As Washington state emergency rooms overflow, here's one possible fix


NORTH MASON COUNTY — Panic hit Shirley Jacobs earlier this year when she abruptly lost her longtime primary care provider.

The 88-year-old, who lives in a cozy lakeside home near Belfair, received anti-inflammatory prescriptions that had to be refilled. She had other off-and-on medical needs. Jacobs worried she'd have to go to the hospital if she couldn't find a new provider soon and needed urgent care — something she's done before.

"It was a blow to everyone," Jacobs said. "None of us had a doctor. I couldn't get anyone to tell me why he left."

She needed a solution fast. One was already on its way.

Jacobs' search for a new primary care physician is one that's become more common throughout Washington, especially in more rural areas like in Kitsap and Mason counties. In other parts of the U.S., the looming physician shortage — ranging from pediatricians to cardiologists — has become an urgent public health crisis, the president of the American Medical Association said in October.

The hole has meant it's become harder for Washingtonians to seek various types of primary and specialty care — but it's also contributed to added pressure on hospital emergency departments, which have been under an extreme amount of stress the past several years.

Some parts of the state have responded to growing emergency department concerns by brainstorming novel solutions. One includes a mobile health team of medical and resource providers in north Mason County, uniquely based out of a local fire department and one of the first of its kind in the country.

Since launching, the model has helped reduce 911 medical calls and fill primary care gaps in the area, but emergency providers say more widespread, long-term fixes are needed to address the crunch for hospital capacity.

"It's hitting almost every emergency department," said Darcy Jaffe, senior vice president of clinical excellence at the Washington State Hospital Association. "There's not any excess capacity anywhere."

Chronic difficulties include increases in emergency department admissions, sicker patients and problems discharging patients who no longer require hospital care.

The growing lack of primary and urgent care options doesn't help.

Last month, a study from the state Office of Financial Management found about 40% of emergency department claims in 2021 were "primary care sensitive" — meaning the visit might have been avoided through better access to primary care. About a third were for nonemergencies.

At North Valley Hospital in Tonasket, Okanogan County, emergency department manager Jody Anderson said patients have shown up with a bad sore throat if their primary care doctors can't see them that day or week. Other providers throughout Washington recounted emergency room visits from those with respiratory illnesses, chronic conditions and complications from delayed care.

Anderson herself went through three primary care providers in the past five years. "I can't imagine what it's like for those who need ongoing specialty care," she said.

For that and other reasons, emergency departments fill up. Emergency staffers face a "microcosm" of stressors — handling a range of life-threatening and urgent conditions while facing burnout and often feeling unequipped to properly treat people with other emergency conditions, like mental health and substance use disorders, Jaffe said.

"It's hard when you go to work and you see half the beds are already full ... with admitted patients," said Dr. Herbie Duber, president of Washington's chapter of the American College of Emergency Physicians. "And then during the course of the afternoon, you just see the waiting room numbers continue to get longer and longer and longer."

Still, hospitals don't want people to think twice about showing up at the emergency room if they need to.

"That's why we exist," said Dr. Arvin Akhavan, medical director of Harborview Medical Center's emergency department in Seattle. "If people are concerned that something emergent has gone on, they should see an emergency physician and they should go to an ER."

A medical clinic on wheels

In Belfair, a 4,100-person Mason County community surrounded by forest and lakes, local fire department staff noticed they were responding to more and more calls for emergency medical services.

In 2019, the North Mason County Regional Fire Authority responded to about 2,400 fire and EMS calls, the majority of which were for medical emergencies. By 2022, the number had jumped to 3,000-plus.

Fire Chief Beau Bakken found the increase was primarily being driven by a rise in calls for less-critical cases, like colds or management of chronic conditions, rather than life-threatening emergencies that require advanced medical care, like gunshot wounds or strokes.

"911 was becoming the default for accessing not just emergency care but all types of medical care," Bakken said.

EMS responders statewide have seen a similar trend, with the percentage of calls for basic medical support reported to the state nearly doubling in the past five years.

