CJCares Community Paramedics: Reducing Frequent Emergency Service Use by Connecting High Utilizers to Appropriate Care Services

Community paramedicine enables paramedics or emergency medical technicians (EMTs) to provide a range of services beyond traditional EMT responses to better support the delivery of health care, including behavioral health treatment and services. This model is expanding rapidly across the U.S. as communities seek to provide services that can reduce reliance on hospitals and jails. The Central Jackson County Fire Protection District (CJCFPD) in Jackson County, Missouri, is a perfect example of the community benefit made possible with a community paramedicine program. Theirs is called CJCares.

The CJCares program was started in 2017 to address the issue of frequent and non-medically emergent users of 911 services in Central Jackson County. CJCares operates with two firefighter paramedics available Monday through Friday from 7 a.m. to 5 p.m. One such firefighter-paramedic goes by the name Mickey Hill. Hill is a community paramedic with CJCFPD and a member of the CJCares team. According to Hill, that means he will do everything in his power to keep you out of the hospital and out of jail if you do not need to be there. In addition to being a trained firefighter and paramedic, as a CJCares responder Hill also received Crisis Intervention Team (CIT) training, a training generally reserved for law enforcement.

Hill notes that the CJCares team discovered early on that mental and substance use issues correlated with frequent 911 use. With this relationship in mind, the CJCares program sought to link those in need to community treatment services and mental health care providers. CJCares has since partnered with the State of Missouri, and created a Narcan® leave-behind program, which enables emergency responders to leave free doses of the opioid-poisoning-reversal medication behind when they respond to a scene where they think opioids may be involved. They also educate police officers and non-transporting fire departments on the use of Narcan® and are able to get the lifesaving medication for free from the state.

Hill describes the CJCares program as a parallel to the creation of fire prevention divisions in fire departments. “In the 1970s fire departments throughout the United States started fire prevention divisions, because we were having a lot of fires that resulted in many lives lost.”  “So,” Hill explains, “we decided that we needed to try to prevent these tragedies from happening.” Similarly, the CJCares program is also based on a prevention model.

Prevention programs at CJCFPD continue to expand. One recently implemented is called the CJCFPD Opioid Response Education (CORE) program. Together with the Blue Springs and Grain Valley Police Departments, Comprehensive Mental Health, and the Missouri State Hospital Association, Hill and his partner do home visits to people who have had opioid poisoning and been revived. Within 48 hours, they work to connect the individual to needed resources, whether that is food and stable housing or urgent medical care.

“We try to do anything that we can to keep them out of the hospital and criminal justice system,” Hill explains. People who misuse opioids, he says, “have a 90 percent recovery rate if they can get into treatment.” According to Hill, the moment after reversing an overdose, “when for lack of a better term, they just died,” can be an effective opportunity for intervention and initiation of treatment.

The CORE program has helped 10 individuals since it began, but CJCares has worked with 350 individuals over the past 4 years. The 2 community paramedics carry a caseload of 15 or 16 people at one time. “I think our biggest challenge right now is the capacity of our program,” Hill says. “We spend about 12 to 14 hours just on resource management for each person. With two people, it’s hard to completely take care of everybody’s needs and not let somebody fall short.” (As of this writing, Hill’s partner left the department, so he is running the program on his own.)

The CIT training Hill and his partner received has been critical to their success. They obtained a special waiver from the state to complete the program and were the first two non-law enforcement officers in the state to be CIT certified. Hill notes that emergency medical technician training is 6 months long and paramedic training is 2 years, but they receive very little education in dealing with mental or substance use issues. The CIT training filled in these blanks.

CJCares works closely with the Blue Springs Police Department to address frequent users of 911. Blue Springs has a city ordinance that makes it a civil crime to misuse 911 services. When it is determined that an individual is using 911 inappropriately, the CJCares team will contact them and try to offer them the resources they need. If the individual isn’t receptive to help and is charged with misuse of 911, CJCares staff will attend court with them and recommend that they be transferred to mental health court. When they complete the requirements of mental health court, their charges are dropped, according to Hill. “This keeps them from going to jail, which is not what they need,” Hill says. “They need some help.”

Hill meets monthly with CIT-trained police officers and mental health professionals to talk about the individuals they see most often. “We’ll go out monthly with these police officers and do what we call ‘knock and talks,’” Hill says. “We go to their residence, try to catch them in person and offer our services.”

Some resources are easier to access than others. “The mental health services are becoming a lot more available,” Hill notes. Still, when COVID-19 hit and many programs went to a telehealth model, Hill and his partner found themselves struggling to help people connect to services. Specific services, like housing and transportation, are hardest to come by. Some of the available housing is in extended-stay motels, but the frequent occurrence of substance use at many such locations makes them a bad environment for lots of individuals, Hill says.

Transportation is difficult for a lot of elderly residents, who may not be able to afford a cab or van service to doctor’s appointments. They end up calling 911 and are taken back to the hospital. “It’s just a revolving door,” Hill says. He has taken people to fill out their Medicaid paperwork to help fill in the gaps.

Hill is clear on what other fire departments need if they want to start a community paramedicine program. First, they need to be specific about their goals, and second, realistic about their capacity. Unsurprisingly, funding can be an issue. “Unless you’re hooked up with a hospital, or some type of primary care provider, you have no way to bill for your services,” Hill says. “So, everything we do is funded by the fire department.” He estimates that with two people’s salaries, a dedicated SUV, and a full line of advanced life support equipment, “It probably costs the department somewhere between $250,000 and $300,000 dollars a year to fund our program.” But the benefits of the program are manifold. Every time CJCares can prevent an unnecessary 911 call, that keeps an ambulance or a firetruck in service for an emergency that it can appropriately address, Hill points out. Every time they leave behind a dose of Narcan®, a life may be saved. Each person CJCares can connect to treatment and start on a path toward recovery reflects an incalculable benefit to the individual and those around them.

CJCares staff frequently are asked how to replicate their program and Hill is happy to respond. Contact him at email hidden; JavaScript is required.