Assisted Living Facilities And Falls

[x635 4,066]

The Village in which I live, also where I grew up, has a premium Senior Living Facility in town. It's upscale, and costs several thousand dollars a month to live there.

Since it's opened, the local VAC has seen it's call level explode. They go there several times a day. This VAC, which was doing around 300 calls a year, is now doing well above 700. Listening to my scanner, 9 out of every 10 calls is to this facility, which offers various levels of assisted living. As a resident of the Village at the time this facility opened, I thought that something needed to be done to prevent taxing EMS resources, like contracting with Empress or WEMS for private emergencies for the less serious incident. It also taxes Greenburgh ALS, with Car 75 responding to every call. The only upside is everybody at this facility has insurance, and the ambulance corps gets to bill...but that doesn't help with volunteer burnout. I've got to give them credit though, they are a dedicated bunch.

The most common call, and the majority of calls, are for falls. How are so many residents who are spending a fortune to live there, and be cared for falling all the time? Many times, speaking to sources, it's due to staff negligence.

Now, a component of a good EMS system is elderly hazard reduction education. Although this really doesn't affect me, it annoys me listening to this unnecessary EMS calls for falls that shouldn't have happened in the first place.

Ah, it's 1AM and my brain is tired after worrying about a sick friend all day. I don't know where I'm going with this from here...someone pick this up for me. [/rant]

[antiquefirelt 994]

Good chance they cannot bill for helping people up from a fall unless they transport, at least not the patient. We have four large elderly care buildings and spend a lot of time doing the same calls. We're looking at billing facilities a nominal fee for the routine help an injured fall. Typically these places have "no list" policy for their staff driven by their workers comp insurer, so they call 911. We've heard of others doing this across the country and now here in our state, so we're investigating this to offset the overuse/abuse of a taxpayer funded emergency service.

[x635 4,066]

Good chance they cannot bill for helping people up from a fall unless they transport, at least not the patient. We have four large elderly care buildings and spend a lot of time doing the same calls. We're looking at billing facilities a nominal fee for the routine help an injured fall. Typically these places have "no list" policy for their staff driven by their workers comp insurer, so they call 911. We've heard of others doing this across the country and now here in our state, so we're investigating this to offset the overuse/abuse of a taxpayer funded emergency service.

A similar thing happens with my town. However, not all of the calls are falls. Some of them are difficulty breathing calls, etc.

A similar thing happens with my town. However, not all of the calls are falls. Some of them are difficulty breathing calls, etc.

That goes without saying that an elderly population is going to have legitimate medical calls.

My issue is that these people are falling in the first place. The facility requires each patient to be transported to the ER for evaluation regardless of suspected injury.

This facility is supposed to be an upper scale facility, with a high staff to resident ratio. Why are all these patients falling in the first place?

[JackEMT 77]

What are the "restraint" restrictions? My co-worker said his mother-in-law is at a facility in Rhode Island and they are not allowed to put up bed rails because it's a form of "restraint" So the facility puts mattresses on the floor for the residents that are fall risks.

Really?!

[mikeinet 37]

I've seen this as well. A lot of facilities won't even assist a patient if they fall - it becomes a medical emergency and gets a 911 call (oh, and they'll probably charge you for calling 911 on your behalf...)

There really should be some sort of protocols that stop these type of EMS abuses. If a patient has no symptoms, no true MOI and "slipped out of a wheelchair"... why do you need a 911 ambulance to pick them back up and put them back in it? Most staff have plenty qualified medical professionals that can make a judgement call if there's an injury and care for them.

But the nursing homes don't want the liability...they'd rather pass it off to EMS to deal with

[wedgeclose 59]

Completely out of control! It is an epedemic of people making money (Atria) and abusing the 911 system along with it. No less than 4 times a day to them in one town and 4 times a day in the next town coupled with another in the next and the flycar is basically assigned to them. Regardless, of whether they can be billed it is ridiculous! Especially in the evenings and weekends when there is less staff. All of these "assisted living" complexes should be required to have at least one and maybe two persons ON DUTY 24/7 for LIFT ASSISTS. Is it really an insurance issue or rather a lazy issue? People can be trained rather easily in how to lift a patient off the floor.

