It’s early morning and Jesse Ebersole juggles normal, daily responsibilities with today’s weekly sojourn to homes, apartments and streets where frequent ER visitors live.
He and colleague, Vern Hara, are medical specialists serving in the Hawaii Fire Department Community Paramedicine Pilot Program.
Ebersole canvasses East Hawaii and Hara West.
The pilot program — curbing frequent health-related 911 calls that could be better handled by a clinic than a hospital — saves taxpayer money by proactively connecting patients with services.
They hunt red flags of life in crisis: hoarding, medication disarray, scattered garbage, filth, fridge empty or lack of bathing.
“We knock on the door and they recognize us as the Fire Department, trust us as the Fire Department,” Ebersole says.
They arrive assertive, calling out “Fire Department!” Professional demeanors mask uncertainty about what’s inside, such as an agitated patient or dog.
Today’s first patient is self-conscious, worrying a probation violation could mean loss of housing.
Much of the medical specialists’ time is spent asking neighbors for help finding the right apartment, knocking on doors and trying to ascertain whether a given patient is home.
“It’s almost like looking for an Easter egg,” Ebersole says after climbing up, placing a hand on a wall and looking inside to make sure an aging patient hasn’t fallen, unable to get to the door.
“A lot of times what we uncover is an elderly couple where, one, the healthier of the two, is the caregiver for the other — and they’ve been managing this situation for years — and the caregiver gets sick,” Ebersole says. “We get involved when one of them falls. It’s an act of desperation when somebody has to call 911 to get help to get somebody up.”
Hara has helped acutely sick people for 15 years, Ebersole for 27.
After an ambulance call, “you drop them off and it’s over,” Hara says.
But with the pilot program, it feels different.
“With this work, you’re able to see an overall improvement of their life,” Hara says.
But being proactive doesn’t mean it’s easy.
“When they have any type of mental health/behavioral health issues, it’s hard to get them back on the track — because it’s so easy to fall back off the track,” Hara says.
He parks the county vehicle at an apartment complex and asks a tenant for the office. Once there, he seeks the apartment of Douglas Brain, 66, a Hilo poet.
Brain’s been on the street, he says, for “6 1/2 weeks” after an eviction. He’s in emergency, temporary housing after his most recent hospital stay.
Ebersole carefully explains the importance of calling 911 if Brain feels a danger to himself or others, chest pain, uncontrolled bleeding or a true medical emergency, such as a serious burn.
“My blood sugar hit 35 at one point,” Brain says. Normal blood sugar is 80 to 120. Lower levels can impair cognitive function.
For that, “you needed to be in the ER,” Ebersole reassures.
Ebersole notes Brain’s walker resting near the doorway and asks, “how often do you fall?”
“Maybe once every two months, says Brain, whose vision is poor.
Ebersole tells Brain he’ll write a report about the visit.
“That’s the kind of services that is so needed in this community. It’s beyond belief,” Brain says. “You are the only thing that can glue this community back together. We are a lot of homeless, we are in need. But we’re not without our wits. You guys are a service unto your own — and I’m proud to know any one of you.”
Hara asks what happened to Brain’s bed.
“It’s like ‘up in smoke,’” Brain replies. “I don’t know where it is. I wish I knew.”
“We’ll have the guys up at the Office of Aging follow up,” Hara says.
Brain tries to explain, without anyone asking, why he’s worthy of help.
“I’m a good Christian,” he says. “Every morning I start my day with my prayers. I end my day with my prayers. I don’t wish anybody any harm.”
Hara and Ebersole exit and head to their next stop.
“I’m not as brave as Jesse, so it was a little unnerving to me because, for my whole career, we were going to people who were expecting us,” Hara said. At first, he said, he’d “do a little drive-by” to check a residence to be sure of safety “then I go back and go in.”
But he’s past that.
“If we feel a little bit uneasy, we just grab somebody from one of the fire stations,” Ebersole says.
He’s been where a patient caught rainwater in yard buckets for drinking water and had only soda and a candy bar for food. Catching rainwater that way risks leptospirosis, Giardia and rat lungworm disease, Hara says.
