Fire Departments Expand Services to Reach 911 Frequent Callers

Research over the past two decades has revealed that a small number of patients account for the bulk of healthcare costs in the United States. These patients often have complex needs requiring comprehensive care, such as medical, behavioral health, addiction counseling, social services, and more. They are also frequent users of emergency medical services (EMS).  

As first responders for many 911 calls, fire departments will sometimes answer non-emergency or low-acuity calls when the patient’s life, health, or property is not in immediate danger. EMS personnel — including emergency medical technicians (EMT) and paramedics — are trained to respond to medical emergencies and often lack resources to help patients with unmanaged chronic conditions or who are experiencing mental health crisis or struggling with substance abuse, making low-acuity calls a challenging situation for all involved, including the patient whose underlying issues remain post call.  

In the past, first responders had two options when arriving at a 911 call; take the patient to the emergency room or leave them at home. This blog will look at fire departments in Washington that have created dedicated mobile health response teams to provide non-emergency health services during and after 911 calls.  

Early Adopters  

Over the past 20 years, several Washington-based fire departments have piloted programs to support EMS patients with unmet social, behavioral, and physical health needs. Some may have begun to provide additional services to community members with limited social support, while others were a response to a growing community concern, such as an increase in drug overdoses. A common goal is to reduce patient use of EMS services for non-emergency calls.  

Spokane Fire Department  

In 2008, the fire department founded Community Assistance Response, or CARES. It is staffed by firefighters/EMTs and Eastern Washington University Master of Social Work (MSW) students. CARES team members do not answer 911 calls but instead receive referrals from EMS providers after a 911 response. The CARES team manager then assigns patients to team members for follow up and outreach. Teams conduct a social service needs assessment, develop a plan to connect the patient to appropriate long-term services, and advocate on the clients’ behalf for these services.  

Bellevue Fire Department 

Founded in 2012, the Bellevue Fire Community Advocates for Referral and Education Services (Bellevue Fire CARES) follows a similar model as Spokane’s, using MSW students to assist firefighters/EMTs in responding to low-acuity 911 calls as well as providing ongoing support and case management to patients referred to the team by first responders.  

Recently the CARES program paired up with the city’s police department to pilot a four-month program, Community Crisis Assistance Team, for aiding individuals in behavioral crisis from known or suspected mental illness or substance abuse. The project tested three different team models (various configurations of police officers with mental health training and mental health professionals). The pilot evaluation found this approach provided an immediate, sustainable, and coordinated approach for stabilizing individuals experiencing a mental health or substance abuse crisis. 

Tacoma Fire Department 

Tacoma’s Community Assistance Referral and Education Service (TFD CARES) had its origins in 2012 when the fire department began providing non-emergency medical services to individuals in Tacoma, Fife, and Fircrest who were frequent users of 911. Over time, the program evolved to become an instrumental component of the city’s opioid response plan and a long-term departmental initiative.  

In 2018 the fire department started a mobile opioid unit to provide medication assisted treatment in the field — followed by referral to TFD CARES for patient management — and in 2019, it rolled out the Safe Station program, offering medical assessment, transportation to a medical facility, opioid use disorder treatment assessment for outpatient services, first medication dosage (as needed), and connection to long-term treatment services to individuals battling drug addiction. These services are available 24 hours a day, 7 days a week at Fire Station 1 in Tacoma.  

Puget Sound Regional Fire Authority (Puget Sound Fire) 

Puget Sound Fire serves Covington, Kent, Maple Valley, SeaTac, Tukwila, and King County Fire Districts 37 and 43, but also contracts with Kent and Renton for its FD CARES program. Puget Sound Fire started FD CARES in 2013 and initially used a combined team of nurses and firefighters/EMTs to respond to non-emergency 911 calls. It has since added social workers, which allows the team to expand the services it provides, including assessment, referral, and case management.  

FD CARES teams also conduct “proactive” visits with patients who have been high 911 utilizers or who were referred by other firefighters/EMTs in the service area. And, like Tacoma, Puget Sound Fire is piloting a Safe Station program, though this one is a mobile response unit.  

Legislation to Formalize the Approach 

The buzz around various CARES program inspired the Washington State Legislature to pass SB 5145 in 2013, allowing fire departments to hire nurses, social workers, and other non-fire personnel (see RCW 35.21.930).  

This was followed by SSB 5591 in 2015, which gives EMS providers — including fire departments — the ability to develop CARES programs. Codified as RCW 35.21.930, the law allows CARES-based EMTs and paramedics to provide health services in non-emergency situations and the care provided does not exceed their training and certification standards. The legislation also allows EMS providers to seek funding to support local CARES programs (see, for example, Renton’s FD CARES fund).  

Later, in 2017, the legislature passed E2SHB 1358 (codified as RCW 74.09.335 ), shifting EMS away from a fee-for-transport model by directing the Washington State Healthcare Authority to adopt reimbursement standards for public fire and EMS agencies providing services to Medicaid patients who do not require transport to an emergency department.  

New Programs  

East Jefferson Fire Rescue (Jefferson County) 

East Jefferson Fire Rescue (EFJR) rolled out a CARES program early this year. The two-person CARES team receives referrals from first responders in Jefferson County and visits patients where they live to assess and better determine what services that person may need. The team then provides case management and referrals to appropriate follow-up care. In a December 12, 2022, Peninsula Daily News article, EFJR’s fire chief expressed optimism that the CARES program would help to alleviate high 911 call volumes that challenge the short-staffed fire department.  

Clark Cowlitz Fire Rescue (Clark County) 

Through its CARES program, Clark Cowlitz Fire Rescue partners with the Southwest Washington Accountable Community of Health (SWACH) to help individuals in Clark County who have been referred to the team by first responders for in-person follow up. The CARES team consists of a community paramedic and a social worker who uses SWACH’s HealthConnect platform to link patients to the appropriate services, including basic medical, housing, transportation, insurance, and behavioral health. The program targets seniors, people with disabilities, and others who may have limited support from their family and social networks.    

Poulsbo Fire Department (Kitsap County) 

Launched in 2021 with initial funding from Kitsap County’s 1/10th of 1% “treatment tax” fund, Poulsbo Fire CARES is a partnership between the city and the fire department. The program provides in-home, mobile services to individuals struggling with mental illness, mental health distress, substance use, and other behavioral health issues. Teams are staffed by a firefighter/EMT trained in crisis intervention, a social worker, and a substance use disorder professional. The program recently partnered with a private healthcare organization to build out additional staffing.  

Conclusion 

Though this blog focused on CARES, fire departments have also piloted Mobile Integrated Health programs in Seattle, Redmond, North King County, and Arlington. While the names vary, these programs are united by a singular vision: to provide comprehensive, coordinated care to patients whose complex needs cannot be adequately met through a standard EMS response, whether that means helping patients manage chronic conditions or linking them to appropriate services.