Program and Activity Descriptions
1. Persons Experiencing Homelessness (PEH) Support Program
These activities are conducted by CHP Case Managers with the following goals:
- Improve the quality of life and health of PEH
- Reduce the reliance of PEH on the emergency system
- Help PEH proactively manage their health
Homeless Outreach Street Team (HOST) - PEH Support in the Downtown Area
The HOST program functions as a multi-agency, multi-disciplinary team with staff from each agency contributing their unique capabilities to team. The team itself is comprised of personnel from Integral Care, the Austin Police department, ATCEMS CHP, and the Downtown Austin Community Court. The team’s goals include reducing PEH reliance on the 911 system.
Eligibility Requirements: Status as a Person Experiencing Homelessness, currently in Travis County, or neighboring counties within the city limits of Austin.
Pop-Up Resource Clinic Program
The Pop-Up Resource Clinic (PURC) Program is an Austin-Travis County EMS activity developed and implemented by CHP. It is a proactive approach to providing for the needs of the homeless population in Austin. The program hosts multi-agency, multi-disciplinary resources clinics at locations throughout the city. The Pop-Up Resource Clinics are organized by ATCEMS CHP with support from Central Health, and partner with service agencies from the city, county and federal government, clinical providers, as well as non-profit organizations to bring a wide offering of on-site services. Services provided to attendees typically include connection to PCP with on-site provider evaluation, prescription services, identification and document procurement, HIV, Hep-C and other testing, care for substance use disorders, assistance with legal needs, housing needs assessment and assistance, medical funding enrollment and more.
2. High Utilizer Group (HUG) Program
The HUG program is an effort by CHP to reduce certain individual’s reliance on the 911 system and emergency departments for controllable and preventable needs that can be well managed with other resources. Clients are identified via internal surveillance of EMS patient encounters. Once enrolled, a CHP Case Manager completes a universal needs-assessment and develops a plan to address the gaps and connect the client to available resources. This may include medical funding and benefits, primary and specialty medical care, mental health care, prescription services and delivery, social and basic needs support services, and more.
The CHP Commander sets eligibility rates and criteria based on EMS use within the county. General criteria are:
20 or more EMS encounters in 90 days: Automatic enrollment as HUG client
10 – 20 EMS encounters in 90 days: Eligibility is dependent on the cause of the use of 911 being due to a gap in addressable causes/basic needs: Healthcare funding, Primary or Specialty medical care, Mental Health care, prescription services, or transportation.
When a person is suddenly deprived of a basic need, as listed above, they are at risk of becoming reliant on EMS unless the need is met. In these situations, CHP will enroll the client as a HUG-Prevention client in an effort to solve the issue before they become a high utilizer.
Less than EMS encounters in 90 days with a recent change in their ability to access the above addressable causes.
3. Managed Populations Program
The managed populations program is an initiative by CHP that seeks to address specific groups of persons, who because of their situation or history have a tendency to be reliant on 911 and the hospital system for non-emergent needs. This program, through a CHP Case Manager, evaluates new “residents” of the site or location to complete a universal needs-assessment. The CHP CM then works to connect the client to resources necessary to help them proactively manage their medical and mental health needs without reliance on the 911 system. The CHP CM also receives regular notification of residents at the location who call 911 for EMS, evaluates the event, and provides direct follow-up and coaching the resident with the goal of improving their situation and avoiding future needs.
Current Managed Populations
Community First! Village
Austin Transitional Center – this program has evolved following several years of CHP guidance and interaction to a state where CHP presence is no longer required. A CHP CM will connect with and assist residents as needed.
Eligibility: Eligibility is based on residence within an established “managed population”. Managed Populations are defined and designated by CHP Command based on 911 usage and potential for successful intervention.
4. Re-Admission Prevention Program
This program is focused on patient conditions which have a high risk of readmission following discharge. CHP has shown that we can effectively reduce re-admissions for certain high-risk condition through regular at-home medical evaluation and care. The goals of this program include improved patient outcomes and satisfaction, reduced unreimbursed hospital costs, and reduced incidence of medical emergencies in the enrolled patient population. The program utilizes regular at-home medical evaluations, as well as remote patient monitoring, and provides patient reassurance, self-care coaching, support service connections, and when necessary, medication adjustments or necessary treatments in coordination with the treating physician. The typical enrollment period is for 30 days.
