East Jefferson Fire Rescue (EJFR) CARES (Community Assistance, Referral, and Education Service) launched January 2023 and works to reduce the impact of non-emergency incidents to the 9-1-1 system. The CARES team walks hand-in-hand with clients to assess needs, set goals, and support connection to resources and services. Read more about EJFR CARES and similar programs in OCH’s Connecting Community Members to Care Report (updated July 2024).
In late August 2024, EJFR invited OCH’s Director of Programs, Miranda Burger, to ride-along with the CARES team. During the ride-along, the EJFR CARES team travelled between Port Ludlow and Port Townsend. The team travels to south Jefferson County at least once a week as well. Miranda shares her observations and reflections.
8:45 am – I arrive at the Port Ludlow Fire Station where I meet Jeff Woods, EJFR Community Paramedic and his partner for the day, a peer support specialist from Gateway to Freedom. They show me their systems and give me some background on the program. Jeff shares what motivates him in this work, “I had never heard of this program before, but I spent 20 years [in EMS] standing over people thinking, ‘you don’t need to go to the hospital, but you can’t stay here. So, what do I do?’ Now I get to be that solution.”
9:40 am – The CARES team phone rings. It’s a caregiver calling about an established client. Jeff listens for several minutes, gathering essential details to help him determine next steps. The client, and elderly woman Jeff describes as “not a complainer” hasn’t been able to get out of bed today due to a severe headache. The caregiver says, “I thought to myself I don’t want to just take [my friend] to the hospital but I’m worried. Who can I call? I know, I’ll call Jeff.” He asks a few clarifying questions and lets the caregiver know we’re on our way. Jeff shares the value of seeing client’s face to face. “Over the phone interviews just don’t work. You can’t see them. You can’t touch them.” And that’s why we’re going. As Jeff frames it, ‘just to say hi and check it out’.
10:00 am – We arrive at the client’s home where we are greeted by caregiver and the client’s dog. Jeff bends down to pet the dog and greets him by name before conducting a brief assessment with the client. Jeff reassures the caregiver they do not need to go to the hospital and educates her on what to look out for until the client can be seen by her primary care provider in 2 days. As we leave the caregiver exudes, “I just can’t thank you enough. You’re the best.”
10:30 am – We’re back on the road. Jeff turns the corner and pulls over to return a missed phone call. It’s a client’s mother calling for advice. Jeff is mostly quiet and gives space for the mother to vent. He offers support and helps her identify and commit to next steps.
We continue driving and I ask Jeff what prepared him for this unique role. “EMS is not all CPR. 90% of what we do is solve problems. If you want a definition of a fire fighter, it’s a problem solver. When someone calls because of a fall, we try to figure out why they fell and then fix it. That correlates to this job.” Jeff shares that firefighters are experts at talking to people and listening. His approach with the client's mother exemplifies his expertise and he shares, “even if you don’t have an answer, they still feel heard and they feel better.”
10:45 am – We arrive at Jefferson Healthcare to pick up a walker for a client who was recently discharged from the hospital after a fall. “I’ve never gotten a walker from the hospital before, so we’re going to go find out how,” Jeff states as he strolls through the ambulance entrance. After a few minutes of explanation, hospital staff bring Jeff a walker, but there’s a problem. It’s a bariatric walker which won’t work for his petite client. Another few minutes of problem solving, and we drive across the street to pick up the appropriately sized walker from a different building. As we drive away with the walker safely in the trunk, I think about how challenging this would have been for the elderly client to navigate.
11:20 am – Jeff knocks on the door of a camper and the client shouts from inside, “I’m sleeping.” Jeff calmly replies, “that’s what you said yesterday, and I said I would come back.” He presses his ear to the door to better hear. After a few minutes of talking through the door, the client invites Jeff to the front seat. The client visited the emergency room last night and Jeff spends the next 30 minutes listening to understand his needs and goals. He was prescribed medication for a chronic medical condition, but he doesn’t know how to get the prescription filled and is concerned about the cost. Back in the car, Jeff connects with Jefferson Healthcare, the pharmacy, and another case manager from the Jefferson County LEAD (Law Enforcement Assisted Diversion) program working with the client to determine the best path forward. He obtains financial assistance paperwork. The LEAD case manager is visiting the client this afternoon, and they agree she will tackle the next steps with them.
1:00 pm – Jeff knocks on the door of a newly referred client but there’s no answer. This is the team’s second attempt to reach the client. Jeff leaves his card on the door as well as a voicemail, “the firefighters were worried about you so I’m stopping by to check in and see if you’re alright. I’d love to chat if you want to call me back.”
1:30 pm – We deliver the walker. When we arrive, the client is in bed but quickly agrees to stand so Jeff can size the walker for her. Once it’s sized, he quickly shuffles some furniture around to make the bed more accessible. It's a quick 15-minute visit and as we leave the client is using the walker to get a snack from the kitchen.
2:00 pm – We visit a client who has had several fall-related 911 calls. The client is sitting up in bed when we arrive and immediately identifies the cause of her most recent fall, a large pile of laundry that’s accumulated. Jeff proposes a few options including moving the client’s bed or taking the bedroom door off the hinges to allow more room for her walker, but she adamantly declines. They agree to move the pile of laundry out of the walkway. The client confirms that in-home care will bring laundry soap at the next visit so she can tackle the pile.
3:00 pm – We pull into the driveway of our final stop of the day, a client discharged from the hospital last night with a safety plan. His wife escorts us upstairs where we spend the next 45 minutes chatting with him. Before we leave the client shares his intention to re-start mental health support group services.
EJFR has a deep commitment to responding to community needs and has adapted their model of care. “We learned early on that we were sending referrals and then moving on thinking we’d solved it. Then we would connect back and find out no one ever called. So now we follow through to make sure,” says Jeff. The CARES team has two mantras when it comes to community-based care coordination:
1) always pick up the phone, and
2) always follow up.
The EJFR CARES team is the first of it’s kind in Jefferson County and prior to their launch there was no service in the area dedicated to reducing the impact of non-emergent 9-1-1 incidents. EJFR CARES preserves the precious finite emergency response services and seeks to reduce impacts to other finite and costly emergency services as well. As an innovative initiative, the primary concern for EJFR is sustainable financing to ensure this much needed service doesn’t disappear.
Programs like EJFR CARES exemplify the community-based care coordination efforts Olympic Connect seeks to bolster. With the added layers of support Olympic Connect offers the staff time and energy of community-based workers like Jeff can be devoted to what they do best – serving people. When asked what makes the program successful, Jeff replies, “The CARES Team isn’t this awesome thing by itself. It only works because of the other partners who work with us.”
Read more about this and other local successes in OCH’s Connecting Community Members to Care report.