It is time for the VOLUNTEERS to be respected rather than abused! Perhaps doubling the fee to the nursing home should be investigated for lift assist calls. That would stop the abuse in its tracks. Something should be done before there are no 911 ambulances availabe for true emergencies.

[AFS1970 504]

Remember a while back when a facility ordered employees not to do CPR? This is the next illogical step in that process. This is why we have to stop letting the Lawyers and Insurance Agents run the show.

Of course there are many aspects to this problem. Of course there are the nursing homes that simply do not provide this service.

Then there are the EMS agencies that have little if any motivation to cut down on the number of billable patients.

There is the competition within private EMS that has pushed for laws that do not allow for other ambulances to respond in their districts.

There are the manpower (both paid & volunteer) issues that could probably deal with a town's call volume reasonably well if it were not for a few of these facilities, but end up being amplified by this problem.

I am not sure what the solution is, but it is clear from all levels that patient care is not the main concern.

[SECTMB 612]

Next time a request is made to build a care facility in your town/village, those that approve the plan should require provisions for EMS that do not rely on or otherwise burden their existing EMS structure, rather than accepting a one time donation of money toward a new ambulance, which is often the case. That solution wears off faster than a coat of wax on the shiny new bus.

[velcroMedic1987 330]

Completely out of control! It is an epedemic of people making money (Atria) and abusing the 911 system along with it. No less than 4 times a day to them in one town and 4 times a day in the next town coupled with another in the next and the flycar is basically assigned to them. Regardless, of whether they can be billed it is ridiculous! Especially in the evenings and weekends when there is less staff. All of these "assisted living" complexes should be required to have at least one and maybe two persons ON DUTY 24/7 for LIFT ASSISTS. Is it really an insurance issue or rather a lazy issue? People can be trained rather easily in how to lift a patient off the floor.

It is time for the VOLUNTEERS to be respected rather than abused! Perhaps doubling the fee to the nursing home should be investigated for lift assist calls. That would stop the abuse in its tracks. Something should be done before there are no 911 ambulances availabe for true emergencies.

How about the EMS PROFESSION to be respected rather than abused? It shouldn't matter whether you're collecting a paycheck or volunteering. The system is broken and there is nobody on a high level doing much of anything about it.

I HATE when people seek special consideration because they're volunteers. Either be an EMS PROFESSIONAL (paid or not) or rethink your choice of avocation.

[velcroMedic1987 330]

Next time a request is made to build a care facility in your town/village, those that approve the plan should require provisions for EMS that do not rely on or otherwise burden their existing EMS structure, rather than accepting a one time donation of money toward a new ambulance, which is often the case. That solution wears off faster than a coat of wax on the shiny new bus.

But the short term leaders see the shiny new ambulances and don't consider the long term impact of the project.

[SECTMB 612]

You know, voter turnout being what it is, low these days, if a member of the FD/EMS service who really wanted to effect change ran for office and made a coordinated effort with like candidates from other villages/towns, you might actually get a significant number of FD/EMS people into office who could then try to get some changes enacted by bringing these issues we talk about to the public's attention.

If the whole department, their families and friends got behind a candidate it creates a pretty strong voting block. Get Joe, John and Mary from village A, B & C elected, etc. and maybe something happens.

[AFS1970 504]

These facilities are worth a lot of money, both to those that build them, run them and collect taxes from them. There is one about to be built across the street from me. However no attention is payed to the impact on emergency services, or really any public services when something is built.

Stamford has a thriving bar scene, mostly clustered around two streets. I have often wondered what the impact on the sanitation department is from this, do the crowds generate more trash, does it mean a truck has to make an extra pick up, does it mean DPW has to hire an extra crew?

I do not mean to equate the elderly with trash, but it is the same sort of issue financially and politically, that a specific type of building is built with no regard to the community impact.

