouldn’t be able to smoke around the clock. Most important, he wouldn’t be able to take drugs at will, and this is a privilege he simply could not imagine surrendering.
The system Steve cobbled together to overcome these issues worked very effectively, but only for him. When he was under the influence of drugs and fell to the floor while trying to transfer himself from bed to wheelchair, he called 911. When his caregiver was there but could not lift him, he called 911 for assistance. When he ran low on prescription pain medication, he called 911 with complaints of pain, knowing of course that they would likely take him to the hospital where he could request more medication.
The system suited Steve and did not cost him a thing. But each time Steve summoned EMS services to address issues that could easily be prevented or managed in a skilled environment; he used 25% of the available ambulance resource and potentially diverted or delayed care for residents encountering true emergency situations. He was also using state and community funds in a highly inappropriate manner.
The Real Costs of Care.
In this era of scarce public funding and new initiatives in health care, the use of 911 as a chronic point of entry into the healthcare system warrants close examination. It is an issue that is likely to increase enormously as the population ages. The repeated use of EMS services for transport, non-emergency medical issues, or as a consequence of mental health or drug-seeking problems, is spectacularly expensive:.
- “Super users”, according to the San Diego Medical Office, represent less than one percent of the city’s population but account for more than 17 percent of all paramedic and ambulance calls. Just over 1100 frequent users in San Diego cost more than $20 million in ambulance and paramedic charges alone. (http://www.10news.com/news/30807295/detail.html)
- Medstar, an emergency and non-emergency ambulance service, was called more than 800 times by 21 individuals in Fort Worth, Texas, during 2008. Those 21 patients accumulated $962,429 in ambulance charges. Only one in four of those transported have insurance so some of these charges will never actually be collected. (http://getbetterhealth.com/ambulance-service-called-800-times-by-21-people-ems-responds-with-preventive-strategy/2009.10.12)
The bills for “frequent fliers” are passed along to insured patients and taxpayers, and constitute a seriously broken component in the nation’s health care system.
Who is the Super User?
The reasons members of the community become habituated to calling 911 for non-emergency services span a gamut. In Steve’s case, the primary reasons were mental illness and drug addiction. He was bi-polar and drug-addicted as a young adult. He suffered a stroke while still in his 30s and developed left-sided hemiparesis. He was unable to work. His wife left him and his children were estranged by his years of drug use, which continued after his stroke. Over time, Steve found himself alone in his HUD apartment and without resources to fund the level of care he needed. As he aged, his physical condition deteriorated and his drug-seeking behavior escalated. When we met Steve, he had over 40 varieties of prescription medication in his apartment.
Steve, as a recipient of Medicaid, qualified for placement in a skilled nursing facility. Many attempts to place him were initiated by police department social workers. On each of these occasions, Steve would call an acquaintance to pick him up and take him home within 48 hours of his admission. His desire for drugs and inability to have free and ready access to them in a skilled nursing facility always prompted him to check himself out and return home. Even if being home meant frequent injuries, repeated falls to the floor, 96 calls to 911 in the course of a year, Steve was happy to be there with his familiar routine and large collection of medications.
The league of frequent fliers is not limited to drug addicts, however. Many are mentally ill and seeking relief from psychiatric symptoms; they may also seek attention. Some are homeless and some are contending with dementia. Still others know no other way to procure care – while their issues may be non-emergency even in their own estimation, they are unsure of what else they might do, where else they might go to get support, or what those options might look like. Some stubbornly refuse to acknowledge they need daily help and would never dream of paying for it. And sometimes it’s just easier, safer, to stay in the familiar home where needs go unmet simply because change is frightening, inconvenient and hard to initiate on one’s own.
EMS services offer a few additional benefits, as well. They are simply a phone call away and do not require very much of the caller. The wait time is short, the gratification immediate. The professionals who arrive become well known to super users and sometimes are their only social contacts. The routine becomes familiar, even comforting, and it offers a dramatic interruption in an otherwise lonely, difficult life.
The Emergency Boom
The issue of the super user is an emergency.
The chronic and escalating use of emergency medical personnel, transport and other public services for non-emergency access to healthcare is not economically sustainable.
