Developed by Seabourne Consulting, experts in Bright Spot: Pueblo County DOTS Program: Directing Others to Services

Bright Spot: Pueblo County DOTS Program: Directing Others to Services

Photo by Jonnica Hill on Unsplash


This bright spot was originally published in the 100 Million Healthier Lives Change Library and is brought to you through partnership with 100 Million Healthier Lives and the Institute for Healthcare Improvement.

Overview

Detailed Description

DOTS began as a response from the Pueblo Fire Department to the ever-rising burden of increased calls to emergency services. These calls impact the availability of first responders for true emergency purposes and put an immense strain on resources that are already stretched thin across the community while attributing to the rising cost of care.

Identify potential participants: A person with more than ten EMS calls in a twelve-month timeframe is eligible for referral into the program. Referrals are accepted from the Fire Department, American Medical Response and the two local hospitals through the Emergency Department. A referral form was adopted to ensure proper information is being shared with the Fire Department from the various agencies who are referring.

Assess individual needs and strengths: Through a collaborative approach, each participant works with a navigator and outreach personnel to complete an assessment of the living area and medical history. Barriers are identified on an individual basis and through numerous community partners, resources are secured to address the barriers. Oftentimes, it's something as simple as removing rugs that create fall hazards around the house or installing a bar in the bathtub to ensure safety when bathing. Outreach personnel are able to interact with participants in their home environment, which aids in identifying and addressing issues that arise. It also helps participants to feel more comfortable and that leads to a more open and honest conversation.

Provide wrap-around care: A wrap-around model of care is instituted through the use of the outreach personnel that volunteer their time off to participate in the DOTS program. One-on-one conversations are pivotal in ensuring patient goals are clearly identified and barriers to achieving those goals are addressed.

The entire process is geared toward identifying the interventions that make the participant's life a little easier and ultimately reduce the burden placed on first responders. Many times, the interventions are something very simple...removing fall hazards, installing assistive devices or connecting with primary or behavioral health services. Some interventions aren't as easy to implement such as reconnecting a participant with family who can provide caregiver support. This often takes a longer time and requires more intense intervention.

Length of Stay in Program: Program participants are able to remain in the program as long as they are making progress and barriers still need to be addressed. Participation is completely voluntary and can be ceased at any time. Once adequate solutions have been found to the most pertinent barriers, a participant can be graduated out of the program and referred back to their primary care physician. Goal is to reduce the number of EMS calls and creating an overall safer environment for each participant to live and thrive.


Expected Outcomes

  • Decrease in usage of emergency personnel for non-emergency situations.
  • Create a safer environment for residents to live safely at home longer.
  • Decrease in hospital re-admissions and preventable emergency department use. 
  • Better relationships with local first responders in an action oriented environment centered on the participants needs.
  • Participants feel supported in their ability to live in a comfortable environment while addressing any outstanding barriers they may face.

Failing Forward Moments

Not everyone who is a candidate for the program is interested in being a participant. Wrap-around care is incredibly time intensive, but results in a huge return on the investment. Being open to out of the box interventions is sometimes the only thing that will work. Participants are, for the most part, happy to have someone who cares enough to ask what will make their life easier and even happier when action takes place to implement the change

Key Lessons Learned

Look to failing forward


Cost Details

Pilot phase can be implemented at a relatively minimal cost with resources already present. Lots of volunteer time was used from fire fighters during their off time. PTAC purchased a data tracking system for the fire department to track individual/family participant data at a cost of about $5,000 per year. Any scaling of the program would require additional resource.

Key Steps for Implementation

  • Willingness of local first responders to spearhead program
  • Mechanism for tracking participants and data comparisons community agencies participation to address barriers and will and capacity to collaborate cross-sector
  • Neutral convener to facilitate collaboration toward shared goal

Partnerships

Primary Care, FQHC, Hospitals, Durable Medical Goods Provider, EMS, assisted living, home health, VA, Accountable Care Collaborative, RCCO, Behavioral Health, DSS, Catholic Charities, Pueblo Triple Aim Corporation.

Required Staffing (FTEs)

1 split between a director and navigator. Separate volunteer outreach team consisting of 5-7 firefighters who volunteer for program on their off time.

Special Funding

No special funding for the pilot phase, with capacity to serve 12 people, but would need for expansion of program.

Special Infrastructure

Dedicated case management and outreach team.

None but having a way to track Individual/family participants is very helpful.

Training

Knowledge of community resources in addition to firefighter's training in emergency response, EMS.

Types of Staff

Internally, the Pueblo Fire Department dedicated staff time to the pilot phase of the program including a Director to oversee the program and keep data up to date on participants, a navigator to connect participants with community resources and a team of five outreach coordinators to work directly with participants on completing living assessments and medical history evaluation.

Return on Investment Details

We have seen a 55% drop in 911 calls in the first year of implementation among pilot population of 12 participants resulting in a great savings to first responders.


Outcome Measures

  • Avoidable hospital stays among Medicare population
  • Decrease in 911 calls among program participants

Process Measures

  • Number of active participants per month
  • Aggregate number of 911 calls among participants per month
  • Aggregate number of 911 calls in year prior to participant joining program