Mobile Integrated Health Care: A Look at Anaheim Fire & Rescue Community Care Response Unit (CCRU)

Anaheim Fire & Rescue's Community Care Response Unit (CCRU) began as a public-private partnership in 2105 with key EMS leaders in Anaheim to better serve its residents. The first in California, this program consists of a CCRU ambulance that responds to low level, non-urgent medical requests with an ambulance staffed by a certified nurse practitioner and an Anaheim fire captain/paramedic in place of a standard paramedic engine/truck and ambulance response staffed by three or four fire personnel.

Anaheim Fire & Rescue identified EMS as a critical focus area in the agency's strategic plan. Over the decades, fire service delivery has changed where the overwhelming majority of 9-1-1 calls are no longer fire and rescue-related but instead calls for medical services.

Over the past several years, 9-1-1 calls for service increased by 34.09%, 85% were for EMS, and approximately 38% of those calls were for low acuity or non-emergent calls. The majority of the increase in calls can be attributed to the aging population, the implementation of the Affordable Health Care Act, a growing homeless population, as well as the use of 9-1-1 as the main entry point into the health care system for many individuals.

This increasing call volume combined with the continued implementation of the federally-enacted Affordable Health Care Act, led the agency to focus on a Mobile Integrated Healthcare model and the implementation of an innovative pilot program intended to provide the best emergency medical service at an appropriate response level.

The CCRU is an innovative response model designed by Anaheim Fire & Rescue in collaboration from Kaiser Permanente Orange County, Care Ambulance Service, and Metro Cities Fire Authority (Metro Net Fire Dispatch), coordinating with Dr. Gary Smith, a California licensed physician. Dr. Smith also provided physician oversight for the Mesa Arizona Fire & Medical Department, which implemented a similar program resulting in cost savings and enhanced patient care.

As Metro Net Fire Dispatch receives a call, they will help to identify non-emergency patients who may benefit from definitive care within the scope of a nurse practitioner following a pre-approved medical protocol. They then dispatch the CCRU unit, with or without an Advanced Life Support (ALS) unit.

When the CCRU arrives on the scene, the nurse practitioner is able to evaluate the patient and determine if this is a low acuity call that can be better treated at home or referred to their primary care physician. The captain/paramedic addresses any ALS level treatment or other decisions to appropriately treat the patient.

This medical response allows Anaheim Fire & Rescue to provide alternative solutions to the ways it currently manages patients.

The CCRU program aims to reduce total costs to the patient and the health care system by delivering appropriate healthcare services on the scene and provide a positive patient experience, thus preventing unnecessary transports to and possibly a lengthy wait at an emergency department. The impact on local emergency departments is reduced as patients will not need to be transported for low acuity medical issues. By sending the appropriate response to the pre-identified emergency call or releasing ALS units from a call sooner, Anaheim Fire & Rescue is able to keep more apparatus available for more acute medical or fire-related emergencies, increasing our response effectiveness and providing more efficient use of our resources.

The CCRU responds to non-urgent, low acuity medical calls. Acuity is defined as the level of severity of illness.

Patients with low acuity medical problems include complaints such as abdominal pain, back pain, headaches, lacerations, falls, or possible upper respiratory infections, which are common medical issues called into the 9-1-1 system. A nurse practitioner can treat these low acuity calls with medical intervention ranging from treatment onsite or contact with a primary or specialist physician who will follow up with the patient as soon as possible.

These interventions provide increased patient satisfaction of care and allow patients to stay in their own setting and not automatically be transported to the hospital.

The CCRU Partners
As I stated with the launch of the program in 2015, "The introduction of Anaheim's Community Care Response Unit is a game-changer in the delivery of fire and emergency medical services in California. With this pilot program, Anaheim residents receive high-quality medical care for the low acuity calls reducing the need of transportation and wait time - related to a hospital's emergency room visit." The pilot project partners are  Kaiser Permanente, Care Ambulance, Metro Net Fire Dispatch, and Dr. Gary Smith, Supervising Physician.

"For more than 70 years, Kaiser Permanente has been dedicated to improving the health of our members and the communities we serve. We are proud to partner with Anaheim Fire & Rescue on the launch of the Community Care Response Unit," said Dr. Nancy Gin, Medical Director, Kaiser Permanente Orange County. "We believe this innovative and hands-on approach will enhance emergency medical services for the residents of Anaheim." 

