At Home With the At-Risk: Tucson`s TC-3 Program

Because we are the safety net upon which communities have come to rely, fire and EMS departments nationwide are realizing an increased demand for nonemergent care. To meet this need, many are implementing mobile integrated healthcare (MIH) and community paramedicine (CP)-type programs. These community-tailored programs permit crews to get to know their patients in a less-rushed setting than that of traditional, emergent EMS and instead allows for scheduled visits, personalized care plans and in-home posthospital care. 

The Tucson Fire Department (TFD) has responded to more than 82,000 EMS calls in the past 12 months. Of those, only 41% resulted in emergent on-scene interventions and/or an ALS-level transport to the hospital. Our percentage of nonemergent EMS calls is rising, and faster every year. Due in large to a fragmented healthcare system that is increasingly difficult to navigate, the EMS system has become overtaxed, and with limited transport destination options, local emergency rooms are sharing the heat.

For most of us, a disproportionate part of this problem can be attributed to the frequent 9-1-1 user population. In 2014, 50 of TFD’s frequent system users accounted for almost 1,400 calls, with most culminating in an ambulance ride to a local emergency room.

Individual reasons for repeated use of 9-1-1 are numerous: Mental health, substance abuse, chronic and unattended disease, noncompliance with care plans, inaccessibility to definitive care, nutritional limitations, lack of transportation, pharmaceutical misunderstanding, legal status, poor living conditions, homelessness and financial barriers are among the common factors.

So what is a department to do? How do we best capitalize on established resources and infrastructure to address this growing problem cost-effectively? We can no longer afford to do nothing.

Tucson Collaborative Community Care

An often-overlooked but key component of fire departments and EMS agencies is that they almost universally have the trust of their citizens. The first responder’s ability to gain access to homes and the homeless allows personnel to obtain a truly comprehensive picture of the entire patient situation. This includes living arrangements, home conditions, family support, transportation options, medication history, domestic or substance abuse indicators and many other barometers not available to traditional care providers.

The frequent system users of our communities have shown that handing them phone numbers and pamphlets doesn’t work—the system is too complex, fragmented and siloed. We must instead take these people by the hand and navigate them through the intricacies of insurance and social service offerings to get them, and keep them, connected to the help they need. A person who falls repeatedly must have the cause examined, the care provided, the step fixed. The trust patients have that allows fire and EMS personnel into their homes must be extended to caseworker-type relationships. Without this trust an essential bond rarely exists, and patients voluntarily opt out of assistance.

In 2016 TFD introduced Tucson Collaborative Community Care (TC-3), a unique MIH-CP program designed to deliver that assistance. Its direction was simple: Find the people where they are, find the resources to help them and solve their problem—no matter what it is, don’t say no.

With the reallocation of three uniformed staff and the collaboration of a large, ever-growing group of diverse community partners, our impact has been impressive: 9-1-1 responses to our TC-3 clients have dramatically declined, with some completely removed from the 9-1-1 cycle, all showing improvement, and the vast majority reporting their quality of life improved. Our crews feel supported, our reliability for time-critical incidents is improved, and our clients are finally able to get the right help for their often-multifaceted issues.

The work of the TC-3 team is twofold, focusing on care of the individual and coordination of resources within the community. Here’s how it works:

With the click of a button and a signature of consent, responding crews utilize our ePCR system to begin the enrollment process for an at-risk individual. A notification is sent to the TC-3 operations manager, Capt. Mike Bishop, who runs a full query on all previous visits made to the individual, looking for patterns, needs and outcomes. A file is created, and based on severity and urgency, the individual is entered into TFD’s web-based Human Services Referral Program (HSRP) and/or placed into queue for a scheduled in-home visit with our TC-3 coordinator, paramedic Sue Rizzi.

Our HSRP tool allows us to immediately get the wheels rolling via an auto-generated e-mail to key staff at community agencies with which formal HIPAA-compliant business agreements have been made. There they can weigh in on pertinent offerings and communicate with us on any visits, care, services and follow-up provided. An unhurried in-home visit with our TC-3 team allows our personnel to better understand the individual’s needs and limitations. A thorough assessment is conducted, and findings are matched to the services and qualifiers of local community partners. Because real-time follow-up is crucial, TC-3 clients are then identified to the 9-1-1 communications center to allow immediate notification to the TC-3 team each time a client activates 9-1-1.

The help provided by TC-3 is active rather than passive: Appointments are scheduled, contacts are made, paperwork is filled out, and transportation is arranged. Some individuals find solutions immediately, coming out of the 9-1-1 system as they are connected to long-term disease management, palliative care, hospice, home repairs, housing, pet solutions and dietary care, while others require ongoing assistance and contact to keep them engaged and their needs managed. TC-3 personnel navigate clients through the maze of the healthcare system, providing customized, person-centered, inclusive attention pertinent to their specific needs.

TFD’s TC-3 program also coordinates communitywide quarterly meetings to discuss, understand and add to our bank of resources. Representatives of the behavioral health court system, regional behavioral health authority, affordable care organizations, hospitals, veterans affairs, law enforcement, county health, pet welfare, palliative care and hospice programs, private subsidiaries, volunteer groups and a multitude of specialized agencies have collaborated with us in a joint effort toward resolving clients’ issues, multiplying our work as our ability to outreach grows. This networking referral model has attracted the attention and collaboration of some of the nations’s largest insurance agencies as they look for ways to meet the sought-after Triple Aim.

The Next Frontier

Agencies entrusted with first response must remain relevant to the needs of their constituents and meet those needs in a fiscally responsible manner by facilitating better care, better outcomes and lower costs. Just as EMS once was, mobile integrated healthcare and community paramedicine programs are the next frontier of service for departments tasked with first response. Each agency must find or create a program that realistically suits its ability and community needs.

TC-3’s proactive, preventative, navigate/refer/follow up model is well suited to the dense population of its urban setting. Here in Tucson it is saving stakeholders’ money and frustration, augmenting a reliable and efficient emergency response system. Most important, it is helping our at-risk population get the care they so desperately need.

Editor’s note: A longer version of this article originally appeared in Fire Chief.

Sharon McDonough is a deputy chief with the Tucson Fire Department.