HomeMy WebLinkAbout021524P PacketConnecting Community Members to Care
Connecting Community Members to Care
Acknowledgements
Key informant interviews and report
reviewers
Alex McCracken, Central Kitsap Fire Rescue
Anthony Lyon-Lo�us, PA-C, MPH, Peninsula
Community Health Services
Bret Black, Chief East Jefferson Fire Rescue
Brian Gerdes, Port Angeles Fire Department
Casey Jinks, Deputy Kitsap County Sheriff’s Office
Dunia Faulx, MPH, Jefferson Healthcare
Eric McNair Scot, Southwest Washington Accountable
Community of Health
Helen Kenoyer, Olympic Peninsula Community Clinic
Jolene Kron, Salish Behavioral Health Administrative
Services Organization
Kathleen Olson, Molina Healthcare
Kim Hendrickson, City of Poulsbo
Laura Johnson, United Healthcare
Laurel Lee, Molina Healthcare
Lori Kerr, St. Michael Medical Center
Maria Courogen, Department of Health
Matania Osborn, Amerigroup
Monica Vanderheiden, Peninsula Behavioral Health
Stephanie Lewis, Salish Behavioral Health
Administrative Services Organization
Tim Garrity, Sergeant Bremerton Police Department
Olympic Community Health report wri�ng team
Miranda Burger (Program Manager), Ren Mack-Hazelwood (Community Program Coordinator), Yvonne Owyen (Community
Program Coordinator), Celeste Schoenthaler, MPH (Executive Director), and Amy Brandt (Communications Manager)
Executive Summary
Olympic Community of Health (OCH) supports regional efforts to meet individual needs �mely, easily,
and compassionately. OCH serves as a catalyst for change, seed planter, and bridge builder by eleva�ng
community voice, spotligh�ng local innova�on, and advoca�ng for solu�ons that meet the unique needs
of our communi�es.
Local challenges around high use of costly services for non-emergent needs such as emergency
department (ED) visits and 9-1-1 calls as well as gaps in the local healthcare system persist. This report
looks at innova�ve place-based approaches that meet people where they are to improve pa�ent
experience and outcomes, preserve emergency services, and reduce costs. Through this report, OCH
sought to learn more about and demonstrate the value and impact of local programs, elevate crea�ve
ideas, and advocate for sustainable solu�ons.
Table of Contents
Acknowledgements…………………………………………………….……1
Execu�ve summary………………………………………………………….1
Introduc�on…………………………………………………………………….2
Background……………………………………………………………………..3
Program deep dive…………………………………………………………..9
Sustainable solu�ons………………………………………………………11
Call to Ac�on…………………………………………………………………..13
Resources……………………………………………………………………….14
Acronyms……………………………………………………………………….14
Appendix….…………………………………………………………………….14
Bremerton Ambulatory Team……………………………15
Bremerton Police Department Behavioral Health
Navigator……………………………………………….………..16
Central Kitsap Fire Rescue CARES…………………..…17
East Jefferson Fire Rescue CARES……………………..18
Kitsap County Sheriff’s Crisis Interven�on
Coordinator……………………………………………………….19
Port Angeles Fire Department Community
Paramedicine Program……………………………………..20
Poulsbo Fire CARES…………………………………………..21
REdisCOVERY Program……………………………………..22
Salish R.E.A.L. Teams……………………….……………….23
Sequim Navigator Program……………………………….24
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Connecting Community Members to Care
The Olympic region is stronger together. There are many
opportuni�es for legislators, policy makers, and
community partners to expand, replicate, and sustain
these crea�ve solu�ons to local health issues. OCH
intends for this report to serve as a useful tool and
resource for partners as well as decision makers.
Introduction
Olympic Community of Health
OCH is a regional non-profit organiza�on that brings together partners from many different backgrounds,
sectors, communi�es, and Tribes to collec�vely achieve the vision of healthy people, thriving
communi�es. OCH fosters an environment to build bridges between and among the community and
clinical workforce to create a more person-centered approach to health.
The Olympic Region
The Olympic region spans Clallam, Jefferson, and Kitsap Coun�es, and includes the seven sovereign
na�ons of the Hoh, Jamestown S’Klallam, Lower Elwha Klallam, Makah, Port Gamble S’Klallam, Quileute,
and Suquamish Tribes. The unique communi�es and diverse geographic landscapes across the region
impact the services available and the way individuals and families seek care. Below is a bird’s eye view of
the makeup of the Olympic and Kitsap Peninsulas and some key notes to help understand what makes
the Olympic region unique.
See page 13 for ways YOU
can advance and sustain
this life-saving work.
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Connecting Community Members to Care
De�initions
This work goes by many names. The thread that weaves them all
together is mee�ng people where they are to provide �mely,
compassionate care. The care provided under these programs and
services aims to meet the unique needs of the diverse
communi�es in the Olympic region. This work con�nues to evolve,
and programs are providing a range of person-centered services.
Common terms and defini�ons:
Background
The role of emergency response
Historically, the role of first responders was to provide acute interven�on for emergent needs. As one
first responder shared, “I’m a fixer. I want to put the fire out, perform CPR, and get you to the hospital –
then go out and respond to the next one.” Today, first responders are asked to do much more as they
respond to a higher and more frequent number of non-emergent calls for chronic condi�ons unsolvable
in a single visit, such as substance use disorder, mental health, complex medical condi�ons,
homelessness, and others. This shi� taxes limited emergency resources and increases costs to the
healthcare system. A partner shared, “I know I’m not fixing anything; I’ll see them again. It’s like
the same house catching fire every third day.” Leveraging the skills and resources of a variety of
community partners to help solve healthcare problems is essen�al to crea�ng change.
A larger movement
First responders are typically seen as a trusted resource in communi�es, and commonly are the first, and
some�mes only, point of contact with individuals. In rural communi�es, a lack of access to preventa�ve
and primary care can create added burden to emergency response services. Across the na�on, hundreds
of programs intended to lower costs and improve care have been launched. A 2023 study conducted by
the Na�onal Associa�on of Emergency Medical Technicians iden�fied more than 400 mobile-integrated
Community paramedicine
A health care model that allows paramedics and emergency medical technicians to operate in expanded roles by assisting with preventative and primary health care services to improve access to care for underserved populations.
