Minor wounds, rashes, gout pain — these are some of the many medical conditions that should be taken seriously, but they may not merit a 911 call or a trip to the emergency room.

Hawaii health officials are considering how to reduce unnecessary ER visits through a community paramedicine program. The revised emergency transport system that could begin next year would allow medical professionals to transfer patients to predesignated destinations, such as urgent care clinics, or even provide complete treatment at the scene.

“Can paramedics go treat people in the field, in the community setting under a physician’s direction, and offer a treatment when they don’t need to go anywhere?” asked James Ireland, a nephrologist and the former director of the Honolulu Emergency Services Department. “Can they do some simple wound cleaning and start the patient on some antibiotics under the guidance of a physician? I think that’s where the huge cost savings can be.”

When Gov. David Ige signed Act 140 into law June 25, it marked the latest development in an effort to make Hawaii’s emergency response system run more smoothly. Starting as early as next year, the law will allow paramedics or other medical professionals to treat some patients at the scene of an emergency — or nonemergency —  and navigate them to appropriate care at other clinical sites.

The Hawaii Department of Health has until July 2020 to outline the program’s parameters, such as how many additional people will be hired, what kind of vehicles it will require and how to delegate medical treatment.

It likely won’t provide service 24 hours a day. A 2016 Community Paramedicine Working Group recommended the program involve certified health workers, social workers, doctors and a medical director.

Officials say the program could alleviate pressure on overloaded ERs and save the state money, but it will require careful planning, training, partnership-building and vetting. And no one knows exactly how it will be structured yet, especially without a monetary appropriation from the state.

“We have to get cooperation from insurance companies, from clinics and the doctors, but we want to be very precise about how we do this,” said Alvin Bronstein, a physician and the chief of the Hawaii Department of Health Emergency Medical Services and Injury Prevention System Branch. Bronstein expects the program to roll out in stages.

“It’s very important that we do it right since it’s a whole new paradigm,” he said.

Bleeding Money

The state is losing money on emergency transportation, and the health department is currently under a mandate to improve its billing collection.

“We collect about $45 million a year and (emergency transport services) cost the taxpayer about $90 million,” Bronstein said, noting that collections are returned to the state general fund. “We need to optimize.”

The department must draft rules for the program by July 2020 to serve as interim guidelines until 2023. The rules must determine the price for paramedic calls that either involve transport to facilities other than ERs, or treatment at the scene with no transport.

Once those are adopted, the state can bill for those services for the first time, said Rep. Della Au Belatti, the state House majority leader and a member of the House Health Committee. Currently, Hawaii patients who elect not to be taken to the ER are not billed and the state swallows the cost.

“It’s something that we’ve been talking about for some time now, as we continue to struggle with how to make EMS more sustainable and ensure that they are drawing the reimbursements that they should be getting,” Au Belatti said.

DOH currently contracts with several ambulance service providers. The City and County of Honolulu EMS covers Oahu, the private company American Medical Response provides ambulance trips throughout Maui and Kauai counties, and the Hawaii County Fire Department covers the Big Island.

Act 140 authorizes Medicaid programs to provide coverage for health care provided by paramedics, but depends on approval by the U.S. Centers for Medicare and Medicaid Services. That approval has not yet been granted.  

The number of Hawaii emergency transports has increased in recent years — approaching nearly 85,000 statewide in 2018 — but the number of ambulance units has remained relatively static.  

The majority of emergency transports occur on Oahu, which has 19 ambulances that made about 56,600 emergency trips last year.

Many think some of those trips could have been avoided. About 40% of all emergency calls made statewide are ultimately classified as involving patients with minor conditions by paramedics.

The price tag for those patients is hefty: The average cost in 2016 for emergency transportation for patients with minor problems exceeded $3,000, according to DOH data from all Hawaii hospitals except Tripler Army Medical Center.

