A 45-year-old woman with anxiety called 911 28 times with the exact same narrative.
A 60-year-old man with rib pain but without a known medical diagnosis made a “big block of calls” for the same issue repeatedly, as did a woman with repeated falls stemming from shortness of breath.
— summaries of cases presented at the June 23 meeting of Pittsburgh Bureau of Fire High Utilizers Program team
Over two dozen cases like these are reviewed weekly by Pittsburgh Fire Bureau Lt. Chad Hirosky and a small group of fellow firefighters, sometimes allied with city medics and social workers. Together, they form a team of City of Pittsburgh employees making weekly trips around the city, meeting patients one-on-one and forming relationships with them that last anywhere from several days to many months.
Their target patients: “high utilizers.”
The term describes people who have unmet medical and daily living needs posing barriers to their wellness who rely on 911 for care.
The team links high utilizers to available services and supports them until they’re ready to accept the help.
Pittsburgh Fire Bureau Lt. Chad Hirosky is reflected in a piece of broken mirror at one of the locations he frequently checks on while working with the High Utilizer Program team on Thursday, July 27, 2023, in Pittsburgh. The team works to bring supplies and harm reduction tools like the opioid overdose drug Narcan to the site, which is visited by people who use substances. (Photo by Stephanie Strasburg/PublicSource)
As most high utilizers live on their own, their predicament goes largely unseen. “Often, these cases get resolved through mortality, unfortunately, over time and nobody notices. But it’s very reflected within the 911 call list,” said Hirosky, who has been the High Utilizer Program’s developer since the unit was envisioned around 2016 and began operating in 2020.
PublicSource obtained data from Allegheny County on 911 calls often associated with high utilizers from 2015 to April of this year.
Calls to 911 associated with high utilizers make up around 10% of overall emergency calls, but Hirosky and his collaborators view them as opportunities to identify and address people’s problems.
While quality and longevity of life are most important, the cost of excessive 911 calls is also significant.
An ambulance ride costs a minimum of $325 for basic life support and $400 for advanced life support (ALS) services, but fees vary by distance traveled and the level of care provided en route. While they can be costly, 911’s accessibility and quick response time makes it an easy answer to people’s cries for help.
“911 is the lowest barrier of access to help, period,” said former EMS Community Paramedic Crew Chief John Mooney in an interview, prior to leaving the city’s employ. “It's not a great tool for a lot of problems – but it's an easy one to reach for.”
From firefighter to nurse to data miner
An elderly woman with heart issues whose family repeatedly called 911 for her needs may be more suited for palliative care.
— case summary from June 23 team meeting
Hirosky, now in his 26th year as a fireman, went to nursing school 10 years ago. There he saw disparities between the inpatient care people received in hospitals and the lack of care available in their homes once they were discharged.
“If someone's calling 60 times, there's definitely a gap of care" between their needs and what they're receiving from the community, their doctor or other providers, he said. The COVID-19 pandemic and a general societal shift in thinking about the appropriate uses of the 911 system seemed to coincide, said Hirosky.
Hirosky said the most common patients the unit sees are single women in their mid-60s, split almost evenly between Black and white residents.
Visiting around 60 people a month in 2020, Hirosky said the team now regularly sees that many in just two weeks. The team receives around 20 direct referrals each week from first responders, who interact with and can identify high utilizers firsthand.
They also look for specific determinants in 911 call data to identify high utilizers, such as dispatch codes that most frequently correspond to low-stakes calls. Through 911 calls, said Hirosky, “You can see where the dysfunction begins in someone’s life.”
The most common code is 17A4G, which is used to designate non-emergency falls but has become a catch-all for calls from patients with no injuries or apparent symptoms who still require assistance.
“It's just volumes and volumes of calls with this code,” Hirosky said. “There’s so many of them, it's poor resource utilization to send an ALS unit, which is basically just a mobile ER running around the city to somebody that just needs to be picked up off the floor.”
Identifying high utilizers using data is not easy, however. Calls received by EMS and the Fire Bureau are sometimes recorded differently. There are thousands of subtly different dispatch codes to sort through.
