How nurse navigators are helping improve EMS response in Southwest Washington

Nurse navigation programs have been proposed as one solution to overburdened emergency services systems. Instead of sending an ambulance, dispatchers can direct low-level 911 calls to a team of nurses who can give advice or help callers set up an urgent care or telehealth appointment. The idea is to provide patients with the appropriate level of care while freeing up EMS resources to respond to life-threatening calls. Clackamas County recently launched a nurse navigation program, and Clark County has been operating its program in Southwest Washington for more than a year.

Rocco Roncarati is the regional director for ambulance provider American Medical Response’s operations in Southwest Washington. Marlow Macht is the medical program director for Clark County EMS and an emergency physician at Legacy Salmon Creek Medical Center. They both join us to talk about how the nurse navigation program is going in Clark County.

Note: The following transcript was transcribed digitally and validated for accuracy, readability and formatting by an OPB volunteer.

Dave Miller: From the Gert Boyle Studio at OPB, this is Think Out Loud. I’m Dave Miller. We turn now to one of the potential solutions for overburdened emergency services. Under nurse navigation programs, instead of sending an ambulance for low-level 911 calls, dispatchers can direct callers to a team of nurses. Those nurses can either give advice themselves or help set up urgent care appointments. Clackamas County recently launched a nurse navigation program, but Clark County has been operating one in Southwest Washington for about a year-and-a-half. And we thought we’d check in to see how it’s been working.

Rocco Roncarati is the regional director for American Medical Response’s operations in Southwest Washington. Marlow Macht is an emergency physician at Legacy Salmon Creek Medical Center and the medical program director for Clark County EMS. They both join us now. It’s great to have both of you on Think Out Loud.

Rocco Roncarati: Thank you.

Marlow Macht: Oh, thank you for having us.

Miller: Rocco, I want to start with the context for this. How have the kinds of calls coming into 911 changed over the last decade?

Roncarati: What we’re seeing and what we have been seeing is a lot of what we call “low-acuity” medical needs – callers that have a medical need but don’t necessarily require an emergency level treatment, but they do need to access healthcare. Unfortunately, a lot of folks and a lot of callers don’t know of the options that are out there to get the treatment that they need, without having to go to an emergency room.

This program was designed … it’s been in place since 2018. It started in Washington D.C., with our operations there, and it’s evolved from there. But really, it’s taking these low-acuity patients, getting them the care they need and at the appropriate level that they need it, without having to utilize emergency services. We’re very fortunate here in Vancouver. We have a very robust healthcare system. We have numerous urgent cares and alternative services outside of the emergency room, and it has worked for us extremely well here in Vancouver.

Miller: Marlow Macht, why don’t a lot of people these days, who have these low-acuity medical needs – as Rocco just described – know that there are other options, better options for them to go through than calling 911?

Macht: I think anyone who’s had the experience of interacting with the healthcare system would describe it as frustrating and hard to navigate. The more health literacy is an issue, the more access to care is an issue, it becomes more difficult to navigate the system. In addition, it’s hard for people to access primary care. There’s a significant demand for primary care services, and it’s hard for people to get into those appointments. So, our assumption is always, people are doing their best, people are trying the best they can, but the system can be hard to navigate. So we want to do our best as an EMS system to respond to what people need.

Miller: I have more questions about what it would take to head these calls off at the pass, and if we have time we can get to that. But we should hear now about what the nurse navigation program actually does. So, Rocco, can you give us an overview of how it works?

Roncarati: Yeah, a caller that calls through the 911 center – they would call 911, that call would be answered through the Clark County Emergency Services agency. They would determine, based on a preset level of call that the medical director approves, if that patient can be navigated to our nurse navigation team. Our nurse navigation team is located in Texas. So if a caller meets the criteria, they are transferred to our nurse navigation team in Texas, who is gonna be able to spend more time with that caller to determine exactly what their medical need is, and exactly the care that we believe is most appropriate for them. And that can be determined a couple ways: it could be just nurse advice. For example, an infant with maybe a fever, could be nurse advice to give Tylenol and monitor that infant. It could be along the lines of getting them an appointment at an urgent care, because maybe they’ve fallen down and sprained their ankle but necessarily don’t require an emergency ride to the hospital. Or it could be through telehealth, through telehealth physicians who can prescribe medications for that patient. Over telehealth, could be the doctor giving them medical advice of what they should be doing or the care they need.