Co-Response
A partnership between first responders (including law enforcement, fire/EMS, or EMS agencies) and human services professionals (such as behavioral health professionals, social workers, community health workers, or peer support workers). These teams respond to calls involving people with behavioral health and/or complex medical needs to provide immediate response and follow-up care.
Mobile-integrated health
Health care services provided outside of a health care facility by any type of health professional. This term is often used interchangeably with community paramedicine but can be broader to include services provided by nurses, community health workers,
and more.
See appendix beginning on page 15 for examples of local programs.
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Connecting Community Members to Care
Figure 1
health and/or community paramedicine programs across forty states1. Co-Responder programs can be
found interna�onally and in recent years informa�on sharing and collabora�on across programs has
expanded to improve best prac�ces.
“We can’t control what people
choose to call 9-1-1 for. We can
control how we respond.”
–First responder
Across Washington State many co-
responder programs have launched
and statewide groups like the Co-
Responder Outreach Alliance (CROA)
are working to enhance understanding
of various programs, spread best
prac�ces, and advocate for
suppor�ve laws and policies. Figure
1 to the right, created in partnership
between CROA and University of
Washington in 2022, is a visual landscape analysis of exis�ng co-response programs in Washington State.
Programs in blue are affiliated with police, programs in red are affiliated with Fire, and programs in green
are affiliated with “other en�ty.”
In the Olympic region
Health transforma�on provides opportuni�es for innova�ve solu�ons to address gaps in the health care
system. Across the Olympic region, innova�ve
partnerships con�nue to grow to address and bridge
local barriers and gaps. Through the Medicaid
Transforma�on Project (MTP), OCH provided flexible
funding to incen�vize innova�ve health solu�ons on a
local level. Some partners used MTP dollars to pilot
various place- and field-based approaches. Partners
proac�vely sought other funding sources outside of MTP
to launch, expand, and sustain these approaches.
Addi�onally, statewide funding mechanisms like the state
proviso under the Blake Bill have launched opportuni�es
for more programs.
No two programs are the same and, by design, are not a
“one-size-fits-all” approach. Approaches to funding,
1 Na�onal Associa�on of Emergency Medical Technicians, (2023) Mobile Integrated Healthcare and Community Paramedicine
(MIH-CP). Retrieved August 7, 2023, from
chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/htps://naemt.org/docs/default-source/community-
paramedicine/toolkit/mihcp-presenta�on_may-2023.pdf?sfvrsn=2f01f593_2
Source: Co-Responder Outreach Alliance
Retrieved August 7, 2023 from https://croawa.com/uw-partnership/
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Connecting Community Members to Care
Figure 2
workflows, popula�ons of emphasis, and response differs across programs. Effec�ve programs are
developed to meet community needs and do not duplicate or compete with already exis�ng services,
rather they fill a gap. These programs have proven to be strong value adds to the community by working
to preserve costly and limited emergency resources2.
Local needs
The concept of community paramedicine, and other similar programs, began in rural areas. Today, these
programs operate in a range of community types. The Olympic region, largely rural, experiences many
gaps in the healthcare system and naviga�ng complex care can be especially challenging due to limited
services, transporta�on, and other determinants of health. As re�red Port Angeles Fire Department
Chief Ken Dubuc shared, “One, they simply don’t have an alterna�ve. Two, people have
alterna�ves, they just don’t know what they are. Three, there are a lot of folks out there who
can’t afford any alterna�ves, they aren’t insured, they may not have transporta�on, or the
means of accessing services.”
Across the Olympic region, u�liza�on of emergency departments is high. While the height of COVID-19
led to dras�c decreases in emergency department u�liza�on across all three coun�es, this was likely for
the wrong reasons including public fear and stay at home orders. 2021 data show that emergency
department u�liza�on started to increase again across all three coun�es and local hospitals confirm this
trend con�nues today. As Jefferson Healthcare shared, “visits are exceeding pre-pandemic levels.”
Local hospitals confirm they are consistently at capacity and common non-emergent use of the ED is due
to limited resources including primary care, specialty care, behavioral health access, and aging specific
resources.
2 Na�onal Associa�on of Emergency Medical Technicians, (2018) Mobile Integrated Healthcare and Community Paramedicine
(MIH-CP) 2nd Na�onal Survey. Retrieved August 7, 2023 from chrome-
extension://efaidnbmnnnibpcajpcglclefindmkaj/htp://www.naemt.org/docs/default-source/2017-publica�on-docs/mih-cp-
survey-2018-04-12-2018-web-links-1.pdf?Status=Temp&sfvrsn=a741cb92_2
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Connecting Community Members to Care
Limited primary and specialty care
Across all three coun�es, and par�cularly in more rural areas, primary care and specialty care is limited.
It is common for pa�ents to wait extended periods of �me for an appointment. Jefferson Healthcare
shared it is not uncommon for pa�ents to seek care in EDs across county lines in hopes of being seen
sooner and pa�ents express that it is faster to wait for a few hours in the ED than to wait weeks or
months for a scheduled appointment.
Limited behavioral health care
Mental health and substance use disorder services are limited in the Olympic region and workforce
shortages further exacerbate barriers to care. Local first responders and hospitals share that individuals
are frequently brought to the ED for mental health and/or substance use disorder crises because family
members and law enforcement don’t know where else to bring them.
Port Angeles Community Paramedicine Success Story
A 37-year-old woman with complex medical
condi�ons including severe mental illness,
substance use disorder, and developmental disability
was referred to the community paramedicine
program by first responders for frequently calling
9-1-1 and visi�ng the ED for non-emergent
behavioral health needs. Prior to engagement with
the community paramedicine program, EMS and Fire
teams were commonly responding to her one to two
�mes per shi�, many �mes leading to transport to
the ED. Within one year of engaging with the
community paramedicine program the pa�ent’s
9-1-1 calls decreased by 35%. Two years a�er
engaging with community paramedics, the pa�ent
is successfully engaged in behavioral health treatment and is in recovery for substance use disorder.