Eligibility: In general, enrollment eligibility is dependent on the existence of a contract or other service agreement between ATCEMS and the discharging facility. Individual, “pro-bono”, cases are accepted upon approval by CHP Command.
5. Opioid Use Disorder (OUD) Support Program
This program aims to directly reduce the morbidity and mortality associated with overdoses on opioids. CHP personnel respond directly to 911 calls for apparent opioid overdoses when available to establish a connection with the patient and/or their friends and support network. This technique has proven to be more effective at gaining engagement with the patient, and often results in the connection to others suffering from Opioid Use Disorder (OUD). For opioid overdoses in which a CHP was not able to respond to the scene, CHP follows up with the patient within 1 day of the event. Patients are offered connection to OUD treatment including Medication Assisted Treatment (MAT) utilizing a warm-hand-off process rather than referral. CHP Case Managers can assist with routine CHP support services such as funding, medical and mental health support, and housing. Finally, all OUD patients, their families, friends and support network are offered Opioid Overdose Rescue Kits.
Eligibility: Patient is currently experiencing Opioid Use Disorder (diagnosed or patient-described).
Buprenorphine Bridge Program (BBP)
The BBP is a sub-program of the OUD Support Program that provides immediate, on-site treatment for Opioid Withdrawal, and daily withdrawal prevention treatment while the patient is being placed in a Medication Assisted Treatment program. CHP paramedics bring treatment with withdrawal-ending medication directly to the patient, and meet with them daily to administer the medication while establishing their entrance into an MAT program.
Eligibility: Patient is actively experiencing opioid withdrawal symptoms at the time of enrollment (defined as a COW score >= 8) and is willing to begin treatment in an established MAT program. Continued participation in engaging in an MAT program is required for continuation under the BBP.
6. Scene Response Program
The Scene Response Program is an initiative within the CHP team to bring CHP resources and skills to the scene of 911 calls with the goal of identifying alternatives to traditional routes of care. CHP Responders are on duty 24 hours a day, 7 days a week and focus on two primary categories of 911 calls: patients experiencing mental health crises, and low acuity medical needs.
Mental Health Crisis Response:
Responding to 911 calls involving mental health crises, Responders seek to address the patient’s needs through EMS resources rather than law enforcement, and to avoid unnecessary use of the ER for mental health crises. Available assets include the Integral Care EMCOT team, Integral Care and other mental health providers, the Herman Center, PES, and DSMC “yellow pod”. Responders are trained in crisis de-escalation and communication and are often co-staffed with behavioral health practitioners from EMCOT.
Eligibility: 911 EMS call placed for a person experiencing a mental health crisis. Response criteria regarding type of call and response distance are defined by CHP Command based on system needs/capabilities.
Low Acuity Medical Calls:
The goal for medical calls is finding alternatives to ER transport for non-emergent medical needs. This may be accomplished using clinics, our PA, our Street Med partners, or additional CHP follow-up and care. In the event that a CHP Responder determines that further action by CHP may help prevent future emergencies and reliance on 911, the CHP Responder may refer the patient to a CHP Case Manager.
Eligibility: Active EMS call through 911 for a patient experiencing a low acuity medical need as identified by the MPD system, or providers on scene.
Referrals and Service Requests
Referring a person as a High Utilizer of EMS is not necessary because CHP maintains a regular surveillance of EMS calls by individual. However, if the individual has recently lost connection to a basic need or service, as described above, submitting a referral for High Utilizer Group (HUG) Prevention will allow CHP to connect with them before they become reliant on EMS/911.
To submit a referral for HUG-Prevention or OUD Support, complete the referral form:
To connect a Person who is Experiencing Homelessness with supportive services, complete the referral form above, and be sure to click the checkbox “PEH”. The referral will be sent to HOST for management.
To request care for a person under the Buprenorphine Bridge Program (BBP), or the Readmission Prevention Program, contact the CHP Duty officer directly at 512-956-9780.
Pop Up Resource Clinics are generally not held based on outside requests. The locations are based on a combination of PEH population data, EMS call volume, and identified needs of the PEH population in the chosen area. Dates are based on the mutual availability of partner agencies. Both dates and locations occur on a regular rotation. If you would like to request review of a specific location or situation for consideration, please email the CHP Commander at EMSCHP@austintexas.gov.