Effect of a social services intervention among 911 repeat users

Steven J. Weiss MD^a,*, Amy A. Ernst MD^a, Margaret Ong RN^b, Ray Jones EMT^b, Debra Morrow MSW^c, Rosemary Milch^c, Katie O’Neil^c, Jay Glass EMT^b, Todd Nick PhD^d

^aDepartment of Emergency Medicine, University of New Mexico, Albuquerque, NM 87131, USA

^bSacramento City Fire/EMS, Sacramento, CA 95816, USA

^cDepartment of Health and Human Services (DHHS), Sacramento, CA 95823, USA

^dCenter for Epidemiology & Biostatistics, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH 45229, USA

Received 5 October 2004; accepted 1 November 2004

Abstract

Objective: To determine whether emergency medical services (EMS) 911 frequent users would benefit from social services intervention.

Methods: The design was a descriptive prospective subject evaluation. All nonhomeless frequent EMS users (N3x in 1 month) were identified monthly from December 2 to May 3 and contacted by 2 social workers. Information extracted from their contact with the subjects included demographics, ability to enter a social services intervention, and reason for transport.

Results: Eighty-four patients were eligible for inclusion in the study. Seventy-four patients were unable

to enter a social services intervention for the following reasons: not home (2x) (26%), not at address (19%), refused (13%), unable to complete Mini-Mental Status Exam (10%), deceased (6%), hospitalized (5%), safety issues (4%), and others (10%). The reasons for frequent EMS use were cardiac (24%), asthma/chronic obstructive pulmonary disease (25%), seizures (14%), dialysis problems, alcohol problems, and diabetes-related problems (b10% each).

Conclusion: Among all patients, the primary reasons for transport were cardiac, asthma/chronic

obstructive pulmonary disease, and seizures. Only 12% of patients contacted could enter a social services intervention. On the basis of the small cohort of patients that were able to enter a social services interventions, more targeted interventions are warranted.

D 2005

T Corresponding author. Tel.: +1 505 272 5062; fax: +1 505 272 6503.

E-mail address: [email protected] (S.J. Weiss).

Introduction

Frequent users of the medical system represent a burden to the system, to society, and to their own care [1,2]. We recently showed that a small group of patients were

0735-6757/$ - see front matter D 2005 doi:10.1016/j.ajem.2004.11.003

accounting for a large number of Ambulance transports [2]. No previous studies have evaluated the emergency medical services (EMS) 911 calls and the problems among frequent users. People who call 911 repeatedly within a short period not only overburden the existing systems, but also may be in need of extra help or ancillary services. The rationale of this study was to determine if these repeat callers could be contacted for a social services intervention and whether such an intervention could improve the quality of the subject’s life. The EMS system is not presently able to assist with alternative referrals to resources that could help these individuals. Social services interventions have been proven to be cost effective and helpful in other emergency settings [3-9]. We devised this study to determine if a social service intervention was feasible.

The hypothesis of this study was that a social services intervention is feasible for frequent EMS users and is an efficient use of the social worker’s time.

Methods

The study population included all nonhomeless men and women 18 years and older who have had at least 3 calls to 911 in the previous month and can be found by our representatives within 2 attempts. These data were obtained from 911 dispatch records available through the County/ City EMS. The City Department of Social Services was consulted and 2 social workers contacted each frequent user. Descriptive information was extracted from charts and social services paperwork regarding problems and age.

Targeted intervention pilot study

If patients were willing to undergo a social services intervention, the social workers continued their care for a period of 1 month. Reasons that patients were not able to have an interaction with social services included if they were unwilling or unable to consent, if they could not be found or were unavailable, if their Mini-Mental Status Exam (MMSE) [1,9-11] score was less than 22, if they were incarcerated at the time they were entered in the study, if they did not speak English, if there was a safety issue to the social workers, or if the patients could not complete the forms.

We then randomized the available patients to either a social services intervention or observation. We tracked their progress using 2 outcome variables pre- and poststudy: (1) the frequency of EMS calls and (2) the subject’s quality of life (QOL) as measured by the SF-36. The SF-36 is a nationally recognized validated scale for QOL determination that is split into physical component scale and a mental component scale [1,10,12-29] in injured patients [30,31] and in Geriatric populations [32]. Both the physical and mental scales of the SF-36 scale have national averages of 44 F 10.

After signing a consent form, all subjects completed the SF-36. The intervention consisted of traditional social services management including an intake questionnaire, assessment of the patient’s specific problems, and referral to specific community services. All resources of the Department of Health and Human Services (DHHS) were made available. After 30 days, the subjects completed another QOL questionnaire. Outcome variables included number and types of interventions, past vs future ambulance transports, and changes in the QOL as measured by the SF-36. The investigator extracted numbers and types of interventions from the social services records for the sub- jects. At the end of the 30-day period, all subjects in both arms of the study were offered social services follow-up.

