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The plan for avoiding emergency rooms

January 25, 2012

It’s a common complaint- emergency rooms are often full of people that don’t need to be there. Unfortunately, the most expensive place to get medical care is also the default for a lot of people- folks without insurance, people with health concerns after hours, and Rhode Islanders with mental health or addiction struggles.

A special Senate commission is tackling how to better care for that last category of patients. They’ve been meeting since last November to sketch out a system that effectively treats mentally ill or addicted Rhode Islanders without throwing them into an expensive hospital bed. One physician participating in the group puts the problem this way-

We are providing an extremely expensive taxi through the use of municipal ambulances and RIH [Rhode Island Hospital] is the most expensive hotel in the City for this population with an average stay of $650 for a turkey sandwich and place to sleep.

The group released a rough draft of its final report today. It’s still a working document, testimony from a round table discussion today might change the contents slightly, but the broad strokes will stay the same.

The report first details the problem- a small sliver of Rhode Islanders use emergency rooms more than four times a year. Many get expensive and unnecessary ambulance rides. The report says-

EMS personnel estimate that 10% of ambulance transports were for actual medical emergencies.

As for the other 90% of the ambulance rides, they’re not only unnecessary, they’re often done for free. The report estimates that in Providence alone, city firefighters and police officers provide about $800,000 to $1.3 dollars in unpaid transportation services.

So what can we do about this? The commission proposes a few things-

1. Change protocols that make it difficult to take patients anywhere else.

Currently, state rules say medical technicians have to take “intoxicated persons and persons incapacitated by alcohol” to a place that provides “emergency treatment” and is affiliated with or connected to a hospital.  That pretty much rules out community treatment centers.

The rules also say the patient must be assessed by a “licensed physician.” That leaves out other folks (nurse practitioners, licensed physician assistants, etc) who could easily do that job for less money in another setting.

To do something about this, the commission proposes a change to state’s alcohol statute to allow for a “pilot period” where intoxicated Rhode Islanders have the option of being evaluated in the community by other types of licensed health care providers.

2. Create a pilot program testing community options.

When I spoke with Senator Josh Miller, the co-chair of the commission, he said the group plans to propose legislation for a pilot program.  The pilot would use non-emergency vehicles to transport intoxicated or mentally ill Rhode Islanders to the most appropriate treatment location.

The pilot would demonstrate whether this new approach actually saves money and improves results.  It would be run by a community provider that already works with this community. Miller says the state would probably have a RFP (request for proposals) process to select one of them.

Those are the highlights for me, but here are the other proposals in the report-

  • Create a state-wide care partnership
  • Use special Medicaid funding to accomplish some of these goals
  • Help  health care providers and first responders use “suicide/mental health assessment tools.”
  • Develop stable housing options for the homeless.

Miller says he’s hoping the General Assembly will approve the pilot program this year. If all goes well, the state would select a group to run it by the end of the year.

What do you think? Does this sound like a smart solution? Will it work?

4 Comments leave one →
  1. Edward R. Carr permalink
    January 26, 2012 5:42 am

    I believe that this round table group may be on the right track. However real numbers need to be used, for example you stated that a average night in RIH is $650.00 dollars. But you use 90% of the transported person are for Rhode Islanders with mental health or addiction struggles. What are we talking here in real numbers, 90% of 10 people, 100 People, or a thousand people? Using community programs is a great Idea, however you do not have any in the state that provide services for what would be a cross service for mental health and substance abuse, that provide a service long enough to help people. An example would be, trauma and substance and some mental disorders caused by???. Also would the hospital and EMS give up the mony to provide this type of service to save money in the long run?
    Edward R Carr

    • January 26, 2012 9:34 am

      Hi Edward- Sorry to be confusing. That statistic reflects ALL of the ambulance/emergency transports in Providence. So they’re saying that 90% of all trips are unnecessary. That’s not to say all of them are drug/alcohol/mental health related, but city officials can say anecdotally that many of them are.

  2. Ruth Wartenberg, LICSW permalink
    January 26, 2012 7:04 am

    Hi Meghan,
    I’m a clinical social worker and have a great deal of first-hand knowledge of the amount of non-emergency visits to the ER and the quality of care offered to patients in the ER. There is a huge amount of stigma against individuals with mental health and substance abuse issues within the medical profession. Many medical professionals openly express their disdain for these individuals because they are repeat customers, who are often perceived as uncooperative and unpleasant, they have been labelled “non-compliant,” and they are time and resource consuming. Many of the families and individuals I currently work with rely heavily on the ER for non-emergency medical situations that could have been more effectively addressed by their primary care physician or an urgent care center. Low-income individuals and families disproportionately rely upon the emergency room; I’m not sure the reasons for this. I have sent many people to the ER during behavioral health crises (suicidal/homicidal ideation, self-injurious behaviors, intoxication, etc.) because that is the protocol and there is nowhere else to send them. I have told many parents that I have worked with to have their children transported via ambulance during a behavioral health crisis because they are often unwilling to go with their parents, there is a risk that they will jump out of the car or become aggressive. The problem is that the families often wait many hours (some have waited up to 24 hours) to meet wih a social worker, nurse, or doctor. By then, the crisis might have passed, things have calmed down, and they are sent home without any referrals for appropriate services. I’m relieved that our elected officials are recognizing this as an issue and proposing some alternatives. The system we have in place is inhumane, ineffecient, and wasteful.

    • January 26, 2012 9:36 am

      Thanks for the perspective Ruth. The commission had representatives from the law enforcement, health care, and mental health communities. Everyone seemed to agree this is a massive problem that wastes resources and does very little good. I’m sure they’d love your perspective as they design a better solution.

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