Ebersole remembers a 90-something family caregiver exhausted caring for a disabled daughter in her 60s.
Each patient’s situation has unique properties.
It’s surprising “how many people are out there living independently with dementia,” Ebersole said.
Another surprise, he said, is how many are “hanging on by a thread, who are eligible for services but just don’t know how to access them.” He thinks the pilot program makes its biggest impact with them.
Milton McNicholl, a retired Hilo Transportation and Terminal mechanic and manager, is a doting elder and loves hanging with his granddaughter.
McNicholl calls 911 when he needs medical care he could probably get at a clinic if he was able to get there.
“The cost of the ambulance is $1,200,” Ebersole coaches. “So if you can get those vouchers …”
McNicholl says he keeps close track of his taxi coupons. But they don’t last long enough. Residents are limited to one book of 15 coupons per week, enough for three round-trip journeys of 4-9 miles.
Ebersole says the program could become permanent if sustainable funding is found. In other communities, that has required partnerships with hospitals, fire departments and insurance companies.
Ebersole hopes new, weekly Tuesdays outreach with Hawaii Island Family Medical Center has potential to become permanent (if it’s cheaper for Hilo Medical Center to pay for program intervention than higher ER costs).
Hilo Medical Center declined to comment for this article.
The pilot program is funded by a grant from the Hawaii County Office of Aging.
“The chief is supportive of it. The mayor is supportive of it,” Ebersole said. “Everybody realizes we’re in a position to do a great deal of good with a small amount of resources.”
While the fire medics search for a patient, an elderly woman who answers the door — not the right person — seems confused and feeble. It’s possible she might qualify for benefits. Hara, outside on the stairwell, presses against one end of a step as a safety check.
The fire medics transform into investigators.
Ebersole gets permission to enter and steps inside.
He asks what day it is, what month, what year. The woman stammers and can’t reply correctly. By the final question, she simply doesn’t answer.
She has dementia and can’t say who lives with her or who takes care of her.
Ebersole points out multiple shoes of various sizes at her doorstep. She must have others living with her. What are their names?
But her damaged memory doesn’t cooperate.
“You gotta do some detective work a lot of the times,” Hara says, “like, Jesse will go and look at some of her medications.”
Ebersole steps into the next room to assess the woman’s medications and she sits back down in her chair at the television and appears to forget anyone, aside from her, is in the room — until Ebersole begins asking questions again.
Hara lifts a coffee cup from the table and, from its warmth, knows the woman has not been alone long.
“Vern’s a great detective,” Ebersole says later. “I would never have checked the coffee.”
Fresh fruit and bread tell him someone is caregiving for the woman, probably a family member.
The fire medics thank her and leave a pamphlet, with information about the pilot program, along with their phone numbers and a note to the woman’s loved ones so they’ll know someone stopped by and how to get help.
Hara says outside that the family might not know that Medicaid might pay for a family member or friend to be a caregiver. A few minutes ago, they knew nothing about the woman. Now, they know her name, doctor’s name, pharmacy, family caregiver, that she lives with multiple people of varying ages and has access to food and medicine.
Although they’d prefer she not be alone, they’re happy she appears well-cared for.
The next patient lives by himself, has high blood pressure and heart problems, is blind, has psychiatric issues and is addicted to painkillers.
“The case worker wasn’t aware of how often he’d been utilizing 911,” Ebersole says. A new case worker is working on nursing-home placement.
“He calls all the time for abdominal pain, hoping if he goes to the ER they’ll give him a blast of opioids,” Ebersole says.
Next, they visit a patient’s middle-class home and try to rouse her. But she’s not there. Near the back door, Hara and Ebersole find a Meals on Wheels ice chest, containing fresh food that suggests she’s getting regular meals.
The overarching goal of the pilot program actually isn’t to save money.
“It’s like a collateral benefit, but what’s really our objective is helping those who are unable to help themselves,” Ebersole says. “We’re trying to help our community, our elderly kapuna.”
Email Jeff Hansel at jhansel@hawaiitribune-herald.com.