[SOUSGT 357]

Completely out of control! It is an epedemic of people making money (Atria) and abusing the 911 system along with it. No less than 4 times a day to them in one town and 4 times a day in the next town coupled with another in the next and the flycar is basically assigned to them. Regardless, of whether they can be billed it is ridiculous! Especially in the evenings and weekends when there is less staff. All of these "assisted living" complexes should be required to have at least one and maybe two persons ON DUTY 24/7 for LIFT ASSISTS. Is it really an insurance issue or rather a lazy issue? People can be trained rather easily in how to lift a patient off the floor.

It is time for the VOLUNTEERS to be respected rather than abused! Perhaps doubling the fee to the nursing home should be investigated for lift assist calls. That would stop the abuse in its tracks. Something should be done before there are no 911 ambulances availabe for true emergencies.

You might want to consider having the local government pass a law requiring that private nursing facilities be required to have a nurse accompany the patient to the emergency facility as they are paying for "skilled nursing care" and until the patient is turned over to another "skilled nursing facility" (the ER), they are not getting the same standard of care. I am not putting down EMS but the exact phrasing may may work. Also when the nurse is stranded at the hospital waiting for a cab for an hour or two at 2 am, they may triage better.

[N1Medic 69]

Another thing I love is when the patient falls....and then they notify the doctor several hours later and he wants her transported to the ED. Or it's an excuse at shift change to ship them out so they have less patients to deal with.

[Dinosaur 844]

It is amazing how we criticize everyone about calls at assisted living facilities while we don't cover all our own calls and have our own system problems.

Glass houses!

If it is a tax-paying facility in your community, you have to go there when they call. Even when it is often and for what you consider minor or unwarranted calls.

[mikeinet 37]

I think we're discussing a major tax on our system that's CAUSING us to not be able to cover everything in our owns...??

[AFS1970 504]

How about a public information / education session with the staff. One would think that as a nurse they would have a basic concept of what is and is not an emergency, but as we all know these facilities are relying less on RN's and more on other positions. They are also marvelously bad at dealing with EMD questions. This leads to a far greater amount of high level responses because the answers are generally "UNKNOWN" which upgrades the call. The correct answers will get the downgraded responses.

Some of my favorites are when asked if they are with the patient they say "someone is". That has to be followed up with are you that someone?

Most of the answers are either I don't know or just send someone. It is not uncommon for the staff to have someone not involved and nowhere near the patient make the call. This leads to the response of an Ambulance and often Fire Apparatus for what turns out to be a minor call. This leads to burnout, which leads to lack of response, which leads to calls to reform the system.

However the facilities are usually run by boards made up of lawyers and insurance agents who just want to pass the patient off to EMS as fast as possible with no actual treatment they can be held responsible for. There is a solution out there, but not enough people are interested in finding it.

[emt688 0]

Forgive me from speaking out of turn, but the town, and ASVAC were consulted when the "facility" was being built/established.  ASVAC was 300-ish calls probably thought they could handle it, or since they had just started billing, maybe get rid of that god-awful strawberry colored bus and afford a real one (or two!).

 

In the adjoining town we suffered greatly from a similar facility that also took up a large percentage of calls; though in hindsight most falls were in fact medical in nature; first time I ever used a hare-traction splint in real life...

 

I digress.  Poor planning, poor management (ongoing), and a 'bring it - we'll handle it' approach has led to the current situ with 700+ calls and 75 constantly tied up for non-medical calls.

 

Falls at a place like that are purely mismanagement.  Both of it's own and wastefully of other's resources.  Greenburg or ASVAC or the town has to lay down the operating parameters that make sense for the community, not be dictated by "that facility" policy.  Be proactive - take back your turf!

 

 

[dmc2007 17]

Not to beat a dead horse here, but this is where regionalization would help. The residents in this facility weren't beamed down from Mars, and while some may be from out of area, I'd wager (based on my experience talking to patients in these facilities) that most of them came from nearby communities. And, despite the jokes we've all made about gravity being stronger at these places, many of these residents used 911 services previously, so the net change in call volume to the system (on the regional or county level) on the whole probably isn't that great. If you have a regional system, you can easily shift resources to cover the relocation of these residents and their demand for services. Let us not forget that these are services that they have paid for, both in their lifetime as taxpayers and through the rent they pay to the facility, which in turn pays real estate and payroll taxes. 

