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Want to reduce ambulance transport and health care costs?

Renee Despres
Sunday, November 13, 2011 - 11:42

As debates rage in Washington about reducing health-care costs, policy makers should sit up and take notice of results of a pilot program involving frequent 911 callers in Baltimore, Maryland.

The program paired frequent 911 callers with case workers who helped them access other services, such as a regular doctor, Meals on Wheels, and support groups. Inappropriate calls for ambulance transport dropped by half, significantly reducing costs and the stress on emergency medical services (EMS).

The program, called Operation Care, was conceived and implemented by the non-profit agency Baltimore Health Care Access and ran as a three-month pilot in Baltimore City, Maryland during 2008. A research team from Johns Hopkins Children's Center evaluated the impact of the program on Baltimore City's emergency services networks. Results were published in the April issue of the American Journal of Emergency Medicine.

Why It Matters

People who frequently call 911 often have multiple physical and mental health problems, limited options for accessing health care, and little social and familial support. They tend to call for an ambulance for non-emergency situations – or for emergencies that could have been prevented. Many researchers have theorized that reducing these calls from “frequent flyers” – and simultaneously giving those people access to more appropriate health care and social support – could lead to significant savings and better health outcomes.

But exactly how to channel frequent ambulance users into more appropriate health-care services has remained the many-thousands-of-dollars question. Some programs have targeted specific problems – for instance, providing blood glucose monitoring equipment to people with diabetes. Operation Care is unique in its use of intensive case management services.

The Study

The Johns Hopkins researchers identified frequent 911 callers in Baltimore City. They then teamed up 10 of those frequent callers with a case worker who helped them access basic health and social services. During the 12-week study period, calls to 911 for ambulance services dropped by almost half. Researchers estimated savings to be more than $14,300 over the 12-week study period.

Researchers identified the 25 people in Baltimore City who had most frequently called 911 to request an ambulance during the previous year. One person had called for an ambulance 147 times during the year; another had made 110 calls requesting an ambulance. Of those 25 people, the researchers identified 10 people they could include in the study. The other fifteen had died, were incarcerated, in a hospital, or were otherwise unavailable. All 10 agreed to participate.

The participants, like other typical frequent 911 users, had serious health problems. All 10 had two or more chronic conditions, such as high blood pressure, diabetes, and heart disease. Seven had either a mental health or a substance abuse problem or both. The average age was 60 years; the youngest was 39 and the oldest 89 years. Nine out of the 10 had health insurance, mostly Medicare. Collectively, the 10 study participants had called 911 and requested an ambulance in 2007.

For the next three months, those 10 people met weekly with a case worker who helped them deal with their medical and social needs. The case worker assessed their medical needs, taught them how to navigate the health-care system, put them in touch with primary care physicians and specialists, referred them to various support programs, and educated them on ways to limit 911 calls to true emergencies. The case manager referred patients to insurance assistance programs, medical specialists, adult-care services, food services like Meals on Wheels, psychiatric evaluation, and support groups for substance abuse.

Nearly 70 percent of the referrals were to non-medical services.

The researchers estimated that these 10 people would make 100 calls to 911 during the three months of the program. But they made only 57 calls, just over half as many as expected.

In three months, the program generated savings of more than $14,300, more than $6,300 of which was for the city fire department – after factoring in the cost of the case worker's salary. Researchers said the real savings were probably greater, as this number did not factor in any money saved from unnecessary trips to emergency rooms and freeing up ambulances for other callers.

But savings weren't the primary goal of the program. “The original idea was to help these frequent callers get better access to medical and other care and, in doing so, Baltimore City ended up saving money and resources, a welcome side effect,” says lead author Michael Rilke, M.D., a pediatrician and a quality and safety expert at Johns Hopkins Childcare’s Center.

From Ambulance to Hospital – and Back Again

Frequent callers to 911 systems often need a host of other services – services that a busy EMS crew can't provide. But there's a huge gap between what emergency medical technicians (EMTs) – the people who work on ambulances – and doctors and nurses in emergency rooms can offer, and what these people need.

In busy EMS systems EMTs hardly have time to drop one patient at the hospital before they're paged out on another call. Baltimore City EMS crews run about 150,000 calls a year, which works out to nearly 411 calls per day.

Once the EMT turns over her patient to the nurse or doc in the emergency room, she's done with that patient. She gives a report – to which the nurse or doc may or may not pay attention – but there's no system in place for the EMT to follow up on the empty fridge, the filthy house, the undertaken medications.

And in a typically overloaded emergency room, Mrs. Smith's need for a case manager to make sure she's got a primary care physician, Meals on Wheels, and heat in her home often takes second stage to the cardiac arrest happening behind the curtain to the left. Is this the fifth time Ms. Smith has been here in two weeks? That's usually worth a comment or two by hospital staff. But rarely does it lead to intensive case management, a social worker visiting Mrs. Smith at home, or any other changes to Mrs. Smith's life.

So at 2 am the next morning, Mrs. Smith calls again.

But – and here I'll differ from the Johns Hopkins Childcare’s Center researchers – Mrs. Smith's calls are not “unnecessary,” even if her physical condition does not warrant the ambulance crew taking her to the hospital. The calls these frequent users place are often very, very necessary – even if there's no immediate life threat present. These are cries for help, requests for social support, basic health care services, and someone to just plain care for a few minutes.

That's why Operation Care is one of the most important programs I've seen. Not only does it suggest a way to cut health-care costs – it suggests a way reduce stress on EMS systems and emergency rooms, and provide humane and real care to some of our most vulnerable citizens.

As researchers cautioned, the study was very small, and it does not provide definitive answers about reducing inappropriate use of EMS in all populations. It's no panacea for rapidly rising health-care costs. But a little high-talk, rather than high-tech, medicine is certainly an avenue worth exploring.


Rilke, M.L., Dietrich, E., Kodeck, T., & Westcoat, K. (2011) Operation care: A pilot case management` intervention for frequent emergency medical system users. American Journal of Emergency Medicine.


Photo credit, Mercedes Benz ambulance: didbygraham via Flickr Creative Commons