In the small parking lot of the Gustav Swanson Natural Area near the Poudre River in Fort Collins, Barbara Scott sat in a camping chair under the receding shade of an oak tree with her daughter, Marie, and her mother, Darlene Wiedrich.
On the ground sat an infant car seat —27-year-old Marie would deliver in the coming weeks. With a tank top covering her protruding belly, she folded blankets and stacked clothes — the entirety of their possessions mostly fit within the three shopping carts nearby.
UCHealth community paramedic Julie Bower approached the three women. “Hello, how are we doing today?” she asked. She was greeted with smiles.
Bower, a community paramedic with advanced training, was dressed in navy blue slacks and a navy blue polo shirt, stiffened by the bullet-proof vest she wore underneath. With a radio hanging from her hip, she may be mistaken at first for a police officer, but her badge says UCHealth and the back of her shirt says EMS. She is part of the UCHealth Community Outreach, Response, and Engagement (CORE) team.
Bower listens to the women and then examines Darlene, 87, and in a wheelchair. She has edema that’s obvious in the swelling of her feet and legs. Darlene is supposed to be on medication, but Barbara says they can’t afford the $150 it costs to pick up the prescription at Walmart. Julie advises the family to make sure Darlene elevates her feet often to help with swelling and directs them to a community service down the road that provides prescription assistance.
Bower’s advanced paramedic skills include social, lifestyle and chronic disease management, and allow her to communicate directly with physicians and be their eyes in the field. Her co-worker, Stephanie Booco, lets Bower take the lead with this family because she has an established relationship. Booco is the coordinator for the program, and is dually licensed in counseling and addictions.
Bower asked Marie if she’s experiencing Braxton Hicks, sporadic contractions often referred to as “false labor.’’ Bower likes to check in with Marie regularly because she hasn’t been getting prenatal care and is due mid-August. Marie said she’s feeling fine.
Barbara, 51, also needs medication assistance. She asks where the nearest emergency room is because she said she has a “dent in her chest” after an altercation a few days before with her other daughter. She also shows Bower the bruises on the inside of her arm. Bower explains that the walk-in clinic is even closer and would be able to help her.
The Scott family had come from South Dakota around May. While Marie and Darlene get shelter through Catholic Charities, Barbara still sleeps outside. During the day, the family stays together. They say they are trying to get transportation so they can live with friends in Nebraska once the baby is born.
Once the family’s concerns are addressed, Bower says goodbye so she can move along to care for others experiencing hardship and disconnection from health care services.
In the coming months, the number of people experiencing homelessness is expected to grow as unemployment remains high, according to the National Alliance to End Homelessness. Eviction rates are expected to rise as unemployment insurance runs out for many people who have lost jobs. Nearly 50% of the people that the CORE team regularly checks on already are homeless.
“What we are seeing as things unfold in the media and coming out in the police interactions, is that a lot of people are in crisis, and a lot of times that’s due to lack of resources and a lack of understanding what medical or behavioral health needs they are facing,” Booco said. “We must get people connected and educate others on what they are dealing with. It’s about providing the time and effort to get people squared away with their needs.”
The CORE team provides an important community service
Bower and Booco make a strong mobile health care duo. They work 10-hour shifts, Monday through Thursday, combing the community for at-risk people who may have health care questions and concerns — people who may otherwise seek answers at the local ER. The team also respond with representatives of other community agencies who need on-scene help, or follow-up on referrals from those agencies and local physicians.
Although the UCHealth community paramedic team has been working closely with community members who need their help in northern Colorado way before the pandemic, their services are more important than ever as the economy lags. Their job is to provide people care where they need it – even if that’s on the streets. Their work helps to keep people healthier, while also cutting health care costs by keeping people out of the emergency rooms.
Providing health care on the streets
Bower first met the Scott family about a month ago at the Northside Aztlan Community Center, a temporary homeless shelter set up at the start of the coronavirus pandemic that has since closed. At the time, Barbara was complaining of a sore back, not an uncommon complaint among those who are homeless and sleeping outside.
“It was one of our stops,” Bower said. The UCHealth CORE team does weekly rounds at homeless shelters, food kitchens, parks and other areas where homeless people stay.
“We go in the morning, walk through and look for anyone on our list of people calling 911 the most, checking in and following up with them, listening to their complaints and educating them as to the best place to go, whether that’s a walk-in clinic or the ER,” Bower said.
Reducing ER visits through education about the right care, right place
Those who call 911 the most are “high utilizers” and defined as someone who calls 911 four or more times in a 90-day period. In January 2020, there were 50 to 80 high-utilizers in the Fort Collins area.
To ensure the team dedicated the appropriate amount of time and resources to meaningfully increase those callers’ ability to manage their own health care needs autonomously and increase access to resources that may also be perpetuating their calls to 911, the team focused on approximately 20 of the highest users each month, Booco said.