East Jefferson Fire Rescue CARES Success Story
The second day the CARES program launched an elderly male
was observed in his parked car at the fire sta�on parking lot
with a visibly dislocated shoulder. The man indicated that
he had fallen a few days ago and was struggling to perform
ac�vi�es of daily living, including bathing, pu�ng his sling back
in place, and managing his pain medica�on. The CARES team
connected with the man’s primary care provider to refill pain
medica�on and coordinate a referral to the VA for surgery
as well as connected to home care. The man received his
surgery shortly a�er the interven�on and has since recovered.
See Appendix 6 on page 21 for program spotlig ht.
See Appendix 4 on page 19 for program spotlight.
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Connecting Community Members to Care
Limited resources for aging popula�on
Local hospitals also share they see a high volume of aging pa�ents for needs that could be prevented or
addressed at home with appropriate support. In-home caregiving, assisted living, and skilled nursing
facili�es are all extremely limited in the Olympic region. Pa�ent discharge from the hospital is frequently
delayed, up to several weeks, due to lack of home-based services. ED staff frequently encounter families
without long-term care plans for aging family members or knowledge of available resources. According
to local hospitals, there is a need for increased services for the aging popula�on as well as educa�on for
families about resources and end of life care.
The total cost of care
The cost of a visit to the ED is difficult to predict and 9-1-1 response costs vary depending on the services
provided. An es�mated 13% to 27% of emergency department visits in the United States could be
managed in physician offices, clinics, and urgent care centers, saving $4.4 billion annually3. It is
challenging to capture cost savings of these programs as they o�en prevent calls and visits before they
occur.
Working with the Health Care Authority (HCA) and an independent third-party consultant, the Port
Angeles Fire Department completed a comprehensive cost of service analysis and determined that the
costs to the Port Angeles Fire Department every �me a pa�ent is transported to the hospital is $2,002,
which includes first responder �me and use of equipment. They further es�mated costs to the Port
Angeles Fire Department are not much less even when transport does not occur and very conserva�vely
es�mate 9-1-1 response without transport costs $1,000. Considering the above informa�on, the
3 Weinick RM, Burns RM, Mehrotra A. How many emergency department visits could be managed at urgent care centers and
retail clinics? Health Aff 2010;29(9):1630-6. htp://www.ncbi.nlm.nih.gov/pmc/ar�cles/PMC3412873/. Accessed June 16, 2016.
See Appendix 3 on page 18 for program spotlight.
Central Kitsap Fire CARES Success Story
Central Kitsap Fire CARES responded to an elderly couple in
need of help transferring in and out of bed. The couple had
called 9-1-1 for assistance twenty-eight �mes over a two-
week period. The CARES team coordinated with community
resources to install a li� and educate the couple on
appropriate use. The couple had zero 9-1-1 calls in the two
months following the interven�on and expressed gra�tude
for the kindness and compassion of the CARES team.
Central Kitsap Fire CARES Success Story
Central Kitsap Fire CARES team responded to a 9-1-1 call for a 16-year-old expressing suicidal idea�on. The
CARES team connected with established mental health treatment providers and suppor�ve family members to
coordinate a more effec�ve safety plan. The adolescent was able to stay home in contact with familiar mental
health treatment and avoid an unnecessary hospital visit.
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Connecting Community Members to Care
Figure 3
Community Paramedicine program conserva�vely es�mated cost savings to the Port Angeles
Fire Department in 2021 and 2022 to be over $850,0004.
One example of cost savings can be found from the Port Angeles Fire Department Community
Paramedicine Program. A 72-year-old woman with complex medical condi�ons and SUD, was referred to
the program for frequently calling 9-1-1 mul�ple �mes a day or week for assistance with nonemergent
tasks. Community Paramedics found she
was experiencing side effects from
conflic�ng prescrip�ons and coordinated
with her primary care provider to
address the issue, including obtaining a
new prescrip�on and follow-up to other
suppor�ve services such as in-home care.
Addi�onally, the Community Paramedics
connected with the pa�ent’s family to
increase social supports. Since
interven�on by Community Paramedics
the pa�ent has had a 95% reduc�on in
emergency department visits and 9-1-1
calls4.
Community-based care coordination
Another area where these programs have demonstrated impact on pa�ent outcomes and costs is
through improved community-based care coordina�on. Place-based programs that meet people in the
field have a ripe opportunity to navigate individuals to the best resource at the ini�al point of contact.
This not only improves costs and outcomes, but helps individuals experience beter quality of life so they
require less intensive care overall.
4 Port Angeles Fire Department Community Paramedicine Program, (2023) Impact Statement. Supplied by Port Angeles Fire
Department May 1, 2023.
Poulsbo Fire CARES Success Story
A 62-year old male made six calls to 9-1-1 in the last 12 months related
to chronic alcohol use. The CARES Team arranged care and transporta�on
to medical detox. Following discharge from detox, further assistance was
needed to secure inpa�ent treatment. The CARES Team worked with the
individual’s private insurance and various treatment facili�es to find an
affordable treatment solu�on. The pa�ent successfully completed inpa�ent
treatment and has connected with local outpa�ent SUD treatment and
re-engaged with his primary care doctor and medica�on management plan.
The pa�ent and his wife expressed gra�tude for the CARES Team.
See Appendix 7 on page 22 for program spotlight.
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Connecting Community Members to Care
Figure 4
Program Deep Dive
Inventory of local programs
OCH explored some of the unique local programs to beter understand the various approaches, shared
and individual challenges, and to spread successes. There are many field-based services happening
across the region and this is not intended to serve as a comprehensive inventory of all programs. The
program spotlights take a closer look at different examples of programs to inspire future collabora�on
and innova�on across the Olympic region.
See appendices beginning on page 15 for spotlights on these local programs.
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Connecting Community Members to Care
Key takeaways
There are many diverse approaches to this work. No two programs are the same. While each program
takes a unique approach to mee�ng their community needs, commonali�es across programs have
emerged.
Successes
Collabora�on is key. Programs are collabora�ng within their communi�es to avoid duplica�on of services
and ensure individual needs are met. Most individuals interac�ng with these programs experience
complex needs that cross spectrums of care. Successful programs include a mul�-disciplinary approach
that capitalizes on partner’s unique exper�se and strengths to reduce stress on emergency response
systems and improve how individuals with complex needs are being connected to appropriate services.