Changes in QOL results were compared using an independent samples t test. Results for ambulance use were compared using v² and Relative risks. The University and City Department of Health Services Institutional Review Board both approved all phases of this study.

Results

Eighty-four patients were included in the study. The average age was 49 F 2 years with 4 patients younger than 18 years and 17 patients older than 65 years. The reasons for frequent EMS use were cardiac (24%), asthma/chronic obstructive pulmonary disease (COPD) (25%), seizures (14%), dialysis problems, alcohol problems, and diabetes- related problems (b10% each). In 25 cases, all transports were for different complaints. The Number of calls per month ranged from 2 to 8 with an average of 2.9. These results are summarized in Table 1.

Seventy-four of the 84 patients identified were unable to participate in the intervention. A total of 10 patients (12%) were enrolled in the intervention over the 6-month course of the study. Reasons patients were excluded from the intervention were the following: not home (2) (26%), not at address (19%), refused (13%), unable to complete MMSE (10%), deceased (6%), hospitalized (5%), safety issues (4%), and others (10%). Reasons patients were unable to take part in a social services intervention are summarized

Table 1 Specific problems that were the recurring cause of

transport by 911 during the study period

Some patients had enough transports to fit into more than one category.

Diagnosis	N	%
Cardiac	20	24
Asthma/COPD	21	25
Seizures	12	14
Dialysis problems	7	8
Alcohol problems	6	7
Diabetes-related problems	8	9
No contributing factors	17	13

Table 2 Reasons for exclusion of the subjects from the social services intervention
Reasons	N	%
Not home (2x)	22	26
Not at address	16	19
Refused	11	13
Unable to complete MMSE	8	9
Deceased	5	6
Hospitalized	4	5
Safety issues to social workers	3	3
Others	5	6
Total excluded	74	88
Percentages are out of the 84 patients that took part in the study.

in Table 2. There were no deviations from the study as planned.

Targeted intervention pilot study results (10 patients)

Change in the SF-36 results for the physical score was

-3.3 F 4.6 in the control group and +4.0 F 4.1 in the intervention group. Changes in the physical component score were significantly different (diff = 7.1 F 2.7. P = .02; 95% CI, 0.8-13.4) between the 2 groups. Change in the mental component scale of the SF-36 was +13.1 F 20.6 in the control group and +1.0 F 18.7 in the intervention group. Changes in the mental component scale were not signifi- cantly different (diff = 12.0, P = .4; 95% CI, -16.6 to 40.7). There were physical score improvements in 4/5 patients in the intervention group and none of the patients in the control group. There were mental score improvements in 4/5 of both groups. The number of EMS transports was equivalent between the 2 groups before the study at a rate of 3.2 transports per person per month for both the control and intervention groups. The 6-month Transport rate after the intervention phase was 0.8 transports per person for the control group and 5.0 transports per person for the intervention group. This represented a significant increase in the intervention group’s use of EMS in the months after the study period (RR = 1.76, 1.17-2.65, P b .01).

Discussion

We found that an attempt to help all nonhomeless 911 repeat users with a social services intervention was not an efficient use of social services time. This is the most crucial finding in the study. The social services team made serious attempts to enlist all patients but were unable to include 88% of all the patients they contacted. For an interesting set of reasons, most frequent users of EMS were either unavailable or unconcerned in the intervention. This suggests that the broad use of social services would lead to a lot of time spent trying to find patients and get them

interested in help, with little ability to intervene in their lives. After many discussions with our social workers, we have concluded from the fact that only 12% of the frequent EMS users are interested in being helped, and that social services support needs to be directed more critically to the needed problems or the specific EMS patients. This study was concluded with the belief that the social workers need to focus on a need-related group rather that on general frequent users. Future studies will look at the focused ability of social services to aid with patients with specific problems such as falls, drug/alcohol problems, seizures, chest pain, diabetes, asthma, dialysis, and cardiac disease.

The use of social services in conjunction with EMS is novel. This is the first in a series of studies evaluating the most practical way to include social services in the pre- hospital environment. Working with all nonhomeless repeat- ers was too broad and may have led to futile efforts by our social workers. By picking referrals carefully, we may see much more prominent changes in the patient outcomes. Table 3 shows suggested social services interventions that could be accomplished in a diagnosis-focused system.