But who can 911 call when faced with its own emergency?
In the case of the Steve emergency, 911 called Lifecare Innovations. Having become aware of our clinical expertise within the realm of guardianship, the savvy but exasperated police social workers called us to review the case and identify potential solutions. Steve had called 911 fifty times in the prior four months alone, and the police department was eager to find a way to circumvent this pattern.
As skilled and experienced Lifecare Managers, our first step was to meet Steve and begin developing a working relationship with him. We knew it would be far simpler to move forward with a cooperative, engaged client. Given his loneliness and isolation, he was receptive to the attention and offers of assistance, though he staunchly maintained he would not transition to a skilled nursing environment on a long-term basis, and certainly not without assurances of a private room equipped with cable television and the ability to smoke. He did agree, however, to allow access to his medical records and to seek a short-term placement for him that would offer rehabilitative services to build his strength.
Our hope was that Steve would transition to the skilled facility setting that we located for him and gain a fuller understanding of just how well his needs would be met over time in this supported and structured environment. Steve, however, was powerless over his addictions. In keeping with his customary pattern, he found an acquaintance to come and pick him up and he left the facility within 48 hours.
Out of the Box
Clinical and legal creativity were needed to de-rail this well-worn pattern. It was clear to us that Steve would always abandon facility placements quickly as long as his apartment full of medication was waiting for him out in the community. A team consisting of Lifecare Innovations clinicians, police social workers, the fire chief, the police chief and an attorney concluded that we needed to explore:.
- Steve’s competence in view of his ongoing drug addiction and the choices his addiction compelled. Even a limited guardianship would allow us to get Steve into a safe placement with treatment for his drug addiction.
- Whether or not the apartment to which he always escaped could perhaps be made a less attractive option for him. If the apartment was no longer a viable place to go, Steve might actually stay in the facility long enough to recover and benefit.
Our Lifecare Manager began dialogs with each of Steve’s physicians, both in the community and in the hospital emergency department where he was well known. Illinois law requires that a guardianship petition be accompanied by a physician’s report attesting to the alleged disabled person’s inability to make decisions for himself. While each of the physicians we talked with affirmed that Steve was unsafe in his current circumstances, none was prepared to document his poor decision-making in a formal report for the court.
His landlords, though, were prepared to say that Steve was no longer suited to their building. He resided in a multi-unit HUD complex. When we contacted the property managers, they informed us that Steve had failed his last apartment inspection, due in part to dirty conditions, and had not rectified the problem. More important, however, was the landlord’s distress over the hundreds of burn holes Steve’s cigarettes had made in the carpeting, bedding and other flammable surfaces. Steve himself was multiply burned, very probably as a result of nodding off or falling while holding a lit cigarette.
Public safety was now a concern; it wasn’t just Steve who was endangered by his habits, but everyone who resided in that building. The landlord, with the full support of our multi-disciplinary team, decided to initiate eviction proceedings. With no place to which he could serially return, and with no friends/relatives willing to take him in, Steve would now find that a safe facility placement would be his best and only option.
Just as the eviction proceeding commenced, Steve’s health posted some reversals. On one of his trips to the emergency room, it was discovered that he had a urinary tract infection and a bowel obstruction. This latter condition required surgery and several weeks of observation and recovery. By the time Steve was discharged from the hospital, it had been many weeks since he had last abused medication. His mind was clear, and his decisions were no longer driven by the pursuit of drugs. His apartment was no longer a place to which he could return to begin the cycle anew. Finally, he was successfully placed in a beautiful, safe, skilled nursing environment where all of his care needs are fulfilled – and where he has stayed.
Steve has lots of new friends at the facility, and pours his energies into physical and occupational therapies. Well placed and well cared for, Steve counts among his occasional visitors the paramedics who transported him to the hospital for 25 long years.
An investment of less than $5,000.00 for Lifecare Innovations services saved Steve’s community at least ten times that amount by halting the cascade of 911 calls from the address they knew so well.
Steve’s caregivers no longer wear badges, and none of them drive ambulances. The abuse of EMS services has stopped, and Steve’s new life has begun. © Lifecare Innovations, Inc.