Robust programs include bi-direc�onal referrals, meaning partners can refer into the program as well as
the program referring out to community partners. This approach secures stakeholder buy-in and ensures
a no wrong door approach to community members in need receiving care.
More and more programs are collabora�ng across city, county, and state lines to share lessons learned
and best prac�ces. Partners are flexible to adapt to the changing community needs. Innova�on means
trying things that haven’t been done before and these programs are evolving to improve systems and
processes.
As the Olympic region, and Washington state, con�nues to face health-serving workforce challenges,
these programs are helping to alleviate some workforce burnout. Many local programs have tailored
their scope of services to the skillsets of available staff. For example, some of the Fire CARES models
heavily rely on EMT services versus paramedic due to workforce capacity. This balance appreciates
responsivity to community needs and workforce capacity.
Challenges
Many first responder agencies are inexperienced at managing the administra�ve burdens of seeking
funding, repor�ng to funders, collec�ng and tracking data, and managing contracts. Administra�ve
constraints detract from the ability to provide direct services. As Central Kitsap Fire CARES shared,
“Firefighters shouldn’t be spending 50% of their �me chasing grants.” Funding to support these
programs in the Olympic region has largely been grant-based and sustainability is unsure from one grant
cycle to the next. Most programs are braiding mul�ple sources of funds.
Successes
-Reduced stress on emergency response systemsand improved 9-1-1 response to complex needs
-Collaboration across multi-discplinary partnersand bi-directional referrals
-Collaboration across programs to improve caredelivery
-Services tailored to the skills of the availableworkforce
Challenges
-Administrative burden
-High caseloads
-Limited and insecure funding (sustainability)
-Inconsistent standards, training, and measures ofsuccess across programs
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Connecting Community Members to Care
The need in communi�es is great and caseloads across programs remain high. Many local programs are
limited in how many individuals they can serve to ensure �mely and responsive follow-up. Referrals
increase as programs con�nue to demonstrate their value.
Many of these programs are new or recently expanded. Standards for policies, training and measures of
success have not been implemented and it can be difficult to compare programs.
Suggestions for programs
As programs work to launch, expand, and con�nue to refine, partners have iden�fied a set of
sugges�ons for programs to consider:
Sustainable Solutions
Added value
Innova�ve approaches to mee�ng people where they are and direc�ng individuals to the most
appropriate and least costly type of care is an important piece of the puzzle to crea�ng a region of
healthy people, thriving communi�es. These programs have significant impacts on improved pa�ent
outcomes, experience, costs, and enhancing a community-based care coordina�on network to direct
people to appropriate resources across the full-spectrum of care.
Many gaps in our health care system exist and these programs have proven essen�al to filling and
addressing gaps for individuals to ensure the right care is received at the right �me and place. Through
collabora�ve partnership and local innova�on, these programs are saving payors thousands of dollars,
preserving capacity of essen�al high needs services, addressing and preven�ng workforce burnout, and
beter mee�ng individual needs with compassionate, �mely care.
Invite elected officials to see your work first-hand.
Build up ability to track quantitative data in addition to the qualitative stories.
Collaborate with key community partners such as hospitals, behavioral health teams and programs, Managed Care Organizations, and local referral sources to better coordinate response.
Coordinate with other like programs to standardize data collection and analysis.
Conduct, or partner with, a community needs assessment to understand the unique challenges and needs of the community.
Use a broad spectrum of data, including EMS, to inform program planning and quality improvement.
Plan for program expansions over time to meet increasing referrals.Consider incorporating telehealth into the broader spectrum of care.
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Connecting Community Members to Care
Sustainability in action
Across the na�on and Washington State, first responders, community partners, elected officials, and
community members are seeing the value of these programs. The interest of federal, state, and local
stakeholders has enabled some programs to secure grants to cover the ini�al development and
opera�on of their program. Yet most programs launched by local organiza�ons, such as EMS, con�nue to
fund these programs out of their exis�ng budgets.
Minnesota Medicaid Reimbursement2
In 2012, Minnesota became the first state to pass legisla�on authorizing Medicaid reimbursement of
EMS-based community paramedics. The Na�onal Associa�on of Emergency Medical Technicians Mobile
Integrated Healthcare and Community Paramedicine report highlights one rural community
paramedicine program receiving such reimbursement, “the only available reimbursement is for the 15
percent of pa�ents who have Medicaid…in 2014 reimbursements from Medicaid totaled about $10,000
–not enough to cover costs.” The program men�oned has braided funding from EMS opera�onal budget
and local hospitals in addi�on to receiving reimbursement for Medicaid. They hope to nego�ate savings
arrangements with commercial insurers in the future.
Tri-County’s tips for success:
1.Start small.
Gradually build acceptance of your
program among referral partners.
2.Think local.
“My program wouldn’t work in Ft. Worth, or in New York City, and their
program wouldn’t work here. Your program needs to fit local needs.” -
Allen Smith, Tri-County Health emergency response manager
Clark Cowlitz Fire and Rescue & Southwest Washington Accountable Community of Health
Southwest Washington Accountable Community of Health (SWACH) partnered with Clark Cowlitz Fire
and Rescue to develop and implement community paramedics under the CARES model using MTP funds.
SWACH leveraged their community-based care coordina�on hub and role as a community connector to
facilitate meaningful partnership with local hospitals and Area Agencies on Aging who now provide
funding to the program as well as funding from the fire district. Community paramedicine has been
integrated into the community-based care coordina�on hub workflow which has allowed the program to
track outcomes and is a piece of the larger care coordina�on puzzle. SWACH’s Director of Community &
Clinical Linkages, Eric McNair Scot shared, “There is no end of need that this program is mee�ng.
It’s not in any way duplica�ng efforts.”
Moving forward, Clark Cowlitz Fire and Rescue hopes to expand the CARES program to include addi�onal
local fire departments. SWACH plans to support community paramedicine programs through outcome-
based payments under their community-based care coordina�on hub, which will con�nue under the
next MTP renewal waiver.