Without the CORE team, police officers often have no other choice but to respond to these types of calls and, often, transfer the person to the emergency room. The top eight high-utilizers accrued thousands of dollars in basic evaluation costs alone (the cost of ambulance transport, medical and behavioral health evaluation once at the emergency department) in the past year, according to Booco. Those calls tie up multiple community resources.
“We can have anywhere from 12 people responding to one person’s call, every time they call,” said Lt. Dan Murphy with Fort Collins Police Services. “If we can stop them from calling because we connected them to resources and took the time to follow up, it really provides better service.”
The CORE team’s high utilizers are 72% male, with an average age of 52. Sixty percent have drug- or alcohol-related health care needs; 15% have medical needs, and 6.7% have medical and alcohol/drug or mental health needs.
The work is paying off. Data from the past 90 days shows there has been an 18.9% decrease in call volume by high-utilizers and the total number of high-utilizers has shrunk to 26, so the team can focus on all of them in a month.
CORE: One component of UCHealth Community Paramedics Division
In March and April during the peak in Colorado of the coronavirus pandemic, mental health calls to the FCPS more than quadrupled compared with the same time last year. Police often call upon community paramedics, specifically the CORE program, to help with those calls. It’s another tool in the toolbox, Murphy explained.
“This is the best model for continuity of care and providing better resources,” he said.
Most recently, Fort Collins Police Services reported on its response to a man in a mental health crisis who had climbed on the roof of his apartment building. The man requested the UCHealth CORE team, having been helped by the team before. Along with FCPS negotiators and the Poudre Fire Authority, the professionals were able to gain the man’s cooperation and without incident safely get him the behavioral health services he needed.
The CORE team’s goal when responding to calls with first responders is to help people avoid incarceration or a visit to an emergency room. The CORE team helps free up police and fire to take other calls.
Along with responding to emergent needs, Murphy encourages officers to make referrals to the CORE team when they believe a person could benefit from being connected to community or health care services. “Again, it’s a much-needed tool for police,” he said.
“The cops are thinking about (CORE) as a resource they can connect that person with and help improve things instead of taking a call, handling it and moving on,” Murphy said. “That’s exciting. We are handling the issue at the time and solving the problem, but also having follow-up and fostering continuity of care.”
The resources to prevent hospital readmission
As part of the right care, right place philosophy, the community paramedic division received a NextFifty grant that not only funds Booco’s position for a time, but also provided health care monitoring tools for clients referred through the ER or local physicians.
The focus is on those age 50 and older who have physical and behavioral health needs that are not well managed. They seek to help individuals by increasing social connectedness and access to information/resources and skill building, and reducing their use of 911 for needs best addressed by a primary care provider.
The grant paid for blood pressure and glucose monitors and scales to measure body weight for those referred to the program. Data from daily measurements are sent electronically to the team. Bower reviews those results and follows up with patients if there are concerns in their data. In doing so, they respond proactively and help the patient avoid unnecessary and expensive ER visits.
For example, one client is a 93-year-old recently diagnosed with heart failure. The client also has trouble seeing, so the community paramedics team is her eyes, reaching out when they notice an increase in her weight, a red flag of trouble to come. People with heart failure must limit their salt and water intake because of the increased risk of extra fluid buildup in areas such as the lungs. A several-pound increase can mean the patient is retaining fluids at dangerous levels.
During initial visits to set up monitoring devices, the team also evaluates the patient’s home for fall hazards, reviews their medications and assesses their support system, including nutritional, financial and social wellbeing. The team provides health education based on the patient’s situation — it can mean the difference between a simple medication adjustment over the phone or a trip to the ER and hospital readmission.
Expanding the community paramedics division
The community paramedics division continues to look for innovative ways to further their mission. Currently, Booco is applying for a Larimer County Behavior Health Services grant in hopes of being able to hire more team members so that the program can offer 7-days-a-week service in the Fort Collins community.
She is asking for funding to allow the team and its partners to increase effective care and safety during on-scene calls, and better communicate among agencies working with the same clients to reduce duplication of services and gain efficiency by pooling resources.
The team also is hopeful they’ll soon acquire a Colorado Integrated Healthcare Services (CIHCS) license, which would allow them to provide services such as toxicity screening, blood and pregnancy testing, and full mental health evaluations to determine risk level and need, Booco said.
Since the coronavirus pandemic, Bower has started doing in-home COVID-19 testing and other sample collections because some seniors and people with mental health diagnoses are too scared to leave their home to visit their physician, Bower said.
Once a week, the team visits Weld County where a similar program to the CORE team is in place. Thus, the UCHealth team focuses on in-home services in that county.
Tailoring how services are offered in different communities is essential for success, Booco said. That’s why in Longmont they’re currently hiring two behavioral health specialists and one community paramedic to strengthen the services already offered in that area.
“Healthy communities are safe communities,” Booco said. “And I’m not just talking safety as in when the police are called out. I’m talking about the immediate and long-term impacts as a result of providing direct services to citizens, and then education and follow-up.”