 

As for the notion that these calls aren't serious, let us also not forget that falls are one of the leading causes of death and debilitation in the elderly, and can be a secondary symptom of a bigger problem. So while, yes, many of these patients require nothing more than help off the ground, they all need an assessment. Most of the time, these facilities don't have much medical staffing and, if they do, they aren't clinicians capable of making decisions without consulting a physician. Enter EMS. I'm not saying I enjoy going to these facilities at 3 AM after running all day, but the need for the service is there. 

 

As for the issue of the medic having to respond to every call, that seems like a failure of resource utilization that is indicative of a bigger problem. If the resource is limited, than an appropriate emd program should triage calls appropriately (as best you can given the often lackluster communication and clinical skills of the caller from these facilities). 

[Dinosaur 844]

On 2/8/2016 at 11:04 AM, mikeinet said:

I think we're discussing a major tax on our system that's CAUSING us to not be able to cover everything in our owns...??

 

Can you quantify this "major tax" on your system and explain how it is "causing you not to be able to cover everything in your own towns"?  What are the actual numbers?

 

Is this a major burden on the system or an inconvenience because somebody missed a "pin job" while on a fall call?
 

[AFS1970 504]

I think there are a few factors that come into play here, especially when a VAC is involved.

 

First the dawn of these assisted living facilities was specifically to fill a void in between independent living and skilled (yeah I know) nursing care. This means that the residents are generally somewhat mobile and lucid but that the staff is barely medically trained. This means they will be more likely to call for help, which of course generates more call volume. The impact of that increased call volume still depends on other factors.

 

People join VAC's (and VFD's) at least partially for the excitement. There are other volunteer opportunities but the emergency services offer something the others do not. However anyone quickly learns that the reality is that not every call will be exciting, the majority will probably not be all that exciting. So when there is an increase in low priority calls this magnifies the effect and begins to strip away the excitement factor.

 

Talk to anyone involved in EMS for very long and you will learn about system abusers, both real and perceived. It can become very easy to think of an assisted living facility as a system abuser for no other reason other than so many calls at the same address, even if they are mostly for different residents. This leads to the burnout described here and the perception of a major system drain. It can contribute to a lack of volunteers if they do not think of themselves as still providing a vital service.

 

So what is the answer?

 

Obviously a shortage of volunteers leads to at least the discussion of career staff. This can take many forms including a town giving EMS over to a private company.

 

The facilities could increase training of some staff so that better evaluations were done, but that means a profit making business will have to spend more money which is unlikely. It also means that the difference between the facility and an SNF is getting narrower which may not meet the community's need as well as hurt the business model.

 

These facilities could me made to contract out to a private ambulance service, but that brings with it other issues. First the staff would have to know the difference between a routine call for the contractor or a true emergency which is better served by the local EMS. Any private company coming into a town, may offer to take the whole town not just the ALF's. Often there is a sense of pride / turf that makes a provider not want to see any other companies (commercial or otherwise) operate in their area, whcih may make this not an acceptable option.

 

So there is no one simple easy solution.

[sympathomedic 383]

    I have to say I am saddened by the content of this thread.  Both my parents died in 2014, and both spent time in an Atria in Westchester- they did not die there, but both were moved by EMS during their stays.

It might seems obvious, but the thread makes me want to point out:  These facilities DO NOT MANUFACTURE OLD PEOPLE. These pt's are going to get old and frail no matter where they live. I would rather have a safe, carpeted monitored building with AN ELEVATOR, rather than dozens of folks in dozens of private homes, UNmonitored, UNreliebly medicated, falling and being on the floor for hours before being noticed.

    I ma pretty sure there is no age range excluded by your EMT class. There is no guarantee of exciting calls. I BET if we issued guns to the facility staff and told them to shoot anyone that falls, so every call came in as a gunshot, there would be no problem covering, and no complaining about it (well, other than pt's and families).