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Connecting Community Members to Care
SWACH’s tips for success
1.Talk to your first
responder agencies that
are doing the work to
understand what the
local opportunities are.
2.Facilitate connections to
share best practices and
move towards more
standardization across
programs.
3.Integrate programs with other
community-based care coordination
work to create an effective system for
tracking data and closing the loop on
outcomes.
Acadian Ambulance partnership with Medicaid Managed Care2
In 2013, Acadian Ambulance, one of the largest private ambulance providers in the na�on serving areas
of Texas and Louisiana, launched a mobile integrated health/community paramedicine program. A�er
successes seen under a series of pilots, Acadian partnered with Louisiana Healthcare Connec�ons, a
Medicaid Managed Care Organiza�on (MCO), on a pediatric asthma interven�on. “A�er six months,
we’ve seen beter management of asthma for the children in this program. Their emergency room
u�liza�on has decreased, and their medica�on compliance has improved,” shares Louisiana Healthcare
Connec�ons. Under this partnership, Acadian medics receive a fee per visit from the MCO. Acadian
supplements the addi�onal costs to run the program and plans to approach local hospital systems and
other public and private payers with results as proof of concept.
Acadian’s tips for success
1.Use data to identify
‘frequent user’ groups
to start developing
targeted interventions.
2.Tap into local ‘community health
worker’ network for outreach,
social support, informal counseling,
and screenings for social needs.
3.Understand every patient group
is unique. The needs for children
with asthma will differ from
other frequent user groups.
Call to Action
OCH intends for this report to serve as a useful tool and resource for partners as well as decision makers.
The Olympic region is stronger together, and programs like these are another step towards fostering a
healthier, more equitable 3-county region. Here are ways YOU can advance and sustain this life-saving
work:
Community partners:
•Partner with and make referrals to and from your local program. Find examples of local programs,
including contact information, in the program deep dive section of this report (pages 11-20).
•See a need in your community? Connect with partners and consider expanding or replicating a
program to meet the unique needs of your area.
•Collaborate across programs to create standards for skills, training, and education.
•Advocate to the Washington State legislature to include mobile services as a Medicaid reimbursable
service. Call the Toll-Free Hotline and leave a brief message for your senator or representative 1-800-
562-6000 (TTY for Hearing Impaired 800.833.6388, interpreter services available).
Elected officials:
•Learn more and directly connect with the programs operating in your district.
•Add these programs and services as a Medicaid covered benefit.
•Support policies, bills, and laws that create sustainable funding for field-based approaches.
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Connecting Community Members to Care
OCH solu�ons:
OCH serves as a suppor�ve backbone that creates opportuni�es for collabora�on across Clallam,
Jefferson, and Kitsap Coun�es, and seven Tribal Na�ons. Below are commitments that OCH makes to
con�nue to support mee�ng individual needs �mely, easily, and compassionately in the Olympic region.
•Create opportunities for collaboration
•Elevate regional challenges and opportunities to local elected
officials and advocate for sustainable funding paths
•Partner with ACH’s across Washington State to create
opportunities for collaboration and advocate for
sustainable solutions
•Share innovative successes
•Include this work as a component of community-based
care coordination hub work under the MTP renewal
waiver
Resources
•Co-Responder Outreach Alliance (WA)
•Mobile Integrated Health/Community Paramedicine Program Toolkit
•National Association of Emergency Medical Technicians
•OCH Coffee Break Video Series: Community-Clinical Partnerships
•Rural Health Information Hub - Community Paramedicine
•Stronger Together: Community-based Care Coordination
Acronyms
•CARES – Community Assistance, Referral, and Education Service
•CROA – Co-Responder Outreach Alliance
•ED – Emergency department
•EMS – Emergency Medical Services
•MCO – Managed Care Organization
•MTP – Medicaid Transformation Project
•OCH – Olympic Community of Health
•SUD – Substance use disorder
•SWACH – Southwest Washington Accountable Community of Health
Do you have a program
you would like to share
with the OCH network? Email OCH@olympicch.org
14
Connecting Community Members to Care
Appendix
OCH explored some of the unique local programs in order to understand the various approaches, shared
and individual challenges, and to spread successes. There are many field-based services happening
across the region and this is not intended to serve as a comprehensive inventory of all programs. The
program spotlights, beginning on page 15, take a closer look at different examples of programs to inspire
future collabora�on and innova�on across the Olympic region.
Bremerton Ambulatory Team………………………………………………………….16
Bremerton Police Department Behavioral Health Navigator……………17
Central Kitsap Fire Rescue CARES…………………………………………….……..18
East Jefferson Fire Rescue CARES………………………………………………..….19
Kitsap County Sheriff’s Crisis Interven�on Coordinator……………….….20
Port Angeles Fire Department Community Paramedicine Program...21
Poulsbo Fire CARES………………………………………………………………………...22
REdisCOVERY Program…………………………………………………………………….23
Salish R.E.A.L. Teams……………………….……………………………………………...24
Sequim Navigator Program………………………………………………………….….25
15
Connecting Community Members to Care
Bremerton Ambulatory Team
Kitsap County, WA
Description Populations of emphasis
In the Spring of 2020, Peninsula Community
Health Services (PCHS) collaborated with the
Bremerton Fire Department (BFD) to establish
the Bremerton Ambulatory Team (BAT). The
BAT consists of a medical provider, medical
assistant, and community health worker, as
well as support from behavioral health
professionals, working to reduce the number of
non-emergent EMS calls by meeting people
where they are.
BAT serves individuals who experience barriers to
accessing care in a traditional setting including, but not
limited to:
•Homelessness and/or isolation
•Limited mobility/access to transportation
•Mental illness and/or SUD concerns
•Cultural and/or linguistic barriers
•Health literacy and/or lack of familiarity with existing
resources
How it works
1.BFD sends referral to PCHS when unique,
non-emergency support is needed.
2.BAT reaches out to the client to assess
individual needs.
3.BAT deploys mobile healthcare services to
client residence.
4.BAT helps client address acute needs as
well as connects them with existing
services.
5.BAT provides some case management,
often helping clients navigate insurance,
transportation, housing, food, clothing, etc.