In addition to 17A4G, Hirosky said the most common codes associated with high utilizers are 6D2, for "difficulty speaking between breaths", and 26C1, for sickness and an "altered level of consciousness."
The call volume for 17A4G code was down by 18% in January through May of this year, versus the same months in 2022, with the exception of February, which saw a 58% decrease.
Reviewing patient cases and planning next steps
Two individuals seemingly with no services in their home were repeatedly found, by another individual, fallen in different parts of their house.
— case summary from June 23 team meeting
Before making any referrals, members of the team call or visit each patient to build a relationship and make them aware of their care plans before moving forward. Hirosky and his five-person team meet at the Fire Bureau warehouse each week to review their upcoming cases.
Over several hours on a Friday in late June, they discussed what resources would best address each patient’s needs and divided up the caseload.
Several addresses were already familiar to members of the team, and some patient circumstances were seen so many times that it took fewer than 10 minutes to deliberate each case.
Those with anxiety were to be connected with social workers from the city’s Office of Community Health and Safety [OCHS] and the Metro Community Health Center in Swissvale, while some needed further assessment for their medical issues before the team made plans.
“It is never just one thing with people that has led them to the place where they are when they need help,” said Dr. Sheila Roth, OCHS’ continuum of support program manager. “It's always complex.”
For certain patients who are chronically ill or have psychological anomalies, cases can last several months. Most cases, however, are wrapped up in less than a week. Hirosky said connecting people with services available in the city is a quick process, and the team is trying to reduce the time it takes to connect patients to social workers and services to within 24 hours.
Aid provided to patients extends beyond connecting them to services. The team also gives patients lockboxes so that emergency responders can gain easier access to their residences, and night lights to reduce fall risk.
Patients aren’t always receptive at first
A repeat patient referred up from EMS that hasn’t yet had a resolution and another with shortness of breath and chest pains are to be “fact-finding missions” for the team.
— case summary from June 23 team meeting
Even with the help they provide, Hirosky said it’s sometimes difficult to build trust.
“There's a lot of relationship building, and a lot of people just aren't ready to make that healthy lifestyle change. It often takes multiple calls to the address to get them to say, ‘Things would be better if I could make a big change,’” he said.
Patients have often worried that the team is at their residence for punitive reasons. “We have to assure them that we're not police and that criminality is not really our focus,” said Hirosky. “Our primary focus is the well-being of the person.”
When these fears have been resolved, the team asks patients questions to gauge their level of need and build trust. Hopelessness from the lack of help surrounding patients often means a helping hand is what they’ve been waiting for.
“When they really find out that we're genuine with our efforts, then they’re willing to accept anything we have to offer. They're pretty desperate when we get to them,” he said.
Lack of funding has made handling the increasing workload especially difficult. A majority of the 25 to 30 hours per week the team dedicates to this program are volunteered, and the team’s primary vehicle is a city motor pool car.
Hirosky said the gap between hospital care and in-home help for patients that he saw almost a decade ago is now gradually being filled with his team’s efforts to get at root causes of problems, sometimes known as social determinants of health.
For 81% of patients with whom the Fire Bureau team has worked, 911 call volumes have dropped by 90%, he said. So far this year, Hirosky said there has been a reduction in call volume for 17A4G of around 18.5% compared to 2022.
Hirosky said he hopes more attention would be given to the “marginalized and overshadowed” demographic of 911 high utilizers. “It's a forgotten group of people that just doesn't have a voice.”
“We just want them to be well.”
Elizabeth Szeto is a data storytelling intern at PublicSource and can be reached at firstname.lastname@example.org.
This story was fact-checked by Betul Tuncer.
The Jewish Healthcare Foundation has contributed funding to PublicSource’s healthcare reporting.
These organizations provide services that address health and daily living needs, and are often tapped by the High Utilizer Program:
- LIFE Pittsburgh
- Community LIFE
- Area Agency on Aging (AAA)
- Metro Community Health Center
- Greater Pittsburgh Community Food Bank
- Light of Life Rescue Mission
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