Part I of an interview with Michael Sanderson, Chief of Hamilton Paramedic Services. We talk about three of the programs that Hamilton has implemented to reduce the burden on the paramedic services while simultaneously improving patient care and reducing system costs.
Darkhorse: Can you tell me a bit about the programs you put in place and the catalyst for it?
Mike Sanderson: The impetus was the unnecessary calls we have to transport unnecessarily. We know that we have paramedics responding to a lot of clients that don't need to go to the hospital. They need to have some assistance or some help. Currently, when we respond to an ambulance call, we’re required by the Act to assess the patient, to treat the patient, and to transport the patient unless they refuse.
Some of these calls are drive-bys. Drivers see somebody that's down, they don't bother stopping, they don’t check, but they call 911 to report it. We respond, do an assessment and often transport them to hospital, which ties up staff at the hospital unit and our own resources - whether or not the patient needed it.
Mike Sanderson: So we’ve created programs to mitigate this problem. The first one that we started here was the Social Navigator Program partnering with the Hamilton Police. Our paramedics work with police officers to deal with the frequent users, those clients who are using our services up to one or two hundred times per year. They’re often dealing with addictions, mental health issues, or they’re working their way through the judicial system.
The Social Navigator Program helps to point these people to the right resources. So you have our homeless population being directed now to City Housing Hamilton, or the Ontario Works program to help them get financial assistance instead of living from handouts on the street.
The Social Navigator, the paramedic, looks after their medical needs, while also referring them to the appropriate follow-up whether a primary care physician, a clinic, a mental health support area, etc. Very often, the people living in these conditions don't know what's available to them. The police officer deals with the legal issues that need to happen. Together, they form a very effective system.
We're seeing a 50% to 60% reduction in calls from patients in that category once they're enrolled in our system. It's working to the point, right now, that we’re looking to expand it. We've only got one paramedic assigned to it right now. But working Monday to Friday doesn't quite cut it, because the people aren't homeless and in need just Monday to Friday. We’re looking to extend the hours out to seven days a week.
Darkhorse: What impact has this had on the paramedic service?
Mike Sanderson: Right now we have roughly 30 clients enrolled in the program. On average, they would have used an ambulance 30 times per year. We estimate that the program reduces their call volume by 50% so we’re probably eliminating about 500 transports per year.
Darkhorse: We're talking (eventually) hundreds of thousands or even millions in savings just from averting.
Mike Sanderson: That’s right. Not so much “savings” but a reduction in cost growth. Our cost just for paramedic transport in Hamilton is about $500. That’s not accounting for all the hospital costs associated with these transports. It’s a lot of money - around a quarter million in transport costs alone.
I guess you could call it savings, because everyone wants to hear that we're saving something. The reality is, I’m really just slowing the growth in terms of the demand for the service. Our call volume has been going up by about 5% a year for the last seven years. If I can slow that growth to 3% a year, it will have a significant impact on our ability to effectively serve our clients in the future.
Darkhorse: That’s great… So how did you identify these individuals at risk?
Mike Sanderson: We mainly identify them through referrals. First of all, there are paramedic referrals. One of our staff is in the community and they come across somebody that has some issues. Our paramedic will alert the Navigator who will then make contact with the patient as appropriate.
Some of the clients are actually referred to us through the court system. There are several cases where part of their conditions of probation or conditional discharges are that they work with the community paramedic program or Social Navigator Program.
Darkhorse: That’s excellent.
Mike Sanderson: It's been effective.
Darkhorse: So beyond the Social Navigator Program, you mentioned that you have some other initiatives?
Mike Sanderson: Yeah, so the second one that we started in Hamilton is called the @Clinic Program – originally named the “Strathcona Project”. It came out of some great research done in conjunction with Dr. Gina Agarwal at McMaster University.
The @Clinic Program is essentially a public housing or a city housing building, primarily with elderly and senior citizens. We’re talking about 200 or 300 people living in a building all above the age of 65. They’re all in a lower socioeconomic level, so they're essentially challenged in terms of resources. Many of them are shut-ins.
We started a program where for half a day per week, a paramedic will go to the facility to do screenings and assessments. At the same time, they’re finding out what the medical conditions are, and they’re getting to know the clients. Where appropriate, they refer those clients, in the building, off to the appropriate resources.
Sometimes, the community paramedic noticed conditions that had been missed, reached out to the patient’s physician, and ended up saving the patients life. In other cases they’ve pre-empted situations that would have resulted in a transport to hospital and expensive interventions.
The research done with McMaster evaluated the number of 9-1-1 calls going into that building before and after we initiated the program. There's been a 40% reduction after intervention by simply hosting a half-day clinic each week.
Darkhorse: Wow, that's fantastic. You’re improving quality of life, reducing costs, and actually saving lives.
Mike Sanderson: That’s right. We've taken that program from one building in the City and expanded it to nine. All of the buildings are with senior citizens, all with socioeconomic issues, all of them high utilizers of the EMS system. And, what's the impact of that? We're seeing the same 40% reduction in emergency transports from those buildings. So, we're talking, again, hundreds of calls a year that are mitigated through the intervention of having a community paramedic there.
It's not rocket science. It's asking simple things, like: Are you controlling your blood sugar? Are you taking medications? What does your weight look like? Are you having other changes?
And, because they're going there on a regular basis and have a regular signup through the registration, the paramedics get to know the individual clients. So, they can say, "Mary, you're not looking as good as you were last week, what's going on?”
What that does for the quality of life for those people is not insignificant.
Darkhorse: Absolutely. It really addresses things when they should be.
Mike Sanderson: The third program that we're doing is what we call our At-home Program. Originally, we used to do referrals to Community Care Access Centers, through a program we called Community Referral by EMS or CREMS.
Community Care Access Centers would look after home care for patients. If the paramedics came across a client that they thought would benefit from home care, they could identify it through our system back to CCAC, who would then initiate home care if appropriate. It was a good start, but it really wasn't solving the problems.
We now have two community paramedics that are funded through the Local Health Integration Network to do community support. And these two paramedics go out to high-risk clients, clients that have been utilizing the system on a more frequent basis.
We identify them through our data analytics that we apply to Electronic Patient Care records. We evaluate how often they’re calling and we revisit the data every week. For frequent flyers, we send the community paramedic out to do an intervention if the patient agrees to it.
The intervention is essentially an assessment of the patient and an assessment of the environment around the patient. The paramedics evaluate the house for tripping risk, and things like that. Where appropriate, they refer them off to the right community resources.
Mike Sanderson: One thing to note: we're not trying to replace anyone’s job here. What we're trying to do is mitigate unnecessary ambulance responses through understanding patient needs. And, again, it’s been a very effective process. We've got several hundred clients in the program right now.
We’re also constantly evaluating its effectiveness. We test the utilization of EMS for the 12 month period prior to intervention, and then the 12 month period after intervention. And as before, we're showing about a 30% to 40% reduction in high-utilization clients across the area.
Darkhorse: That’s great to hear. It seems that these pre-emptive programs all have a similar impact - reduced use of resources, more personalized care, and in some cases, saved lives.