Crisis of care

By Ashley Bergner
Newton Kansan – March 23, 2014

Ryan Dick and Garrett McKinney with Newton Fire/EMS practice treating a "patient," Darrell Graves, in the back of an ambulance at Station No. 2 in Newton. ASHLEY BERGNER/NEWTON KANSAN

Ryan Dick and Garrett McKinney with Newton Fire/EMS practice treating a “patient,” Darrell Graves, in the back of an ambulance at Station No. 2 in Newton. ASHLEY BERGNER/NEWTON KANSAN

It’s after midnight, and the nurses and doctors staffing the emergency room at Newton Medical Center are scrambling to respond to an influx of patients. However, statistics show that if 10 patients walk through the doors, on average only two of those patients have true, life-threatening emergencies.

Dr. Ted Cook, medical director of NMC’s emergency department, estimates that only about 15 to 20 percent of patients at emergency rooms the size of Newton Medical Center’s have true emergencies, such as a major heart attack or severe injury. People using emergency services for non-emergencies is an issue also experienced by ambulance crews — and it can drive up costs and drain staff time.

Why do people call 9-1-1 or visit the ER for non-emergencies? Officials in the local medical community say the issues are complex and trace back to a need to raise awareness about the importance of proactive, affordable primary care.

“It’s an issue that’s affecting the EMS industry nationwide,” said Newton Fire/EMS Chief Mark Willis. “… Somebody has an incident, and they don’t know who else to call.”

“People can’t get to the care they need, and so the ER is the answer,” Cook added.

Visiting the ER

Dr. Cook said one of the challenges inherent in ER care is trying to define what is a “true emergency” — an anxious patient may interpret an illness to be more serious than it truly is. Or, the patient may visit the ER for a condition that could be treated more effectively in a different setting.

Emergency rooms are designed to treat acute, not chronic issues, Cook said. It may be appropriate to visit the ER for a flare-up of a chronic condition, such as diabetes, but chronic, ongoing pain might be better served by a long-term pain management program through a specialist. Patients also may decide to make an emergency visit to the ER late at night after being ill for several days, when they probably should have visited a primary care doctor.

Another motivation for visiting the ER can be financial, Cook said. Federal guidelines stipulate every person with an emergency has to be seen within an ER regardless of their ability to pay. Those with limited resources who feel they have nowhere else to go may use the ER for care, and many end up not paying the bill.

“It’s cheaper for them to come to the ER, where they have to be seen, than to go to an office where they have to pay money,” Cook said. “The ER becomes their health insurance.”

The time a patient spends in the ER, from “door to door,” is, on average, about two hours and 20 minutes. It takes time to be evaluated by nurses and doctors, process labs, and prescribe treatment. Non-emergency patients in the ER can contribute to backlog.

“We have functional limitations on what we can do,” Cook said.

Calling 9-1-1

Of the 2,921 EMS calls in 2013 in Newton, about 80 percent resulted in an ambulance trip to a medical facility. Non-transports were due to a variety of reasons and highlight the increasing complexity of providing EMS services.

Chief Willis said calls for non-emergencies could trace back to a gap in health care: uninsured/underinsured patients needing treatment. The aging population also is increasing, and the elderly may turn to 9-1-1 if they do not have family or neighbors they can call for help.

“It’s not like people are abusing the system,” he said. “They just don’t have anybody else to call.”

However, similar to the ER, 9-1-1 can’t take the place of primary care, and community members shouldn’t call EMS to get medical advice, Willis said. They treat emergencies — not diagnose conditions.

“We are not physicians,” he said. “We’re not comfortable going out to a scene and telling someone whether or not they’re having a heart attack. That’s beyond our scope.”

People also may be unaware of how EMS is funded. Medicare, Medicaid and insurance providers won’t provide reimbursement unless a patient is actually transported to a hospital. If EMS crews provide services in a home but don’t transport the patient, that becomes an out-of-pocket expense for the patient.

Providing primary care

Dr. Cook said local organizations can help to reduce recurrent ER visits by working together to make sure patients receive quality primary care.

Willis and others in the EMS industry see potential in the “community paramedicine” model. A report from the University of California, Davis, defines “community paramedicine” as an integration of primary and emergency care. An example of this could be follow-up home visits for patients who have just been discharged from a hospital, helping to prevent hospital readmissions.

Health Ministries Clinic also is helping to bridge the health care gap and promote the importance of primary care. As a federally-qualified health center, it provides primary medical, dental and behavioral health services from board-certified professionals in an integrated setting, regardless of a patient’s income level or insurance coverage.

Health Ministries’ Executive Director Matthew Schmidt is excited about the organization’s move to a holistic care model. Under this new model, a patient could receive treatment for both depression and diabetes — different conditions that can affect each other — in one session.

“We believe it is important for everyone to have a medical home,” he said, “a place where patients can partner with their medical providers to not only treat illness, but also to proactively encourage health. This also helps to ensure that people are treated in the right setting. It is expensive and inefficient to provide primary care services in an emergency room.”

“We are in a great community in terms of the level of cooperation in the medical community, Fire/EMS, the Health Department, Health Ministries and Prairie View,” Willis said. “I’m pretty confident that we could establish a model for community paramedicine as it evolves.”

Gwen Romine, KSFFA Webmaster