Tips for success
1.Complete a needs assessment and outline
what specific problems the program will
address.
2.Consider multiple ways to deploy field services
(mobile clinic, co-locating with a community
partner, etc.).
Funding Contact information
•Services billed to patient insurance
•PCHS has income-based sliding-scale fee and
financial assistance programs
PCHS, Assistant Medical Director
Anthony Lyon-Loftus, PA-C, MPH,
aelyonloftus@pchsweb.org
Website
www.pchsweb.org/mobile-locations/mobile-
bremerton-ambulatory-team-bat-/
16
Connecting Community Members to Care
Bremerton Police Department
Behavioral Health Navigator Program
City of Bremerton, WA
Description Populations of
emphasis
The Bremerton Police Department Behavioral Health Navigators
collaborate with Bremerton police officers to co-respond to calls that
involve individuals experiencing suicide ideation, mental or behavioral
health, child protective services, adult protective services, or complex
health issues. The Navigators act as a community liaison to connect their
clients to community resources that meet their individual needs.
Navigators work closely with partners to avoid duplication of services and
ensure individual needs are met timely easily and compassionately. Key
partners in this work include:
•Bremerton Fire Department
•Kitsap Mental Health Services
•Peninsula Community Health Services
•Kitsap Community Resources
•St. Michael Medical Center
•Local R.E.A.L. Teams
Anyone in need of resources
with emphasis on people
experiencing:
•behavioral health
•complex health
•and/or child protective
services related call
How it works Data
1.Bremerton police officers co-respond with navigators on
calls involving individuals experiencing behavioral health,
complex health, child protective services, and/or adult
protective services.
2.Once the scene is secured, navigator works with client to
identify needs.
3.Navigator connects client with appropriate resources.
4.If navigator is not available to co-respond, police officers
send internal referral and navigator follows up with
individuals.
506 referrals to Navigators in
2022
558 individuals contacted by
Navigators in 2022
Almost 75% of individuals
contacted accepted help
Source: Bremerton Police Department 2022
Annual Report
Tips for success
1.Clearly define what you want
your program to accomplish and
the parameters of the program.
2.Hire the right
people for the job.
3.Identify what data is important to
demonstrate the value of your
program and way to track and report.
Funding Contact information
•Kitsap County 1/10th
•Navigators are included in the police department
budget
Bremerton Police Department
Sergeant Tim Garrity,
timothy.garrity@ci.bremerton.wa.us
17
Connecting Community Members to Care
Central Kitsap Fire Rescue CARES
Central Kitsap Fire District, including Silverdale, Seabeck, and East Bremerton
Description Populations of emphasis
Central Kitsap Fire CARES (Community Assistance, Referral, and Education
Service) is a partnership between Central Kitsap Fire and the City of
Poulsbo that connects people with support and services that meet their
individual needs. This program addresses the underlying issues
contributing to non-emergent 9-1-1 calls and ED visits by providing
education and making referrals to local services. Central Kitsap Fire CARES
closely collaborates with and refers to community partners such as:
•Kitsap Mental Health Services
•Knights of Columbus
•Fishline
•Kitsap Division of Aging and Long-Term Care
•St. Michael Medical Center
•Local substance use disorder providers
•Local school districts
Anyone in fire district
How it works Data
1.9-1-1 call triage identifies cases
appropriate to refer to Fire CARES
2.Referrals are received through Julota
3.Phone call or in-person visit by CARES
team paramedic and social worker
4.CARES team refers individuals to
appropriate community resources
5.Discharge from program after individual
needs are met
289 referrals received and 186 people assisted
January-June 2023
27 individuals connected to care January-June 2023
19 avoided 9-1-1 calls because of on-scene
activity/home visit and 20 time fire crews relieved
in the field January-July 2023
Source: City of Poulsbo
Tips for success
1.Utilize a common data system for referral
and data collection.
2.You can mix and match approaches that will work best
for your community. You don’t have to re-invent the
wheel. There are many other programs to learn from.
Funding Contact information
Braided funding from multiple sources
including:
•Kitsap County 1/10th
•WA Association of Cities
Grant administered through the City of
Poulsbo
•Central Kitsap Fire Department operational
support including vehicles, office space,
employee time/benefits, administrative
support
Central Kitsap Fire Rescue, Chief Medical Officer
Alex McCracken, amccracken@ckfr.org
CARES team
Jesse Graham, Paramedic/Firefighter, jgraham@ckfr.org
Kloe Tran, MSW, ktran@ckfr.org
Website
www.ckfr.org/cares/
18
Connecting Community Members to Care
East Jefferson Fire Rescue CARES
East Jefferson County
Description Populations of emphasis
East Jefferson Fire Rescue (EJFR) CARES works to reduce the impact of low
acuity/non-emergency incidents to the 9-1-1 system and identify solutions to
clients by connecting them to appropriate services. EJFR CARES refers
community members to the most appropriate local services including:
•Believe in Recovery
•Jefferson Healthcare
•Local R.E.A.L. team
•Jefferson County Public Health
•Local community-based
organizations
•Elders over 65
•Veterans
•Unhoused
individuals/families
•People with unmet
behavioral health needs,
including substance use
disorder
How it works Data
•Referrals received from 9-1-1 providers and other local
partners.
•EMS assesses individual needs (emergent or not) and refers
appropriate cases to CARES.
•Cases prioritized by referral urgency.
•CARES responds to referral (in-person and/or phone),
completes assessment, and develops tailored care plan to
meet individual needs.
•Limited flexible funding is available to meet immediate needs
such as food, clothing, prescriptions, etc.
•CARES team provides follow-up as needed to ensure
connections to appropriate resources is made.
217 new contacts
85% of elder contacts ended
with successful connections to
senior services
89% of veteran contacts ended
with successful connections to
veteran and military services
Source: EJFR Fire CARES, Jan 17-April 30,
2023
Tips for success
1.Stay flexible and nimble to best meet the
community needs. The program will evolve.
2.Mix and match approaches to find what works for
your community. Look at other programs for
lessons learned and ideas.
Funding Contact information
Braided funding of multiple sources.