   As per an article in the NY Times a few years back, nationwide EMS call volume is up 247% in last 30 years.  More since then I bet.

  I have NEVER seen an EKG tech complain that a patient that needed an EKG was not sick enough for them. Never seen a RESPIRATORY therapist  complain that the lungs were not wheezy enough for them to give a treatment. Never had a PHLEBOTOMIST say that they were wasting time on drawing blood on a particular pt. It is ONLY the EMERGENCY MEDICAL TECH who feels that they are only there to serve pt's they feel are worthy.

    I am sorry, but things don't stay the same. The job is changing. The pt population is changing. Safer cars with airbags = fewer sexy trauma calls. Meds = a HUGE decrease in V-fib arrests.   Those same meds = a larger elderly population that just want to grow old in safety and comfort. Be nice, be professional: your job is to provide that.

  Or as one of my favorite movie lines, from Ghostbusters goes, " I am sure a person with your skills and qualifications would have not trouble finding  work in either the food service or housekeeping in industries."

sorry for the ad-

 

[sympathomedic 383]

Oh- and one more thing:  Please don't make it anyone's fault but our own that these calls tie up the medic. YOU can solve that one with priority dispatch and common sense. Stop sending ALS on calls for falls  with no LOC.  (Seth covered that in an earlier thread) If that is asking too much, then send medics NO lights, NO siren, in an in-service status until cancelled or the call is triaged to BLS.

[mikeinet 37]

On 5/1/2016 at 11:20 AM, Dinosaur said:

 

Can you quantify this "major tax" on your system and explain how it is "causing you not to be able to cover everything in your own towns"?  What are the actual numbers?

 

Is this a major burden on the system or an inconvenience because somebody missed a "pin job" while on a fall call?
 

 

As has been discussed in numerous areas of this thread - we're all getting called for things that are not "emergencies". 

 

If you live in an assisted living facility and you need to call 911 because you fell and can't get up...? Even down to needing to have a cath replaced... why is that an ambulance call? Why don't these facilities have proper staffing to deal with the needs of their patients. 

 

It has nothing to do with "wanting to go on the GOOD calls" (like a pin job) - it has to do with allowing our emergency services personnel  to serve those that are in an emergency situation. 

 

To the above scenario of the assisted living facilities... i've personally been on those calls where i've been patient side and hear tones drop for a cardiac arrest and it being the Xth call in town where we're out of resources... and we end up having to pull in mutual aid... which takes more time than if we were able to respond. 

[mikeinet 37]

6 hours ago, sympathomedic said:

   As per an article in the NY Times a few years back, nationwide EMS call volume is up 247% in last 30 years.  More since then I bet.

  I have NEVER seen an EKG tech complain that a patient that needed an EKG was not sick enough for them. Never seen a RESPIRATORY therapist  complain that the lungs were not wheezy enough for them to give a treatment. Never had a PHLEBOTOMIST say that they were wasting time on drawing blood on a particular pt. It is ONLY the EMERGENCY MEDICAL TECH who feels that they are only there to serve pt's they feel are worthy.

  

 

I think I agree to disagree with this... 

 

Do you see a respiratory therapist treating a patient at 2 in the morning because their mother on the other side of the country thought they "didnt sound right" on the phone so called 911? Did you see an EKG tech being called to run an EKG because the local one that was sitting next the patient couldn't do it because of "insurance reasons" so they had to call someone else who was just as qualified as themselves? 

 

[sympathomedic 383]

I don't think 911 dispatches respiratory therapists.

I have run 12 leads for free for friends, because going to their PMD = $50 copay. I didn't complain about it. Does that qualify for the example in the last sentence of your post?  I was acting as an EKG tech because the PMD office next door to the station would charge $50 insurance co-pay for the identical procedure.

If you want me to complain about having to take care of people, you will have to try harder. It is what I signed up for. It is what I do. Volly and paid for 30 years. 64 hours on a quiet week.

Maybe I am on the wrong site?

