Pilot Upstate program attempts to improve 911 response

Greenville NewsJuly 1, 2014 

Hiccups. Hangovers. Prescription refills.

In the past year, the nearly 70,000 calls for help to Greenville County EMS included non-emergencies like these.

But instead of dispatching an ambulance and paramedics, these 911 calls were diverted to a nurse who arranged for help in a more appropriate health care setting.

It’s part of a pilot program designed to reduce unnecessary ambulance transports and costly ER visits, said Dr. Angelo Sinopoli, chief medical officer at Greenville Health System.

“It’s a partnership between GHS and Greenville County EMS to address patients that come to the ER who have avoidable ER visits,” he told The Greenville News. “Those patients who have non-urgent conditions are diverted to a nurse call center now.”

The year before the pilot launched, Greenville Memorial Hospital saw about 5,000 patients who were taken to the ER by ambulance that didn’t need emergency care, he said. Memorial sees about 105,000 ER visits a year.

After observing nurse call center programs in other states, officials wanted to try it here as a way to cope with limited medical resources, said Dr. Marty Lutz, medical director of Greenville County EMS.

Of the 1,506 calls that were diverted to the nurse during the pilot year, which ran from June 2013 to May 2014, 380 people wound up not going to the ER, he said.

That probably saved $60,000 to $80,000 a month in ER charges, Sinopoli said.

Limited resources also have forced EMS operations everywhere to look at ways to cut costs and be more efficient, said Greenville County EMS Director Tim Gault.

During the pilot year, EMS saved 684 hours that they otherwise would have been rolling to answer those calls, he said.

And that translates into a savings of almost $300,000 to Medicaid and other insurers, he said. And it’s allowed paramedics to focus on patients with critical medical needs and reduced the response volume for area fire departments as well, Gault said.

True emergencies

When a county resident dials 911, the call still goes to the main call center. And an ambulance is dispatched immediately if it’s a true emergency, like someone suffering chest pain, a gun shot wound, or injuries sustained in a wreck.

But the dispatcher now has the option based on a series of questions to route calls that don’t seem urgent to the call center nurse, who can then gauge the true nature of the situation and advise the best way to proceed.

“Either they can be given advice about what to do that may solve their problem over the phone or be directed to the doctor’s office, or an appointment can be made for them to be seen in a clinic, whereas prior to this, an ambulance was required to be dispatched and take the patient to the ER,” Sinopoli said.

For example, a man who called 911 after having the hiccups for two days was advised to take a spoonful of sugar by the nurse, who then arranged transportation for him to an urgent care center.

Sometimes these calls are from patients who’ve become accustomed to getting primary care at the ER, Sinopoli said, or have no transportation to the doctor or clinic. In that case, he said, the nurse can help them get that transportation.

“Sometimes, it’s as simple as getting a Yellow Cab to the doctor’s office,” he said. “And that $10 cab fee is a lot less than the ambulance.”

A typical ambulance run costs about $400, officials said.

And, Lutz said, some patients have few resources and no insurance, and the ER sees all comers.

Some calls come from people who have no other access to care, Sinopoli said.

But some seem to defy explanation, the doctors said.

One, said Lutz, was from a man who wanted the ambulance crew to show him how to operate his deceased father’s nebulizer so he could sell it online. Another was from a woman who’d cut her leg shaving, he said.

Next steps

One man called 911 because he was constipated, Sinopoli said, while a woman called so she could be taken to the ER to get a new asthma prescription for her daughter, who was playing outside.

“We had somebody call 911 to bring him to the ER so he could have somebody show him how to use his mother’s CPAP (continuous positive air pressure) machine,” he said.

“A lot of that kind of call is being diverted now. If someone needs a refill, we’ll even call the doctor’s office for them, or call in a prescription for them or arrange transportation to the clinic or doctor’s office instead of going to the ER.”

All the diverted cases have been reviewed to make sure the patients got the appropriate care, he said, and all had good outcomes. Moreover, he said, the service has been well-received by the hospital, EMS and even the diverted patients.

“We have had some patients call 911 just to talk to the nurse,” Sinopoli said, adding that GHS expects to create a direct line for these patients without going through 911.

The pilot service, which operates from 9 a.m. to 9 p.m. when the majority of calls come in and when other health care providers are available, was approved by the state Department of Health and Environmental Control, Lutz said.

Tony Keck, director of the state Department of Health and Human Services, said the program is a great model for improving the quality of care while reducing costs.

“It is having a positive impact on county residents served by GCEMS, while reducing unnecessary emergency room visits and EMS transports,” he told The News.

“The spirit and success of this partnership is one of several GHS initiatives that helped inspire the statewide Healthy Outcomes Plan (HOP) initiative now operating in every South Carolina county,” he said.

HOP uses community-based plans to invest in hotspots of poor health, reduce per capita costs and improve health outcomes by providing funding to hospitals, clinics and other community health care providers, Keck said, adding that it serves the needs of more than 8,500 chronically ill, uninsured, high users of emergency department services in the state.

The Blue Cross Blue Shield of South Carolina Foundation provided $300,000 over three years to help fund the project, said grants manager Erika Kirby, who characterized the results so far as “impressive.”

“This triage concept has been done in some other states, but it’s first of its kind in South Carolina,” she said. “It helps patients get the best care while using the system in the most appropriate manner. And it’s saving those financial dollars as well as resources.”

GHS already had a nurse call center for other purposes, but did have to add some staff and pay for software and training, Sinopoli said.

Meanwhile, officials said they hope to expand the program by sending nurses into the community so people don’t call 911 for primary care to begin with and using a second-tier ambulance for less acute calls that don’t require paramedics.

“If we’re down to one or no ambulances in the county and someone is a real need, and we don’t have an immediate resource, that’s what makes me angry,” said Lutz. “It’s a matter of being available to folks who need us.”

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