Maryland Nurse Journal - July 2022

July, August, September 2022 The Maryland Nurse Journal • Page 15
clinical
Reducing Inappropriate Emergency Department Utilization
Through the Salisbury Wicomico Integrated FirstCare Team
(SWIFT)
By: Aaron Sebach, PhD, DNP, MBA, AGACNP-BC, FNP-BC, NP-C, CP-C,
CEN, CPEN, CLNC, CGNC, CNE, CNEcl, SFHM, Dean, College of Health
Professions and Natural Sciences Wilmington University and Mobile
Integrated Health Nurse Practitioner TidalHealth Peninsula Regional
Emergency Department (ED) overcrowding and inappropriate utilization
remain a healthcare concern across the United States (U.S.). Despite increased
awareness of ED overcrowding and inappropriate utilization, the U.S. Department
of Health and Human Services (2021) reported that ED utilization has remained
unchanged over the last ten years. In addition, low acuity ED visits account for
an estimated 12.5% of national healthcare expenditures, many of which could be
more appropriately addressed by a primary care provider (PCP) or urgent care
facility (US DHHS, 2021). Accordingly, healthcare systems have been charged
with implementing innovative initiatives to promote the health and wellness of
individuals and communities while reducing inappropriate ED utilization.
To address inappropriate ED utilization in Wicomico County, Maryland,
the Salisbury Wicomico FirstCare Team (SWIFT) was established in 2017
through a partnership with TidalHealth Peninsula Regional, the Salisbury Fire
Department, and the Wicomico County Health Department. Initially funded by
a $75,000 grant from CareFirst, the program enabled Salisbury Fire Department
paramedics and TidalHealth nurse practitioners (NPs) to engage with high
utilizers of emergency medical services (EMS) in Wicomico County. Additional
program funding was received from Maryland Community Health Resources
Commission (CHRC) in 2018 for $150,000.
High utilizers of EMS are defined as individuals who call 9-1-1 five or more
times in six months. The team engages with these patients in their homes to
address social determinants of health, defined as economic and social conditions
that influence one’s health. Examples of social determinants of health addressed
by SWIFT include housing and food insecurity, transportation, and health
services such as medication compliance and primary care (US DHHS, 2020). As
a result of the assessments, the team connects patients with community health
workers, social workers, primary care providers, durable medical equipment
specialists, specialty providers, and other community resources, as needed, to
address any identified gaps in care. Follow-up telephone calls and home visits
occur based on individual patient needs.
SWIFT paramedics receive specialized training in community paramedicine.
Community paramedicine is a relatively new discipline wherein paramedics
operate in expanded roles to improve care coordination and access to care by
engaging underserved populations. With the SWIFT program, paramedics and
NPs collaborate to provide chronic disease management and address social
determinants of health to enhance the patient experience, improve the health of
populations, and reduce the per capita cost of healthcare. During the 2020 to 2021
fiscal year, the team achieved a 22% reduction in ED visits and a 42% reduction
in 30-day hospital readmission rates among its 180 patients.
To further expand the SWIFT’s reach in Wicomico County and reduce
inappropriate EMS transports for low acuity complaints, the team received
a $270,000 grant from Maryland’s CHRC. Examples of low acuity ED visits
include prescription refill requests, upper respiratory infections, rashes, sprains,
strains, injuries, and toothaches. A subset of patients with these complaints
activate EMS, requiring dispatch of an ambulance staffed with EMS personnel.
9-1-1 calls for low acuity complaints occupy critical community resources with
the potential to delay EMS responses for high acuity medical emergencies.
SWIFT utilized the CHRC grant to implement a Minor Definitive Care
Now (MDCN) program in August 2021, following approval from the Maryland
Institute for Emergency Medical Services Systems (MIEMSS). MDCN was
first introduced in Maryland by the Baltimore City Fire Department in 2021 to
provide immediate on-scene treatment for low-acuity patients by a paramedic and
NP (MIEMSS, 2021).
An NP and paramedic respond to low acuity 9-1-1 calls as determined by
the Medical Priority Dispatch System, an evidence-based series of screening
questions to predict patient acuity and determine the level of EMS response
required. The team responds in a dedicated Salisbury Fire Department Suburban
in tandem with a Salisbury Fire Department ambulance. Upon arrival at a
patient’s residence, the NP and paramedic describe the MDCN program and offer
MDCN treatment on the scene. Treatment can include medication administration,
wound care, and splinting, among others, depending upon the patient’s
presenting complaint. If a patient consents to MDCN treatment, the Salisbury
Fire Department ambulance is released and available for additional 9-1-1 calls.
The MDCN team also performs home safety and social determinants of health
assessments. Based on these assessments, patients are referred to appropriate
community resources. Patients are also referred to their primary care provider
and specialists as needed for follow-up care. Since August 2021, the MDCN
program has engaged with 273 patients who activated EMS. Of these patients, 86
consented to MDCN treatment on-scene resulting in a $182,000 reduction in ED
visit expenditures and a $217 per hour savings of program operation.
In conclusion, the SWIFT program represents a unique and effective
partnership between TidalHealth Peninsula Regional and the Salisbury Fire
Department. The team has successfully increased access to care, reduced
healthcare spending, and improved the overall quality of care for Wicomico
County residents who engage with EMS. Health systems and NPs across the state
are poised to implement similar programs.
References
Maryland Institute for Emergency Medical Services Systems (MIEMSS). (2021). The Maryland
medical protocols for emergency medical services. Retrieved from https://www.miemss.org/
home/Portals/0/Docs/Guidelines_Protocols/MD-Medical-Protocols-2021-Print-20210601.
pdf?ver=2021-06-16-111500-000
U.S. Department of Health and Human Services (US DHHS). (2020). Healthy people 2030: Social
determinants of health. Retrieved from https://health.gov/healthypeople/objectives-and-data/
social-determinants-health
U.S. Department of Health and Human Services (US DHHS). (2021). Trends in the utilization of
emergency department services, 2009 to 2018. Retrieved from https://aspe.hhs.gov/sites/default/
files/private/pdf/265086/ED-report-to-Congress.pdf