Honolulu Emergency Services Department Director Jim Howe said his department welcomes community paramedicine. He pointed to the city’s planned Punawai Clinic as an example of a future qualified medical facility providing an alternative to ERs. The clinic, slated to open sometime in 2020, will serve homeless people in an urgent care environment.

“This is a major improvement in the way EMS services are currently being provided to the community,” Howe said. “This will allow the EMS system to provide the appropriate level of care based on a patient’s medical needs, at lower costs to the patient and health care system.”

Big Island Experience

The Hawaii County Fire Department began to operate a community paramedicine program in 2016 with funding from the DOH Executive Office on Aging, but has since absorbed the costs itself, with two fire medics taking on the extra responsibility for the entire Big Island.

Hawaii County Fire Department EMS captain Vern Hara likened it to wearing “another hat.” All Hawaii County firefighters are already cross-trained as paramedics.

“At first there was some pushback because some people thought it wasn’t our job as firefighters to do this social work, public health nursing kind of thing,” Hara said. “We were scared some of the agencies would have some pushback, but everybody’s been really good. We’ve learned from a lot of public health nurses and social workers and worked hand in hand with them — even the insurance companies and their caseworkers.”

Hara said it’s been encouraging to connect patients with other health care services to avoid ER trips. The program includes home visits and safety assessments, particularly for the elderly, as well as visits to homeless encampments to conduct wound care workshops.

“We had people calling 200 to 300 times a year,” he said. “We actually got two of our highest utilizers into a long-term care facility and now they’re not using our services at all. They’re getting around-the-clock care.”

But the program needs more money, Hara said, for training and to hire more medics.

Cutting Down On Walk-Ins

Reducing overuse of emergency rooms is not just about transportation, but changing the habits of walk-in patients as well.

Community health worker Genie Naone has heard it more than once: The emergency room is simply easier and more accessible for some of her patients, even for non-urgent matters.

One of her clients, a Native Hawaiian in his late 40s, said he only has time to see a primary doctor when he absolutely must for prescription medications.

“He is really busy with work and cannot take off due to no work, no pay,” Naone said. “He utilizes the ER in the evenings when needed. Sometimes he uses the ER if he does not have money to pay his co-pay, as he knows they would bill him and not ask for payment up front.”

From what she’s seen as an intermediary between health and social services at a Native Hawaiian health care system based in West Oahu, Naone believes a community paramedicine program would benefit many of the patients she interacts with.

“Onsite treatment could actually take care of a lot of different things that clients go through,” she said.

The Queen’s Health Systems has been working to reduce unnecessary ER visits, but from another angle, via direct partnerships with community health centers.

Daniel Cheng, an emergency room physician and the Queen’s Care Coalition medical director, helped spearhead an effort to identify frequent visitors to Queen’s emergency departments and redirect them to proper clinical sites. Most patients identified as frequent visitors were covered by QUEST, the state’s Medicaid program, and already had an assigned primary care physician based on their address.

“It’s much more efficient and it also helps certain things get done when a specialist or payer knows that their patient and primary care and acute care are completely aligned,” Cheng said.

It’s been about two years since the Queen’s Care Coalition teamed up with Kalihi-Palama Health Center, Waikiki Health Center, Waianae Coast Comprehensive Health Center and Waimanalo Health Center.

Kalihi-Palama Health Center has seen a dramatic decline in the number of ER visits among the first cohort of patients that Queen’s redirected to its clinic.

“If they have a person we’ve been trying to locate, they don’t have to use the general telephone line, they call the care coordinators directly,” said Emmanuel Kintu, the CEO of Kalihi-Palama Health Center.

Cheng negotiated access to the Homeless Management Information System, and believes Queen’s is the only hospital to have access to the database, which he said has been instrumental in helping Queen’s quickly renavigate patients to their proper “medical home,” as the industry calls it.

“I think you can ask some of them, they actually want to go to their primary care, it’s just a challenge to get there,” Cheng said.