•Association of WA Cities (Port Townsend holds
grant)
•Jefferson County 1/10th
•Jefferson Behavioral Health Consortium
•EJFR supports partial operational costs
East Jefferson Fire & Rescue, Fire Chief
Bret Black, bblack@ejfr.org
EJFR CARES Team Video
https://youtu.be/mLPGlTzRc4I
Website
www.ejfr.org/uncategorized/fire-cares/
19
Connecting Community Members to Care
Kitsap County Sheriff’s Crisis Intervention Coordinator
Kitsap County, WA
Description Populations of
emphasis
The Crisis Intervention Coordinator (CIC) works to divert people experiencing
mental health needs away from the criminal justice system and toward
treatment through referrals to the proper social agencies, whenever available
and appropriate. The CIC uses understanding and skills gained through specific
training and experience to identify and provide a safe, effective, and
compassionate response to law enforcement situations involving people in
mental health crisis. The CIC works with law enforcement, community partners,
and community members to conduct proactive behavioral health outreach and
follow up.
Anyone experiencing
mental health crisis.
How it works Data
1.Patrol officers create log of reports that would benefit from
follow-up to meet individual mental health needs and
promote public safety.
2.Crisis Intervention Coordinator prioritizes reports based on
urgency and capacity.
3.Coordinator follows up with individuals to better
understand their needs.
4.Coordinator connects individual
with various community resources
to best meet their needs.
5.Coordinator assists patrol officers
for high priority events in addition
to responding to referrals.
In 2022:
204 unique community members
served
391 interactions with clients
48 referrals to local R.E.A.L. Teams
Note: 2022 data reflects 1 full-time (4
days/week) CIC.
Source: 2022 1/10th report, Kitsap Public Health
District and Kitsap County Sheriff’s Office
Tips for success
1.Choose a focus area topic in
order to maximize efforts.
2.Create a plan for the program
and share with city and county
elected officials and boards to
obtain support and funding.
3.Plan for administrative and
reporting support to allow
responders as much time as
possible in the field.
Funding Contact information
•Kitsap County 1/10th funds one CIC position Kitsap County Sheriff’s Department, Crisis
Intervention Coordinator/Patrol Deputy
Casey Jinks, cjinks@kitsap.gov
20
Connecting Community Members to Care
Port Angeles Fire Department Community Paramedicine Program
Port Angeles, WA
Description Populations of emphasis
The Community Paramedicine Program’s mission is to improve the overall
health of the community and utilize a combination of medical and behavioral
health training, multi-agency collaboration, and point-of-care treatment to help
solve complicated issues. Key partners include:
•North Olympic Healthcare Network
•Olympic Medical Center
•Peninsula Behavioral Health
•Jamestown Family Health Clinic
•Lower Elwha Tribal Clinic
•Port Angeles Police Department
•Olympic Peninsula Community Clinic
Underserved members of
the community including
people experiencing:
•high use of 9-1-1
and/or emergency
department
•behavioral health
problems including
substance use
disorder,
•low-income status,
•and other social and
medical needs
How it works Data
1.Partner organizations and Tribes
refer individuals with high 9-1-1
and/or ED use.
2.Community paramedic contacts
the individual.
3.Community paramedic connects
the individual with appropriate
services based on their needs.
4.The individual is equipped with
supportive services.
748 unique community members served in 2022
80% decline in ED visits by enrolled patients in 2021
69% reduction in 9-1-1 calls by enrolled patients in 2021
$850,000 cost savings in 2021-2022
Source: Port Angeles Fire Department Community Paramedicine Program
Tips for success
1.Observe and learn
from other
programs.
2.Start small. Remember
change is slow. It’s okay to
reiterate and refine as you
go.
3.Create a plan to meet administrative
requirements like grant writing and
reporting. Learn about funding requirements
upfront.
Funding Contact information
•City of Port Angeles covers benefits
•Clallam County 1/10th provides funding
for 1 FTE
•North Olympic Healthcare Network
provides funding for 2 FTE
Port Angeles Fire Department, Fire Chief
Derrell Sharp, dsharp@cityofpa.us
Community Paramedics
Brian Gerdes, bgerdes@cityofpa.us
Kristin Fox, kfox@cityofpa.us
Website
https://www.olympicch.org/post/shifting-from-reactive-to-proactive
21
Connecting Community Members to Care
Poulsbo Fire CARES
Poulsbo, WA and broader areas of North Kitsap including service to Suquamish and Port Gamble
S’Klallam Tribes
Description Populations of
emphasis
Poulsbo Fire CARES is a collaborative project
between the Poulsbo Fire Department and the City
of Poulsbo with the goal of serving community
members facing behavioral health-related issues and
chronic medical conditions. CARES primarily
responds to referrals from first responders (fire,
EMS, police) but also accepts referrals from some
social service partners. Through CARES, individuals
are connected to resources that meet their individual
needs and assisted with system navigation.
•People with behavioral
health needs
•People with chronic
medical conditions
•People using 9-1-1 to
address non-emergent
conditions
•Approximately 60% of
calls are for elderly/aging
How it works Data
1.Referral received.
2.Referrals prioritized based on crisis and
time-sensitivity.
3.Team makes follow up calls and/or field
visits; works with individuals, caregivers,
health and social service providers.
4.Warm handoff to needed resources
(ensuring connections are made).
5.Continue case management as needed
(limited).
299 referrals received and 257 people assisted
January-June 2023
88 individuals connected to care January-June 2023
74 avoided 9-1-1 calls because of on-scene
activity/home visit and 7 time fire crews relieved in
the field January-July 2023
Source: Poulsbo Fire CARES
Tips for success
1.Hire a program manager, or someone
who can hold the reporting, grants, and
building partnerships pieces of this work.
2.Consider community context and available resources.
This work is not impactful if we don’t have resources to
refer to that meet people’s needs-and close working
relationships with partners.
