Before he retired as the head of the Honolulu Emergency Services Department in 2020, Jim Howe wanted to ready the department for a growing problem facing Oahu: The number of seniors calling 911 for nonemergency medical services.

Between 2015 and 2019, the number of calls from Oahu residents over age 75 increased by nearly 15%. With the state’s population aging fast, Howe knew the numbers would only worsen.

“There’s a direct correlation between the aging population and their use of the EMS system,” he said.

Many of those calls are from people with issues that don’t necessitate an emergency room visit, like anxiety, confusion, minor falls or requests for a blood pressure test.

But Howe also saw a solution that would prevent these calls from diverting ambulance services from needier callers.

On the Big Island, a program that has been operating since 2016 provides home visits and safety assessments for older people, as well as visits to homeless encampments, helping those residents to avoid reaching out to EMS for non-emergencies.

It is based on what’s called a community paramedicine model, in which EMS workers are tasked with providing primary and preventive services. It makes health care services more readily accessible and facilitates more suitable use of the emergency system.

Efforts to establish a similar program on Oahu led to the creation of the city’s Crisis, Outreach, Response and Engagement program, Howe said. CORE is focused on addressing the needs of the homeless community and reducing the number of nonemergency calls made by that population.

Expanding CORE to meet the needs of seniors could reduce the number of 911 calls coming from these community members and help address their issues in a more cost-effective way, an urgent challenge as the state’s population ages, Howe said.

“How do you make sure that they’re accessing and getting the care they need?” Howe said. “That’s the challenge.”

A More Appropriate Response

The Honolulu Emergency Services Department also deals with a number of high-use individuals who call “maybe once a week,” for a nonemergency issue, said Ian Santee, the department’s current deputy director. According to the department, between one-half and one-third of all 911 calls are minor in nature.

Nonemergency callers redirect the department’s resources from those who might need them more urgently.

There are tiers of ambulances that respond to calls. If one of the city’s highest-tier ambulances — which are staffed by paramedics capable of providing more intensive medical services — is tied up handling a lower-level case, it could mean a longer response time for someone dealing with a life-threatening issue, Howe said. 

“It’s using one-size-fits-all for every kind of medical case there is,” Howe said. “It’s not efficient and it’s costly.”

The CORE program was implemented on Oahu in late 2021 to reduce the number of ambulances sent to nonviolent homeless-related 911 calls. It’s set up to help homeless people navigate the insurance system, access medical care and obtain assistance with a variety of challenges from housing to a lack of identification. It also has three ambulances equipped to deal with non-emergencies.

“We’re facilitating (homeless) individuals to find affordable housing or assisted living or foster care,” Santee said.

The focus has primarily been on the homeless population, Howe said, because there were more readily available federal funds aimed at addressing the issue when the CORE program was conceived. The program has so far received $3 million in federal funding. 

A 2019 report issued by the National Transportation Safety Board determined that Honolulu’s system would benefit from utilizing lower-tier vehicles, and the department initiated these services in 2020. Responding with a lower-tier ambulance reduced costs by about 30% per call during his tenure, he said. 

The report also suggested that the department implement community paramedicine to build out a comprehensive EMS system that adequately addresses patients’ needs.

Santee emphasized that CORE’s current priority is to address the homeless population, but agreed that CORE could serve as a blueprint for a program in which EMS checks in with older frequent callers on a regular basis.

“Can it be something that can definitely help the system? Yes,” Santee said. “But as with any system expansion, as with any new venture, staffing and funding is a vital part of everything.” 

In the meantime, Howe says other things can be done to improve the system. One development that could address the needs of the older population is the increased use of telemedicine.

EMS workers can contact health providers and provide some patients needed care on the spot — rather than transporting them to the emergency room. It’s a “big change in the way we have been doing EMS in the United States,” Howe said.

The department has also shared public service announcements and provided education to the public on when people should reach out to 911.

“I don’t think we’re going to get people to not call 911 when they need help,” Howe said. “We just have to make sure that we can give them the kind of help they really need, not way more than they need.”

Civil Beat’s community health coverage is supported by the Atherton Family Foundation, Swayne Family Fund of Hawaii Community Foundation, the Cooke Foundation and Papa Ola Lokahi.