Pueblo county DOTS PROGRAM"DIRECTING OTHERS TO SERVICES"
a collaborative approach to reducing the burden on emergency services...
DOTS began as a response from the Pueblo Fire Department to the ever rising burden of increased calls to emergency services. These calls impact the availability of first responders for true emergency purposes and put an immense strain on resources that are already stretched thin across the community while attributing to the rising cost of care. A person with more than ten EMS calls in a twelve month timeframe is eligible for referral into the DOTS program. Through a collaborative approach, each participant works with a navigator and an outreach worker to complete an assessment of their home and medical history. Together, the navigator, outreach worker and DOTS participant identify barriers and through numerous community partners, a wrap-around model of care is instituted with the intent of reducing the number of EMS calls and creating a safer environment for each DOTS participant where they can live and thrive.
As part of the initial phase of DOTS, a pilot program began in February 2016. The program saw an initial ten participant referrals from agencies such as the Pueblo Fire Department, St. Mary Corwin Hospital, Parkview Medical Center and Pueblo Community Health Center.
Internally, the Pueblo Fire Department dedicated staff time to the pilot phase of the program including a Director to oversee the program and keep data up to date on participants, a navigator to connect participants with community resources and a team of five outreach coordinators to work directly with participants on completing living assessments and medical history evaluation to identify and address safety issues in the home.
"Last year usage" examines the number of EMS calls DOTS participants have in the year prior to their joining the program. The calls in the chart above are an aggregate number of calls of all participants enrolled in the program during the particular month. The reduction in calls across the time spectrum can be attributed to fewer enrollees per month. The initial pilot program had a total of ten participants who were all enrolled by August 2016. As the number of enrollees decreased each month, the number of usage calls also decreases.
In 2016, there were a total of 22,538 EMS calls and approximately 1,878 per month. In comparing the total number of calls (449) among enrollees for the year 2015 to the average number of calls (13,146) for seven months (February-August) 2016, the ten Pilot Program DOTS participants make up approximately 3.4% of all EMS calls for this time period.
Since the inception of the DOTS program in February 2016, there has been a 50% decrease in EMS calls among the participant population
This data shows that there was a correlation between the reduction in EMS calls and participation in the DOTS program. There was a reduction in EMS calls because of the increase in care coordination, environmental changes making for a safer home and navigation services to help connect participants to resources.
In comparing the total number of calls (95) among enrollees from February-August 2016 to the average number of calls (13,146) per month for that same period, DOTS participants make up 0.07% of all EMS calls.
the big picture...
Preventing Avoidable Hospital Stays Among Medicare Patients
As EMS calls among DOTS participants continue to decrease in the community, Pueblo has also made great strides in preventing avoidable hospital stays among Medicare patients. This outcome measure can be attributed to many factors in the community, one of which being the commitment from the Pueblo Fire Department in addressing the highest utilizers of emergency services. Many of the DOTS participants are also Medicare members (elderly with co-occurring diagnoses), making for a direct correlation between the DOTS efforts and the reduction in avoidable hospital readmissions. The Southeastern Colorado Transitions of Care Consortium, made up of representatives from both community hospitals, home health agencies, the VA, durable medical good providers, care coordinators, first responders and local data experts, has also been an integral part in increasing communication among providers and decreasing the barriers patients face when transitioning from a hospital stay back to their home.
Preventable Hospital Stays have been on the decrease in Pueblo since 2012 due to heightened communication among providers and a commitment across the community to limit barriers that often result in a readmission in the 30 days immediately following a person's discharge. Pueblo has seen a 33% reduction in preventable hospital stays since 2011.
And in the end it's not the years in your life that count, but the life in your years