State sees rise in emergency calls for basic life support

Since 2018, a growing percentage of EMS responses reported to the state have been for basic life support calls that don't require advanced medical services. Since then, more than 120 additional agencies started reporting data to the state. These calls might be urgent, but they aren't necessarily considered life-threatening cases that require advanced life support, such as a heart attack or stroke.

Washington state Department of Health (Alison Saldanha / The Seattle Times)

As Bakken analyzed these EMS numbers, he also watched his local emergency providers scrambling to meet patient needs. At St. Michael Medical Center in Silverdale, the only hospital on the Kitsap Peninsula, ongoing challenges eventually led to a chaotic night in 2022 that prompted a nurse to request support in the waiting room from another local fire department.

Bakken wondered how his fire station might be able to help keep less-acute patients out of the hospital while still getting them the care they need. And a new program was born.

North Mason Regional Fire's medical team — known as the Mobile Integrated Health Program — not only aims to lower ER admissions and deliver urgent care to people's homes but also hopes to cut down on health care costs for patients. An ER bill is generally more than 20 times the cost of a clinic visit, Bakken said.

While the program is based on a community paramedicine model that's existed in the U.S. for over a decade, the fire station staffs other types of providers, including a physician assistant or associate (known as a PA), a psychiatric advanced registered nurse practitioner and community resource specialist.

While paramedics generally have a wide scope of practice — ranging from injecting overdose-reversal medication to delivering babies — it "pales in comparison to what a doctor or PA can do," Bakken said.

The team, primarily funded by its public hospital district and various grants, sees patients at home, the fire station or anywhere else in their 132-square-mile service area.

"Bringing health care back into the community has been enlightening," said program PA Adam Boyd, who worked in emergency medicine and primary care in the area for years before joining the fire authority.

On a weekday this spring, 88-year-old Jacobs was the team's first patient of the morning. She cheerfully greeted Boyd and Abe Gardner, community resource specialist, as they settled into her living room.

"I'm here to drop off your meds," Boyd told her. "We're going to be in and out of your hair."

"It's nice to have company," she said.

Boyd spent about 15 minutes talking with Jacobs about her electrolyte intake, hydration, blood count and access to food before checking her vital signs.

He brings nearly everything he needs with him in the team's white Chevrolet, packed with medical supplies. Catheters, IVs, mobile blood testing machines and supplies for wound care and suturing fill the back of the SUV. A small refrigerator keeps specimens and medications cold.

"If you need any help around the house or other things outside, just let me know," Gardner said to Jacobs. He has experience in public health, overdose prevention and post-incarceration reentry programs, and now makes sure patients get connected to whatever nonmedical resources they need — including transportation, groceries, physical therapy programs, fall-prevention measures and support groups.

As the two got ready to head out to their next appointment, Jacobs beamed at them.

"Every time I can't get to a doctor, we've had Adam," she said. "He's wonderful."

Boyd would see five other patients that day, delivering care that ranged from treating urinary tract infections to cleaning wounds.

Jacobs has since found a new primary care doctor in Port Orchard, but if she needed something urgently, she'd still likely rely on the North Mason Regional Fire team, her daughter, Debbie, said later.

"Adam's department filled a huge hole in the community," Debbie Jacobs said. "It's an amazing resource."

"The last resort"

Overcrowding in emergency departments has been a growing problem for years, reaching a particularly difficult point during the height of the COVID-19 pandemic — and as the population ages and care becomes more complex.

Lots of ideas are bouncing around the state on how to fix the problem in emergency departments and what the source of the problem really is. Business groups and hospital leaders have pointed to increasing rates of ER patients with substance use or mental health disorders, often complicated by homelessness. A group of local emergency physicians — led by Duber of the state's American College of Emergency Physicians — responded by warning against stigmatizing users and focusing on other stressors.

