Caring for the Most Vulnerable, Part 3

This is the third in a series about Caring for the Most Vulnerable.

The Community Health Assess and Treat (CHAT) team is part of the Portland (Oregon) Fire & Rescue Department.

CHAT was developed in 2016 and was designed to work with frequent 9-1-1 callers to identify health and social service resources that would reduce their dependence on the emergency prehospital care system for their primary health care needs.

The CHAT team responds to low acuity medical calls and is designed to be proactive and provide individuals who call 9-1-1 for non-emergent health issues the care they need in the moment and then connect them to the right resources to get them on the path to health improvement.

As first responders, firefighters are often the first to interact with a person who has dialed 9-1-1 for medical reasons. About a third of these calls are for issues that don’t require hospitalization or a trip to the emergency room.

Before CHAT was introduced, all 9-1-1 calls typically got the same level of response: an ambulance and transport to an ER.

With CHAT, Portland Fire & Rescue hopes to address the systemic gaps in the public health system which  disproportionately impact the most marginalized community members – people of color, refugees, houseless, seniors, and those with disabilities.

CHAT is funded by CareOregon, the state’s largest Medicaid provider. Medicaid provides health coverage to 84.5 million Americans, including eligible low-income adults, children, pregnant women, elderly adults and people with disabilities. Medicaid is administered by states, according to federal requirements.

CareOregon has invested USD $2.5 million in the CHAT program to build its capacity to best serve those eligible for the Oregon Health Plan (OHP).

Melissa Zimmer is a supervisor with CHAT.

"For the last 4-5 years I have worked in positions where I have worked with the houseless. One thing I remember when I work with these folks is we are all one big event in our lives from being in the same position.

"Unfortunately, in Portland, we see a lot of the houseless folks ravaged by drug use and mental health, but in the end, people need to remember that this is a disease. Mental health is a disease. Addiction is a disease and, yes, people can say they wanted to do it but when you’re addicted, properties inside your body takeover. It becomes a disease. It is a disease.

"The compassion that I have for the houseless and the love that I have for them as an Emergency Medical Technician (EMT) – my goal every day when I’m out there is to treat them like a human being because that’s all they want. They don’t want to be talked down to, they don’t want to be treated poorly. They don’t have the ability or the means to get the resources that you and I have.

"I see a lot of EMTs treat these folks like the stigma that they put under. I too, was there at one time and then learning that the processes that their bodies going through is truly disease. I can understand the medical side of it. It has changed my impression of working with folks with mental health with addiction, and just plain old houselessness.

Newman : If you had the opportunity to teach other EMTs about interacting with people who are living on the streets, what would you say to them? What would be the most important lessons you would share with them?

Zimmer : "This seams like such a easy question but it’s not.

"Be real. Watch your face and tone when approaching. These folks have been through some sort of trauma. We have no idea what it is. At times they will share.. others won’t. Living on the street is a tough game of survival.

"Compassion. Ask yourself why is your compassion any different for this patient than others?

"Respect. I think of it this way, people call 9-1-1 on these folks because they’re sleeping in funny positions or they’re on the road or they just want them out from in front of their building. I like to think of that space that I’m approaching as their living room.

"If you or I were having a really bad day and we wanted to scream in our living room, nobody’s going to call 9-1-1 on us. But if I was standing on the side of the road screaming, somebody sure will call 9-1-1 on me, so have respect for that space.

"I ask if I can come in, I ask if I can stand next to them. I ask them am I too close ? Or I can’t hear you – can I approach you? EMS is a skill of doing. Taking vitals or doing a treatment – we just do it. We come in, throw the blood pressure cuff on or we listen to lung sounds without even really talking to the patient about what we’re doing. With houseless folks there’s been so much trauma, you need to be aware of what you’re doing.

"I would really like to take your blood pressure. Are you OK with that? I’m going to take your blood pressure on this arm. I am going to come closer to you now. Although this should really be a skill you use with all your patients.

"I normalize their drug use. I don’t care that they are using drugs in the moment. I know that sounds weird. I do care that they’re using drugs. I am not going to change the fact that they are addicted to fentanyl or they’re addicted to methamphetamines. What I’m going to do is treat them with compassion and get buy-in from them that I really want to be there and that I really want to help them and I want to focus on what the call was first and then I can approach other health aspects.

"Trauma informed care- would be a class I would teach new EMTs.

"Addiction--one class of addiction (a few hours) is not enough to really understand addiction.

"Responding to the houseless you have one chance to make an impression on this person. They have been treated so poorly throughout their whole entire medical stint, that if you don’t catch that moment, they won’t go to get treatment. I have seen people that are literally letting limbs and fingers rot off because of the treatment they received at the ED or medical facilities. They would rather endure that than ask for help."