What’s nice about this program, because, believe it or not, a lot of callers call 911 when they don’t have access to get to a medical facility. And what nurse navigation does for those patients that do need to have a ride to either an urgent care appointment or, if it does warrant a different sort of a visit, we’ll actually send a Lyft or an Uber to the patient, pick them up, get them to their appointment. Then when they’re ready to return, we’ll make arrangements to pick that patient back up and return them to their place of residence. And there’s no cost to the patient whatsoever.

So if they meet that criteria … and like I said, we have such a robust healthcare system here in Vancouver. We’re extremely very fortunate. We have so many alternative access points to get the care that the patients need without tying up the emergency services.

Miller: Does it ever happen that someone says, “No, I don’t want to talk to a nurse. I really want to have an ambulance pick me up and I want to be taken to the ER”?

Roncarati: Yes, sir. And when that happens, we will immediately send an ambulance to the location and transport that patient to the hospital. So the patient does get the ultimate say and we do give them the option of talking to a nurse – it’s not automatic. We do advise them of the option. And what we’re seeing is that, as this program has been in place over the last 18 months, it’s becoming more recognizable. We have callers that call often who know the program. We’re seeing less of, “I don’t wanna talk to a nurse, I just wanna go to the hospital,” and more of callers really reaching out just to get access to health care.

Miller: Marlow Macht, as Rocco just mentioned, the people who are dispatched to talk to these nurses in Texas, the people who actually meet those criteria … it’s you, if I understand correctly, who set those criteria. How did you decide who or what kinds of calls will be sent to that call center in Texas?

Macht: I’ll just point out briefly, there are two ways that patients can enter the nurse navigation program, either from dispatch, as Rocco described, [or] in the second phase of the program, starting in January of 2024. We also gave EMS clinicians in the field the ability to refer to nurse navigation. It’s still always voluntary, always the patient’s choice.

So, the way to answer your question about how we determine who does that, the most common dispatching system in the U.S. is called the Medical Priority Dispatching System, or MPDS. And that breaks almost all of human suffering down into about 33 chief complaints. Based on a series of protocol questions that dispatchers ask, then it’s assigned a code. And having that code, we can look at what happened when an ambulance was dispatched to that code. How often was a patient transported to the hospital? How often was a time-sensitive procedure performed? And based on the frequency of what we do when we respond to that code, we can try to get the best resource to the patient to meet their needs.

Miller: What are other examples? We heard of an infant with a fever, for example, which, from my own recollection, can be terrifying. Things can get very scary very quickly with infants and fevers. That’s one example where a nurse might get involved. What are some others?

Macht: Another example is an eye injury. An eye injury can obviously be very frightening and anxiety provoking. But what we provide in the EMS service is stabilization of immediate life threats: heart attacks, strokes, cardiac arrest. So a person with an eye injury, in most cases, does not require the service of an emergency or an ambulance ride.

Those are cases where we can refer to the nurse, some can be managed by telehealth, some ultimately do require transport to an urgent care. And there are some cases where the caller will talk to the nurse and the nurse will say, “No, I think the best thing for you is an ambulance.” But we also have that additional information and we’re able to send a basic life support ambulance with EMTs, rather than an advanced life support ambulance with paramedics. So that makes the system more cost-effective, more efficient, while still getting the patient what they need.

Miller: Rocco, how do you build this out? I mean, how do you make it so the nurse navigators know, for example, where to refer people?

Roncarati: Well, it certainly takes partnerships. From basically concept to implementation, it can take anywhere from six to 12 months. It took us going out and meeting with our urgent care health partners, talking to them about what their criteria was for accepting patients and what their limitations were, building those processes into the system. So when a particular caller … for example, not every urgent care has the capability to treat an eye injury, but there are certain urgent cares that do. The program is built in such [a way] that the urgent cares and the other healthcare facilities give us what their abilities are, and then we’re able to navigate that patient to the appropriate level.

It does take support from the 911 dispatch center, the medical program directors, our local fire department partners, hospital partners. It really is a work of everybody, to not only implement the program but to sustain it and keep it successful. But it is a six to12 month process to have it, from start to implementation. Then you have to continually look at what you’re doing, review what you’re doing and make changes. Like Marlow just mentioned, earlier this year, we implemented the ability for our first responders for calls that don’t get caught at the beginning of the call when they call the 911 center, but our first responder partners can now also refer patients to the nurse navigator line, if they arrive on scene and determine that it meets the criteria. So it’s a program that continues to grow.