For example, a yearslong shortage of long-term care and psychiatric beds, and the staff for both, has led to a backlog of patients stuck in hospitals — including in the emergency room. Boarders often take up space in every corner of a hospital, meaning it takes longer for beds to open, Duber said.

Low rates of Medicaid reimbursement also hurt hospitals and primary care offices, many of which have been struggling financially since the pandemic began. When providers are forced to close their clinics or hospitals cut specialty care units due to financial losses, patients again face gaps in care and might eventually seek the ER.

"The emergency department ends up becoming the last resort and last stop that catches everyone," said Anna Taylor, former director of ambulatory services at Summit Pacific Medical Center in Grays Harbor.

Over the years, the state has introduced a variety of potential solutions, including ones similar to the fire department program in north Mason County. During this year's legislative session, state lawmakers made a federal "hospital at home" program permanent here, which allows hospitals to make acute-care house calls.

The state also offered over $10 million in grants to hospitals in financial distress, hoping to prevent unit closures and help keep doors open.

Still, Duber sees room for more work. He wishes hospitals would be clearer on their capacity and staffing levels. He also recognizes ongoing needs outside health care facilities, like for better access to housing and social services, as well as primary care.

"We need a more comprehensive solution," Duber said.

One way forward

In north Mason County, the mobile health team is expanding fast and getting busier.

The program was recently awarded a grant from a statewide first-responder organization and has hired a registered nurse, who starts Monday, to join Boyd, Gardner and psychiatric ARNP Kristi Eilers.

The goal isn't to replace needed primary care clinics or hospitals — it's to support them by addressing medical needs earlier, before they reach a crisis point, Boyd said. He's not the equivalent of a primary care physician, he reminds patients, and tries to connect them with long-term medical providers when possible.

Partnerships with St. Michael hospital, Peninsula Community Health Services, Mason General Hospital in Shelton and other organizations in the area are "integral" to the program's success, Boyd said.

He and the mobile health team can't address every situation. They call for an ambulance when they see patients who need more help. But paramedic crews also often send referrals their way.

"More often than not, people are more comfortable in their own home and are more open to conversation," Gardner said. "And that's where the most trust is built — plus it gives us an opportunity to have a more in-depth discussion."

Sometimes their appointments are 20 minutes. Others span over an hour.

They know their model might not be as effective in larger, more populated areas with more need, like Seattle. Securing stable funding and staff could also be a challenge. But the team is hopeful other rural areas could benefit from something similar.

The year the program launched ended up becoming the first year in nearly three decades North Mason Regional Fire's call volume did not increase, instead dropping by about 100 calls, according to department data. Since April 2023, the program has saved its patients at least $2.5 million in health care costs, not including dollars spent on longer hospital stays, according to the department's analysis.

Patients don't pay for their care. If they have insurance, the program will bill the insurer, and if they don't, the program writes off costs.

North Mason County 911 EMS calls drop for first time in years

In north Mason County, the number of 911 calls increased every year since 2019 — until last year. Leaders at the district fire department credit a new mobile health program that aims to deliver primary care to people's homes and cut down on hospital visits.

North Mason Regional Fire Authority (Alison Saldanha / The Seattle Times)

"We're moving in the right direction," Bakken said.

Word has spread about the team in the past year. When Elise Maupin's son, Jonah, came down with an ear infection recently, the program quickly came to mind.

Maupin, who's lived in Belfair for 12 years, said she's often experienced long waits when trying to schedule appointments with her 4-year-old's pediatrician.

Instead, she made an appointment to see Boyd for the following day.

In the small clinic space at the fire station, Jonah hopped up onto the exam table. Boyd took a look at both ears, listened to the child's heart and lungs with a stethoscope and recommended an oral antibiotic.

Maupin was relieved to have an option outside of crowding into the town's only urgent care center, waiting weeks to see a provider or potentially having to take her son to the ER. She described the care her family members received from Boyd as "wholesome."

"It's great Adam is able to prescribe things," Maupin said of Jonah's visit. "It was super helpful. It kept him out of the hospital."


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