1. HOW TO STOP 9-1-1 ABUSE A County’s Experience Dan Lynch, EMS Director
Central California EMS Agency

2. OBJECTIVES
Understand the importance of identifying frequent users in the EMS system
Acknowledge the impact and cost that frequent users have on the EMS system
Recognize tools and methods to reduce ambulance use by frequent users
Recognize challenges of dealing with frequent users in your system

3. FULL DISCLOSURE I am Not an Expert in Ambulance Abuse
I don’t have all of the answers – I have a lot of opinions.
I know about Fresno County.
Solutions will be different from County to County
There are other programs in the State.

4. FRESNO COUNTY Central California Agricultural Center of the World
Pop 976,000
Pre-hospital Calls
2012 – 165,916

5. THE VALUE OF NOT KNOWING
“Ignorance is Bliss”
“What you don’t know won’t hurt you”
WRONG!!

6. DISCOVERING THE PROBLEM
Hearing chatter from the field
Calls from ambulance crews and hospitals
“Two guys using the ambulance”
“Cesar”
“Lonzel”
2010 – 471 transports
2010 – 329 transports

7. “Fresno, we have a problem!”
DISCOVERY
Frequency
of Use
People %
Once
49478
75.9%
2-3
11438
17.5%
4-5
2351
3.6%
6-10
1392
2.1%
11-20
399
Less than 1%
21-30 97
31-40 30
41-50 11
51-75 18
76-100 6 3
185 1
196
329
471
LOOKING AT THE DATA
(aka: UH OH!)
“Fresno, we have a problem!”
Pre-hospital calls only

8. 5 STAGES of GRIEF DENIAL ANGER BARGAINING DEPRESSION ACCEPTANCE
Who do they think they are!?!
How can this be happening?
There is No Way this data is correct
…or we can put you on a bus to Nevada for FREE
GRRRR!
This is a nightmare

9. DISCOVERY Identified “Target Audience”
Created a list of “Top 50” Abusers

10. DISCOVERY Impact of “Top 50” Abusers 4,367 responses Cost: $3,895,364
(year 2012 data)

11. DISCOVERY
Identify the abuser.
Look at the underlying problem.

12. DISCOVERY
IHSS 80%

13. Goal: HOW DO WE SOLVE THIS? Help them out of the system
NOT shut them out of the system
Denying service is the last resort

14. Odd Jobs

15. Hospitals Social Services
SOLUTIONS
Create a Multi-Disciplinary
Task Force
“The Group”
Create Policy for EMS Personnel
At some point, we will have to deny service
Topic: Frequent User
EMS
Mental Health
Social Services
Homeless Services
Hospitals Social Services
Law Enforcement

16. SOLUTIONS – Set Back Multi-Disciplinary Task Force
No interest from other participants
Excuses....
News Media Intervention
Exposed the crisis and abuse
Public and political outcry
Back on track

17. The Process Identified Frequent User Are they in the “System”?
Yes
Are they in the “System”? No
Determine Responsible Agency
Yes
Can they be referred?
(or refuse) No
Mental Health
Social Services
Homeless Services
Law Enforcement
EMS Agency Abuse Policy
Engage person
Keep “The Group” advised of abusers
Follow-up
Engage person

18. Identified Frequent User
EMS ABUSE POLICY
Identified Frequent User
(not in system or refusing services)
Group Notified
*Letter – 1st Notice
30 days
Group Notified
*Letter – 2nd Notice
30 days
Group Notified
*Letter – 3rd (final) Notice
10 days
EMS Medical Director
Order of Suspension of Ambulance Services
Group Notified
*Hand-delivered or Certified Mail
Letters include reference information on where to obtain care or services.

19. EMS ABUSE POLICY Defines an Abuser
Twelve or more responses within a 90-day period
The count does not include calls for 5150 transports.
Provides a description of the process
1st, 2nd, 3rd Notice and Suspension Order
Provides an appeals process
Appeal panel
Direction for Field Personnel
CCEMSA Policy #570

20. EMS ABUSE POLICY Field Direction Sit-up/stand/walk = No Transport
V. AMBULANCE PROVIDER RESPONSIBILITY
A. Upon contact with an EMS abuser, who is specifically determined to be an abuser by the EMS Medical
Director, the ambulance personnel will make an initial scene assessment upon arriving on scene.
1. If the patient is not ambulatory, cannot sit unassisted, meets 5150 criteria, meets trauma center
criteria, or the paramedic recognizes a medical condition that requires immediate medical treatment, normal policies and procedures for patient assessment, treatment and transport shall be initiated. The EMS Medical Director may modify these criteria on a case-by-case basis.
2. If the patient does not meet the above criteria, the EMS crew will advise the individual of the
following:
“You have been identified as abusing the ambulance system. The EMS Medical Director has
suspended ambulance transport for you. You need to consider alternative transportation. If you
feel this is in error, you can contact the EMS Agency at (559)
We are not transporting you to the hospital.”
Sit-up/stand/walk = No Transport

21. EMS ABUSE PROCESS IMPLEMENTED - March 2012
RESULTS
January 1, 2011 to December 31, 2012
Number of Responses
Weeks
EMS ABUSE PROCESS IMPLEMENTED - March 2012

22. RESULTS 1991 calls / year Savings: $1,771,990 Dept Engaged 8 16%
1st notice 7
14%
2nd notice 4 8%
3rd notice 3 6%
Suspended 1 2%
Dead 5
10%
Active 22
44% 50
100%
1991 calls / year
Savings: $1,771,990

23. RESULTS “Top 50” from 2008 to 2013 2011 – Out of Control
2013 Goal of 1140

24. *** WARNING *** WATCH THE BACK DOOR!
Others will be entering the system – not in the “top 50”
Person # 1 – 113 responses (Dec 19 and Mar 1)
Person # 2 – 101 responses (Jan 4 to Mar 31)
Person # 3 – 50 responses (Jan 2013)
Person # 4 – 170 responses in 2012
Watch List of 22 people – “Nip it in the bud!”
Need to feel immediate resistance.

25. Challenges Law Enforcement
Keeping other agencies / departments involved
Do not overwhelm
Keep number of abusers manageable
Consistency
Keep engaged with abuser
If you give them slack, they will take it.
Everyone is treated the same
Interesting reactions
Small Fire Dept
Physician Group

26. Case Study #1 – “Cesar” 43 y/o male Substance abuser – alcohol
Heavy user of the system:
Defiant – “I can use the ambulance whenever I want”
2008
2009
2010
2011
2012
2013 27
179
471
710
247 33

27. Suspension of Transport- April 6, 2012
Case Study #1 – “Cesar”
Number of Responses
Suspension of Transport- April 6, 2012

28. Case Study #1 – “Cesar”
Number of Responses
YIKES!!

29. Case Study #2 – “Richard”
31 y/o male
Substance abuser – alcohol & drugs
Heavy user of the system:
2008
2009
2010
2011
2012
2013 6 1 24
170 5

30. Case Study #2 – “Richard”
Suspension Order
Second Notice
Third Notice
First Notice
Number of Responses
Homeless Services Engaged
Mental Health Engaged

31. The Short Version Admit you have a problem.
Find out who your abusers are.
Get help from the people that can do something.
Also look at other programs in other counties.
Create a process to engage.
Stay consistent and constant.
Keep EMS field personnel advised. (IMPORTANT!!)

32. CONTACT INFORMATION
Dan Lynch
Phone: (559)
Abuse Policy: EMS Policy #570
Website: ccemsa.org
me for samples of notices or suspension orders