"Care Ambulance is proud to be a vital partner in Anaheim's Community Care Response Unit. This innovative program is consistent with our values: excellent patient care keeping customer service at the forefront," said Troy Hagen, Care Ambulance Service Chief Executive Officer.

"Metro Net Fire Dispatch uses one of the most advanced medical protocol dispatch systems available today," said Gary Gionet, Metro Net Fire Authority manager. "Anaheim Fire & Rescue's program allows us to fully utilize our protocol software which can automatically identify to our dispatchers a situation where an alternate response such as the Community Care Response Unit is appropriate." 

"With the introduction of our program in Arizona, we have been able to more effectively treat and refer to medical and behavioral patients with a realized cost savings of more than $3 million. I anticipate that Anaheim's Community Care Response Unit will be equally successful in California," said Gary A. Smith, MD, MMM, FAAFP - Supporting Physician, Anaheim Fire & Rescue, Mesa Arizona Fire & Medical Department., CA.

Has the CCRU Has Been Successful?
In most agencies today, evaluating their medical responses would indicate that 30-40% would be classified as low acuity calls and do not need the typical response of four firefighters and two paramedics. Mobile Integrated Healthcare strategies such as the CCRU that can treat and release in the field or evaluate and determine the patient falls into the BLS category are a much more efficient and effective way to provide service and save the health care system significant money, and improves the patient experience.

Impact on the Homeless Situation
With the rapid increase in Anaheim's homeless population, the CCRU has been a point of contact for the fire department. The CCRU was staged at the Santa Ana Riverbed to help treat and evaluate the needs of the homeless in coordination with other city departments, including the police department. They were involved in the Homeless Coalition that assisted during the relocation of several homeless encampments. In situations such as this, the CCRU was able to evaluate all the residents and treating multiple patients with MRSA. This unit would also visit such encampments to provide care on an ongoing basis.

Impact on the Anaheim Jail
The CCRU has also impacted other department s in the city, such as the police department. Since its inception, calls of this unit to the Anaheim jail have successfully diverted over 50% of those patients from being transported to the ED. This has saved the police department countless officer hours in transporting and standing by with inmates at the emergency department keeping the officer on their normal duty assignment and has saved time and money for the health care system.

Increasing Unit Availability
During a normal working day, each time an ALS engine or truck is dispatched to medical aid, they are committed to that call until the patient is evaluated and released or transported ALS or BLS to the emergency department. These calls can range from 20 minutes to two hours, at which time the unit is unavailable for other calls. If the unit is on one of these calls and another call is dispatched into that first-in, a unit from another area is sent to the call resulting in a longer response time. As more units get dispatched on calls, the response times get increasingly longer, and the coverage of the city decreases.

The CCRU has helped decrease the ALS units' response times during the hours the CCRU unit is in service, which prior to the pandemic was 40 hours per week.

What Do the Stats Tell Us?

Number of patient contacts – 1,500+

ALS units released after CCRU response – 92%

Average on-scene time for the CCRU – 26 minutes

Frequent chief complaints – Falls, Weakness, and Anxiety

Percent of patients not transported to the ED – 51%

  • 8.91% were repeat EMS callers
  • 12.9% of patients had a prescription written by the nurse practitioner
  • 20.7% of patients had medication administered on-scene by the nurse practitioner
  • Top five medications: Zofran, Rocephin, Toradol, Albuterol and Decadron
  • Over 56% were insured by Medicare, MediCal, and CalOptima
  • Age distribution by gender:

            Female – 75% were 50 & over

            Male – 62% were 50 & over

  • 32% Living alone
  • 16% Homeless
  • Multiple patients have been placed into alternative living arrangements or are being provided with other services by allied organizations due to engagement with this unit.

A testimonial which is common after service from this unit. "Anaheim's Community Care Response Unit treated one of our guests onsite in their own surroundings," said Janet Folliott, owner/caregiver of the Orange Park Guest Home. "The opportunity to stay home and receive excellent onsite medical care allowed our guest to maintain their independence, reducing their stress and worry." Orange Park Guest Home – Anaheim

Summary
This unit has proven to be a valuable asset to the department and, more importantly, is an example of the type of deployment strategies that the fire and emergency service must deploy to provide more effective and efficient service in the future.

After two years of experience with this unit, we identified that the best hours of deployment would be from 0900-2300. To be effective throughout the entire system, at least six of these units would be deployed during the timeframe noted. This was incorporated into the department strategic planning process prior to my retirement in 2018.


Randy R. Bruegman, (Ret.), CFO, FIFireE, IAFC President, 2002-2003.

Picture: EMSWorld

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