triggered when a series of calls suggests mobility issues or when responding
crews repeatedly determine calls are “not of a medical nature.” The location is
electronically flagged; resources, referrals and interventions follow. The following example illustrates the usefulness of this algorithm.
>>Case2 Crews began responding to RAP Client 2, a 76-year-old woman
suffering from dementia who lived in a recreational vehicle (RV) with
her husband. The RV had been permanently parked at a local campsite
facility, and the patient had been recently discharged with the diagnosis
of bilateral cellulitis, which affected her already deteriorating mobility.
Without the provision of additional resources, the patient adopted the
9-1-1 system (calling up to three times per day) with requests to change
diapers, reposition herself in bed, change her urine-soaked clothing and
linens, sort her laundry, reach her equipment, and review medical and
In spite of retirement income with full benefits, the couple refused
relocation assistance. In a coordinated on-scene response involving the
Adult Protective Services (APS) department, RAP and law enforcement,
the couple was removed against their will and placed in an appropriate
facility. And although APS officials didn’t have grounds to remove the
couple against their will, law enforcement readily determined this need
based on scene assessment and the eRAP data displayed on-scene by the
Prior to eRAP, it was difficult to track calls that were non-medical in
nature. The in-home vulnerability algorithm combines dispatch records
(without personal health identifiers) with ePCR records to track the entire
9-1-1 effect of any patient. In locations with multiple residents, eRAP can
recognize and indicate them separately.
Despite efforts to direct the patient into a more stable situation, the
patient continued this behavior. One day, after being released from jail after
9-1-1 abuse charges had been dropped by attorneys, the patient walked to his
usual payphone and called 9-1-1. HOT and RAP confirmed the incoming call
via CAD View, arrived at the scene and cancelled responding units. Since the
patient didn’t have what they considered to be a legitimate complaint, the
teams escorted the patient to a clinic and introduced him to the clinic staff
During the clinic’s offer of assistance the patient discretely slipped outside
and called 9-1-1 from the payphone. RAP again identified the incoming 9-1-1
call via CAD View and intervened again.
The HOT sergeant immediately requested the city shut down this particular payphone. Remarkably, one day later Client 3 attempted to call 9-1-1 again,
but encountered the dead phone. He walked to the clinic to inform staff and
inquired if he could use their phone. Instead, the clinic staff instructed the
patient to sit until he felt better. The patient took their advice and began
watching television. Client 2 has stopped calling 9-1-1, preferring to watch
television in the clinic. HOT visits him regularly while arranging for benefits and
placement in a care facility. He has had only one EMS encounter in the past
four months—a projected EMS and fire savings of $75,000–100,000.
RAP CLIENT 4 9-1-1 ENCOUNTERS, PAST 12 MONTHS
immediately to a SIP officer, who responded to the emergency department
with a treatment counselor. Within one hour, the patient had been placed back
into his treatment program with an admonishment that further behavior would
result in re-incarceration.
BETWEEN THE LINES
San Diego’s most dynamic and demanding EMS patients have a profound
and complicated effect on the community. Its most chronic 9-1-1 users
have frequent encounters with law enforcement, psychiatric services, jail
services, homeless services and the court system. In these cases, habitual
EMS use is one effect of a severely troubled and afflicted individual.
Although EMS can usually identify the vulnerable, EMS doesn’t necessarily
have the expertise to provide total case management. These patients need
referral to coordinated multi-pronged services because isolated case management focused exclusively on health may offer no benefit.
Once RAP navigates an individual out of the EMS system, EMS use can
be dramatically reduced. However, elimination of 9-1-1 calls doesn’t necessarily indicate overall success. As a case in point, while Client 4 dramatically
reduced his 9-1-1 calls, SIP counselors became taxed as he began exhibiting
increasing and extreme attention-seeking behavior. Thus, RAP simply
shifted a burden to another provider, as is often the case. EMS is likely to
reencounter patients like this during periods of recidivism. Subsequent
9-1-1 encounters require immediate intervention and navigation back into
their treatment programs to discourage a return to his or her former 9-1-1
dependence, and reinforce treatment thus far. For this reason, RAP actively
supports efforts to keep clients in their respective treatment programs,
partly by extension of eRAP technology to case management partners.
THE FUTURE OF ERAP
San Diego EMS is currently engaged in the expansion of eRAP technology to case management partners. RAP hopes that this extension will
help provide the necessary connections for coordinated and responsible
community care. Monthly meetings with stakeholders, including the
city attorney, are allowing RAP to design appropriate electronic sharing
practices. A goal of the RAP is to create a “spoke-and-hub” bidirectional
data sharing with all stakeholders and ultimately link to the Beacon HIE.
This will require the development of suitable HIPAA-compliant consent
protocols similar to those employed by SIP, as well as adaptable programming methods.
With such a system in place, EMS sees the role of eRAP extending
beyond its most chronic users, soon helping to assist others in the community with disproportionate health burdens. For example, eRAP could
facilitate case management of select high-needs beneficiaries (e.g., dual
eligibles) who are engaged by managed care programs. In addition, eRAP
technology can provide a means to significantly assist in injury and disease prevention.
Anne Marie Jensen, EMT-P, is the RAP coordinator for San Diego EMS-Rural/Metro of San Diego
and San Diego Fire-Rescue Department. She received a California EMS Authority Award in 2010 for
her work in EMS-related technology and was selected as 2012 paramedic of the year by her peers.
James Dunford, MD, is the medical director of San Diego EMS and professor emeritus of
emergency medicine at the University of California San Diego School of Medicine
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resource access program (RAP) on frequent users of health services Prehosp Emerg
Care. 2012; 16( 4):541–547.
3. The San Diego Beacon eHealth Community. (2012). In the San Diego Beacon eHealth
Community. Accessed Nov. 16, 2012, from www.sandiegobeacon.org.