Even for many of the patients amenable to social services, our social workers were unable to make significant inroads into the system problems that they were facing. Often, the subjects had exhausted social services systems and were still not improving. Again, this suggests that social services sup- port needs to be focused on patients with solvable problems. ED social services have been depicted as one of the significant types of interventions, according to the Society for Academic Emergency Medicine (SAEM) preventative task force. The theoretical basis for this is found in the social services literature. A social worker within the medical sys- tem can use Crisis Intervention and Task Centered theories to provide optimum care in brief patient care settings. Payne

[33] describes the Crisis Intervention model as an action to interrupt a series of events, which lead to a disruption in people’s normal functions, whereas Task Centered models focus in the defined categories of a problem. According to a study by Keehn et al [9], the greatest decline of emergency department recidivism occurred when social workers used a proactive approach after the Task Centered model. Both models, although somewhat different, are attempting to improve a patient’s capacity to deal with the problems vital for overall life satisfaction [33]. Harrington [34] supports the use of the Crisis Intervention model by stating that bthe emergency room social worker exemplifies in a crisis- oriented context, to make a difference in real terms in situations of patient and family need-physical, environ- mental, and emotional needsQ.

On the basis of limited pilot study data, if patients were amenable to social services intervention, there was a significant improvement in the physical portion but not the mental portion of the QOL. This was unexpected by us because emotional support is more of a social workers’ focus. We believe that it may be a reflection of usage and knowledge of resources. Many of the clients were house-

Table 3 Social services intervention suggestions

1. Falls Conduct a home safety assessment, including the following: assess the flooring for cracks, carpet, and steps. Do pull bars and hand rails need to be installed?

Discuss the option of using a walker or cane.

Help the patient with obtaining LIFE-ALERT, a program that provides an apparatus worn around the neck for easy accessibility to get immediate medical assistance if they are not near a phone.

Assist with arranging full medical examination including optometrist, magnetic resonance imaging, and a yearly physical examination.

1. Drug and alcohol complications

Aid patient in finding appropriate services, eg, narcotics anonymous, alcoholic anonymous, residential or outpatient detoxification support.

Address psychosocial issues and stressors that may have occurred because of their substance abuse issue.

Address Medical complications that are a result of substance abuse such as, syncope seizures, contractED diseases from intravenous drug use, liver damage, and dental complications.

1. Epilepsy Help patient make the appropriate doctors appointments such as a neurologist as well as their primary doctor.

Assist with obtaining the appropriate medications and make sure that the medications the patient has currently are not expired.

Come up with a plan for patient and family/friend support if a seizure was to occur in a public area to keep the patient safe at all times.

1. Chest pain Find reasons the patient is calling 911 to differentiate whether the call is a medical or

psychological issue, such as anxiety.

If the patient’s chest pain is caused by cardiac complications, do they need to see a cardiologist and make a medical appointment?

If the patient’s issue is psychiatric in nature identify the triggers for anxiety and discuss with client referrals for appropriate long-term counseling and a doctor for a medical evaluation. Help the patient with obtaining LIFE-ALERT.

1. Diabetes (both insulin and noninsulin dependent)

Assess the patient’s knowledge of illness.

Assist the client in obtaining doctors appointments for evaluation of medications and appropriate management skills.

Provide education materials such as literature or videos.

Do they need a public health nurse referral to help remind tem of their diabetes regimen? Is a nutritionist needed for evaluation of diet?

bound and cared for by family members who may or may not have proper medical training. Therefore, the intervention may have improved the ability of the patient to physically manage his or her own care or the ability of the caregiver to physically manage the patient’s care.

We were surprised to find that patients receiving the intervention uniformly used EMS more in the follow-up months of the study. We would explain this as being related to increased attention from the medical establishment leading to an increased awareness of available resources. However, this effect was on the basis of a small number of patients and needs to be reproduced in larger studies.

Preventive services are an important part of the future of EMS. Consensus articles have been written but only a few studies have been completed. This direction for expansion of Scope of practice for EMS personnel is practical, realistic, and cost effective.

Limitations

The length of the study was a limitation. We originally estimated that 20% to 25% of patients contacted could

be enrolled. We found that the final results were closer to 10%.

Another limitation was bias among patients. Many of the patients were weary of being labeled as frequent users of the system and were resistant to taking part in a study that tagged them as such. The low recruitment for a social services intervention was not a deficit in patient entry but a statement about the problems encountered by frequent users of the EMS system. The systems in place are not adequate for this marginal group of people.

Conclusion

Most frequent users were nonelderly adults. Three categories of problems comprised the great majority of the cases (cardiac, asthma/COPD, and seizures). Use of a social services intervention on all frequent users of EMS is not an efficient use of their time as only 12% of patients contacted can enter a meaningful interaction. In cases with meaningful interactions, these interactions do seem to improve physical QOL and increase EMS use. A more focused use of social services may be more efficient.

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