Emergency responders look for ways to keep more people out of the hospital

By ELLA NILSEN, Concord Monitor staff

Sunday, December 20, 2015  (Published in print: Sunday, December 20, 2015)


When a patient calls 911, health officials say the emergency room isn’t always the best place for them to go, depending on the health issue they’re facing.

But unless that patient refuses transport, the emergency room is inevitably where they’ll end up, whether they’re having a stroke, suffering from a chronic health issue such as high blood pressure or diabetes, or experiencing a behavioral health episode.

“It’s not always that every patient needs the emergency room,” said Dr. David Hirsch, the medical director of Emergency Medical Services at Concord Hospital and a trained EMT. “There haven’t been any alternatives to help them get what they need.”

Now, Hirsch and other emergency and health care providers in Concord and Hopkinton are looking at ways to keep more patients out of the emergency room, including working together to keep patients at home or have them referred to community health services more appropriate to their needs.

This could include EMTs treating more patients at the scene and even going on house calls. Officials talking about the plan are also talking to the Concord Regional Visiting Nurse Association to try to ensure increased EMT care complements their services, rather than supplanting them.

“It’s changing the philosophy from fee for services (to) patient-centered care,” said Hopkinton fire Chief Doug Mumford, one of the local chiefs heading up the initiative.

Another important piece of the initiative is trying to reduce hospital readmissions.

Since the passage of the Affordable Care Act, hospitals are required to try to reduce their readmission rates or face a penalty. Putting these ideas into practice is still a long way away; officials from the fire departments and hospital are in the planning stages.

They are also constrained by the current federal definition of an ambulance, which designates an ambulance as transport to a hospital only.

“Because of that, if you transport anywhere else to a more appropriate facility, you don’t recoup any of your cost,” Mumford said. “You probably know it would be better for your patient, better for the facilities, better for everyone all around.”

In Concord, fire Chief Dan Andrus said his call volume is set to exceed 8,000 patients this year for the first time. Andrus attributes the spike to the state’s aging population.

“I think we need to get in front of this silver tsunami,” Andrus said. He said the integrated care for a rapidly aging population is preferable to shuttling people back and forth to the emergency room.

“My vision is a significantly larger number of our patients are seen in home,” he said. “We see fewer emergency department transportations, and we are able to deal with calls at the source and manage our own call volume. And get people better care.”

At the Concord Regional Visiting Nurse Association, outgoing CEO and President Mary DeVeau said she sees an important potential partnership between her group and local EMTs for a unique issue visiting nurses sometimes encounter.

The problem the CRVNA faces is when older patients get out of the hospital and refuse home follow-up visits from nurses because they are afraid they will be charged for a visit, or are fearful a nurse might suggest they should live in a nursing home.

“Many times they won’t let us into their homes,” DeVeau said. “They’re afraid they’re going to lose independence; our goal is to keep them independent in their homes.”

DeVeau and Andrus have found the same fear doesn’t exist when EMTs are called in, especially if they are responding to a service call when an elderly patient falls down and can’t get up.

“If we’re not allowed in and the EMS gets in, that’s where we can work together,” DeVeau said.

In addition to dealing with the needs of older patients, Andrus said his crews also see a lot of people who are having psychiatric emergencies and are in danger of hurting themselves or those around them.

The emergency room isn’t an ideal place to bring people with behavioral health issues, but that’s the only place Concord EMTs can take them, said Peter Evers, CEO of Riverbend Community Mental Health in Concord.

“Many of those folks who have a long history probably have some pretty bad memories of being restrained,” Evers said.

If a patient experiencing a behavioral health issue is taken to the emergency room, there’s an 80 percent chance they will need to be committed to New Hampshire Hospital, which specializes in psychiatric services. If they are seen in the community, the likelihood they’ll need hospitalization drops to 20 percent, Andrus added.

Riverbend recently received a grant to start working with Concord’s police and fire departments to create an alternative drop-off center for those who need psychiatric help, or people who are seeking help for other behavioral health issues, such as addiction.

“We’ve got all the right people around the table,” Evers said, adding the program has been up and running for the last two to three months. Riverbend is currently working to renovate an intake building close to downtown Concord where patients can go instead of the emergency room.

Other things are being planned as well, such as trained mental health professionals riding along with the city’s police to work with people in crisis.

Whatever the case may be, health officials are hopeful that when the new model is eventually implemented, it will deliver better care to patients.

“We’re trying to get the resource that the patient needs when they need it,” Hirsch said.

(Ella Nilsen can be reached at 369-3322, enilsen@cmonitor.com or on Twitter @ella_nilsen.)