[AFS1970 504]

No these facilities do not manufacture the elderly. However they do by their very nature gather them together in one place. This has the effect of concentrating the call volume. It was said in  a previous post that most of the residents were from the immediate area, but if they were living at home they would have been spread over multiple EMS districts.

 

As for wasted resources being fixed by priority dispatching, that only works if the facilities fully participate. I am a dispatcher, I work with EMD every day, and sometimes it feels like facility staff work very hard to disrupt the EMD system.

 

There is a code for inter facility transfer, but it is only used when there is no obvious chief complaint. After going through all the questions, there is a question on what response is being requested, because they called 9-1-1 the system codes this as an emergency response requested. If there is a chief complaint, say something relatively minor, like a fall this can be downgraded if we get the correct (or sometimes any) information. However when they decided to have security in the lobby call for EMS when the staff is in a 3rd floor room, so most answers go in as unknown (especially with level of consciousness)  it triggers a high response with ALS & FD, simply because the information was not provided. Most facilities can not give you a patient age, when you ask you are given a DOB or a year of birth. This slows down the often adversarial call taking. The basic question "are you with the patient" is often met with the cryptic "someone is" which means we have to ferret out information like, "are you that someone"? No? OK now we can go on with more questions.

 

Most of the time we are sending extra units to these facilities only to have them canceled on arrival by the first unit who gets there and realizes what is really going on. This directly leads to the characterization that these facilities are unreasonable system draws, which leads to all the other factors.

Edited May 3, 2016 by AFS1970

[mikeinet 37]

7 hours ago, sympathomedic said:

I don't think 911 dispatches respiratory therapists.

I have run 12 leads for free for friends, because going to their PMD = $50 copay. I didn't complain about it. Does that qualify for the example in the last sentence of your post?  I was acting as an EKG tech because the PMD office next door to the station would charge $50 insurance co-pay for the identical procedure.

If you want me to complain about having to take care of people, you will have to try harder. It is what I signed up for. It is what I do. Volly and paid for 30 years. 64 hours on a quiet week.

Maybe I am on the wrong site?

you've totally missed the intent of my statement.

[antiquefirelt 994]

I think and hope a lot of people are missing the issue. We shouldn't be complaining about doing EMS calls for anyone anywhere. Now comes the BUT. But, facilities that market and charge for care in addition to housing should not use EMS to reduce their WC costs by having "No Lift" policies for their employees. This means every time someone is on the floor, EMS is sent to pick them up. This is a relatively new policy stance that seems to be effecting all areas of the country. In my 'burg these calls result in needless transports more than 75% of the time as the patient has ceded all rights to the facility to make decisions and they will not sign a refusal of care or transport form after hours when the actual medical staff has gone home. This results int eh pt. and family being billed for a transport and ER visit when it was a simple fall or even in some cases, the pt. just sat down or laid on the floor and cannot answer "why". 

 

So I can see a growing frustration in EMS for tying up units to respond to calls that rarely have actual injuries, but result in increased health costs for the patients while tying up resources. The answer is a higher level than the providers. Good bosses need to work on this problem so providers can continue to treat every patient with care and compassion regardless. We are starting to see many places up our way bill these facilities. We're looking into how they accomplish this ourselves.

[wedgeclose 59]

On 2/3/2016 at 4:14 PM, wedgeclose said:

Completely out of control! It is an epedemic of people making money (Atria) and abusing the 911 system along with it. No less than 4 times a day to them in one town and 4 times a day in the next town coupled with another in the next and the flycar is basically assigned to them. Regardless, of whether they can be billed it is ridiculous! Especially in the evenings and weekends when there is less staff. All of these "assisted living" complexes should be required to have at least one and maybe two persons ON DUTY 24/7 for LIFT ASSISTS. Is it really an insurance issue or rather a lazy issue? People can be trained rather easily in how to lift a patient off the floor.

It is time for the VOLUNTEERS to be respected rather than abused! Perhaps doubling the fee to the nursing home should be investigated for lift assist calls. That would stop the abuse in its tracks. Something should be done before there are no 911 ambulances availabe for true emergencies.