Funding Contact information
Braided funding through various grants
including:
•Department of Commerce
•Salish Behavioral Health Administrative
Services Organization
•Kitsap County 1/10th
•City of Poulsbo and Poulsbo Fire offer in-
kind funding for core staffing
City of Poulsbo, Program Manager
Kim Hendrickson, kimberlyh@cityofpoulsbo.com
Poulsbo Fire, Captain and CARES Operational Manager
Jake Gillanders, jgillanders@poulsbofire.org
Website
•https://cityofpoulsbo.com/poulsbo-fire-cares/
•https://www.olympicch.org/post/poulsbo-fire-cares
22
Connecting Community Members to Care
REdisCOVERY Program
Port Angeles, WA and surrounding areas
Description Populations of emphasis
Olympic Peninsula Community Clinic’s (OPCC)
REdisCOVERY program strives to reduce overdose, reduce
non-emergent EMS, and ensure every member of the
community has access to care. The REdisCOVERY team has
found success by collaborating with:
•Clallam County Corrections Facility
•Clallam County Health and Human Services
•Clallam County Sheriff's Office
•Department of Transportation
•City of Forks Jail
•Forks Police Department
•Olympic Personal Growth
•Peninsula Behavioral Health
•Port Angeles Community Paramedicine Program
•Port Angeles Police Department
•Reflections Counseling
•Sequim Police Department
•Washington State Patrol
•Individuals who are un and/or under
insured
•Individuals experiencing homelessness
•Individuals identified needing assistance
accessing services
How it works Data
•Outreach teams visit community spaces to
proactively reach vulnerable populations.
•Partners send referrals and the team responds
within 24 hours.
•The team provides care coordination to meet
individual needs.
946 indivdiduals served
437 individuals received bridge medical and/or
behavioral health care
Source: Olympic Peninsula Community Clinic, Jan-Jun 2023
Tips for success
1.Outreach teams need to feel supported by leadership in order to support the community.
Funding Contact information
Braided funding through various contracts and
grants including:
•HCA
•WA Association of Sheriffs and Police Chiefs
•WA Association of Cities
•Clallam County 1/10th
•ARPA funding through Clallam County Health
and Human Services
Olympic Peninsula Community Clinic, Director of
Programs and Personnel
Helen Kenoyer, hkenoyer@opcclinic.org
Website
https://www.vimoclinic.org/rediscovery_program.php
23
Connecting Community Members to Care
Salish R.E.A.L. Teams
5 teams covering Clallam, Jefferson, and Kitsap counties
Description Populations of emphasis
R.E.A.L. (Recovery, Empowerment, Advocacy, and Linkage) Teams are
the Salish region’s approach to implementing local Recovery
Navigator Programs as required across WA State as a result of the
Blake decision. R.E.A.L. is a client driven, harm reduction model to
support individuals along their recovery journey, at their individual
pace. Each R.E.A.L. Team consists of a project manager to engage
community and conduct outreach, a case manager, and two recovery
coaches to directly respond to referrals.
R.E.A.L. Teams provide 24/7 support and respond within 90 minutes
to referrals received.
People presenting with SUD or co-
occurring AND legal system/law
enforcement nexus AND who have
not been successful engaging with
treatment in the past.
How it works Data
1.Referral to R.E.A.L. Team by law enforcement or
community members.
2.R.E.A.L. Team responds according to individual
client’s needs with the goal to support people
towards recovery at their own trajectory.
3.Warm handoff referrals as needed.
4.Flexible funding is available to meet the client’s
needs.
5.Operational Workgroup gathers local boots on the
ground to problem solve around individual cases
as well as community barriers.
6.Operational Workgroups meet regularly to
coordinate care and avoid duplication across
involved partners.
7.Policy Coordination Group (PCG) engages higher
level leadership who can support system change.
1,731 individuals served regionally:
•Clallam: 874
•Jefferson: 157
•Kitsap: 700
88% of regional referrals responded to in 0-
15 minutes
Source: Salish R.E.A.L. Program data July 2022-May 2023
Tips for success
1.Be mindful of duplicaton. Create and maintain open communication with community partners.
Funding Contact information
The Salish Behavioral Health Administrative Services
Organization funds 5 programs covering the Olympic region.
•$1.2 million/year provided via state proviso
•An additional $600k provided via state general funds to
support transition to 24/7 coverage
Salish Behavioral Health Administrative
Services Organization, Deputy
Administrator
Jolene Kron, jkron@kitsap.gov
24
Connecting Community Members to Care
Sequim Navigator Program
Sequim, WA
Description Populations of emphasis
The Sequim Navigator program is intended to expand needed in-the-field
crisis response and services to the Sequim area. Designated Crisis
Responders (DCR) work closely with community partners and law
enforcement to respond to people with a behavioral health need, assess
for appropriate intervention and solutions, and make referrals to needed
services. The DCR also educates community members about the crisis
system and what services are available to community members
experiencing concerns.
Anyone currently in Sequim
experiencing mental health
and/or substance use disorder
How it works Data
•DCR is available T-Th, 12 hour days
•DCR rides along with Sequim Police Department, checks on people of
concern, and responds to referrals
•Referrals are primarily received from local crisis line, law
enforcement, Jamestown Healing Clinic. Any community member
may make a referral.
•Each referral is assessed for appropriate intervention. Interventions
may range from involuntary or voluntary hospitalization to brief crisis
counseling and referral to appropriate community partner.
•DCRs engage with community to provide education about the
program and broader behavioral health crisis system.
180 encounters
Source: Peninsula Behavioral
Health, September 2022-June 2023
If you have concerns about
someone who may be
experiencing a behavioral health
crisis, please contact
Volunteers of America 24/7
crisis line: 1-888-910-0416
Tips for success
1.Build strong relationships with
community partners. The work
is made better by many people
working together.
2.Be bold, write up an idea,
and get started. Don’t be
afraid to think outside the
box.
3.Make sure you have the right
person where and when they
are needed to meet the unique
needs of your community.
Funding Contact information
•Funding from Jamestown
S’Klallam Tribe through the City
of Sequim
•Crisis services are reimbursed
through the Salish Behavioral
Health Administrative Services
Organization
Peninsula Behavioral Health, Crisis Intervention Services Supervisor
Monica Vanderheiden, monicav@peninsulabehavioral.org
Website
https://peninsulabehavioral.org/get-immediate-help/
25
Connecting Community Members to Care 26