Miller: Rocco, you mentioned that all the nurses are based in Texas. What do you think is lost by not having a local person at the other end of the phone?

Roncarati: Well, fortunately, all our nurses … We do have this program in several states across the country. All the nurses are licensed in every state where we have the program. So regardless of who picks up the phone, you’re talking to a nurse that is licensed in the state where that call is originating from. I think, with technology today over the phone and then being able to connect via telehealth, I really don’t believe that any connection is lost, because they’re talking to a healthcare professional. And oftentimes, we call a nurse advice line through our health insurer or through other means, where we just need to talk to somebody about something that we’re experiencing or something that we’re feeling. And I don’t think that’s lost at all by a nurse who’s picking up the phone in Texas, but providing that level of care by being licensed in the state …

Miller: It makes perfect sense to me that any qualified nurse could provide helpful information about the safe dosage for Acetaminophen for an infant with a fever, and they will have information in front of them, as you’ve outlined, about what services are available at different urgent care clinics.

But they’re not gonna know the neighborhood where somebody is, or what the weather is like, or what it’s been like in that neighborhood or city in recent days or weeks – all of which are more subtle things. And I don’t even have a clear sense exactly how it would play into the provision of healthcare. But I have a gut feeling that it wouldn’t hurt. I’m wondering if you think there’d be any advantage to having the nurses be local?

Roncarati: I don’t. I mean, I would be interested in Marlow’s opinion on that. But what we have is, by having it centralized in one location, you’re able to provide this level of service, just based on the fact that it all comes into one location. I don’t think you lose anything by not having someone local that lives in the area. Because again, whether you’re talking to that nurse or physician for medical advice or a level of medical care, I truly believe that you are getting as high a level of care whether that nurse is located in the city of Vancouver or located in another state.

Miller: Marlow Macht, what do you think about this question?

Macht: I would say I think about it similarly – anything in healthcare involves trade-offs. And certainly, in EMS, the trade-off we are thinking about all the time is, the more paramedics we put out there, the less experience each individual paramedic has. And in this situation, we are taking on the order of about 100 calls a month with the nurse navigation, so we couldn’t offer this 24/7 level of service if we tried to provide it locally.

There’s a saying in EMS that if you’ve seen one EMS system, you’ve seen one EMS system. But chest pain in Texas is similar to chest pain in Washington. And most of healthcare, we gain more by giving consistent, high quality care than we lose by trying to make it incredibly bespoke or tailored to the situation.

Miller: What else would you like to see, Marlow, to improve emergency response times and just to help ease some of the burden on a very overburdened emergency system? This is not a silver bullet. This is one seemingly helpful piece in Southwest Washington, Clackamas County now, perhaps Multnomah and Portland in the near future. What else would you like to see, just in Clark County?

Macht: I think the key thing that we need to do as an EMS system is focus on the quality of care that we provide. So, it is a very small number of EMS calls where time-sensitive nature and getting there is really critical. And absolutely we want to be there for those calls, and we want to respond in a timely and appropriate fashion to those calls.

But one of the things, I think, the way in which EMS is changing, is that there are other ways to measure the quality of the care provided other than just when the first paramedic arrives, when the ambulance arrives. So we’re part of a national collaborative that’s focused on improving airway management. We’ve done important work to increase the safety of our community by increasing the percentage of patients that are transported without lights and sirens. So my focus is primarily on improving the quality of care. I do think we’re able to meet the response time guidelines, but I think we can continually improve the quality of our care.

Miller: Rocco Roncarati, we’re almost out of time. But I mentioned that this program started in Clackamas County in September. It’s been in Southwest Washington for about a year-and-a-half. What’s happening with Portland or Multnomah County?

Roncarati: I know they’re looking at the program right now. Again, from concept to implementation is about six to 12 months and you really have to have everybody on board with it. While I can’t speak for Portland, I can say that I know they’re working on some of the partnerships and some of the aspects of connecting with urgent cares and so forth, and getting that coalition built to implement a successful program in Multnomah County, along with everybody else. It’s just getting everybody together and it just takes a little bit of time.

Miller: Rocco and Marlow, thanks very much.

Macht: Thanks for having us.

Roncarati: Thank you.

Miller: Rocco Roncarati is regional director for AMR’s operations in Southwest Washington. Marlow Macht is the medical program director for Clark County EMS. He is also an emergency physician at Legacy Salmon Creek Medical Center.

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