VENTURA COUNTY EMS AGENCY - Health Care Agency … · 11/12/2019 · Ventura County EMS Agency 5...

VenturaCountyEMSSystemAssessmentReport

VENTURACOUNTYEMSAGENCY

Submittedby

November12,2019*

*ThisreportisbasedondataandinformationcollectedthroughJune2019.

VenturaCountyEMSAgency 2 EMSSystemAssessmentReportVERSION2.0

TableofContents

ExecutiveSummary……………………………………………………………………………………………….4

SummaryofMajorRecommendations……………………….............................................................. 5

Introduction…………………………………………………………………………………………………………..8

Methodology…………………………………………………………………………………………………………..9

LimitationsandDisclaimers…………………………………………………………………………………....10

CountyDemographics………….…………………………………………………………………………………11

BackgroundandDiscussion…………………………………………………………………………11

SWOTAnalysis–CountyDemographics……………………………………………………….14

LocalEMSAgency/SystemOverview….….……………………………………………………………... 15

VCEMSAOrganizationandStaffing..………………...………………………………………… 15

QualityAssurance/QualityImprovementStructure…………………………………….. 16

PrehospitalEducationandTraining…………………………………………………………….20

SWOTAnalysis–LocalEMSAgency/SystemIssues…………………………………….. 24

SystemFinancials………………………………………………………………………………………………….25

SystemRevenue………………………………………………………………………………………… 25

PayorMix………………………………………………………………………………………………….. 28

Rates/Billing………………………………………………………………………………………………30

ProviderFinancials……………………………………………………………………………………..33

FinesandPenalties……………………………………………………………………………………...41

SWOTAnalysis–SystemFinancials……………………………………………………………...45

EMSSystemDeployment………………………………………………………………………………………..46

ReviewofCurrentStructure………………………………………………………………………..46

SystemStatusPlan………………………………………………………………………………………50

Discussion–Structure/SystemStatusPlan…………………………………………………..52

ConfigurationOptions…………………………………………………………………………………55

SpecialtyCare……………………………………………………………………………………………..58

Staffing……………………………………………………………………………………………………….60

InfluencingFactors……………………………………………………………………………………..62

CommunityParamedicine/MobileIntegratedHealthcare……………………………..65

TechnologyinEMS………………………………………………………………………………………67

SWOTAnalysis–EMSSystemDeployment…………………………………………………..73

EMSSystemCommunications…………………………………………………………………………………74

SWOTAnalysis–EMSSystemCommunications……………………………………………77

ResponseTimes…………………………………………………………………………………………………….78

SWOTAnalysis–ResponseTimes………………………………………………………………..90

CriticalCareTransport…………………………………………………………………………………………..91

SWOTAnalysis–CriticalCareTransport…………………………………………………….. 94

Non‐Emergency…………………………………………………………………………………………………….95

BackgroundandDiscussion……………………………………………………………………….. 95

BehavioralHealth……………………………………………………………………………………… 95

Paratransit/Ambulette………………………………………………………………………………. 98

SWOTAnalysis–Non‐Emergency………………………………………………………………..99

FindingsandRecommendations…………………………………………………………………………… 97

Discussion…………………………………………………………………………………………………100

SummaryofAllRecommendations……………………………………………………………..100

OptionsforFutureContractingCycle…………………………………………………………102

Appendices

AppendixA:ProjectDocumentRequestList………………….…..……………………….. 106AppendixB:SummaryofSelectedStakeholderComments……………………………112AppendixC:ProjectBibliography…………………………………………………………………116

ExecutiveSummary

TheVenturaCountyEMSsystemcomparesfavorablytootherEMSsystemswehaveassessedinCaliforniaandnationally.ThesystemenjoysmanystructuraladvantagessuchascentralizeddispatchwithEMD,robustqualityimprovement,astrongclinicalfocus,experiencedproviders,cuttingedgecommunityparamedicineprograms,excellentcooperationbetweenstakeholdersandarelativelystrongsocioeconomicpopulationbase.Stakeholdersaregenerallyquitesatisfiedwiththesystemandnostakeholdersrecommendedeliminationofthecurrentcontractedambulanceprovidersinfavorofanewsystemdesignwithcompetitivelyprocuredambulancecontractors.

OuroverridingconsiderationsinreviewinganEMSsystemare(1)whetheritisfocusedonprovidingexcellentclinicalcare;(2)whetheritutilizesevidence‐basedpracticesasopposedtoentrenchedpracticessimplybecause“we’vealwaysdoneitthisway”;and(3)whetherthesystemiseconomicallysustainablegivenavailablerevenuesforthedesiredlevelofservice.WefindthattheVenturaCountyEMSSystemishighlyfocusedonprovidingexcellentclinicalcare.Weconcludethatincentivizingevidence‐basedpracticesandsafetyshouldbepursuedinthenextcycleofEOAprovidercontracts.Finally,wefoundthatthesystemappearstopresentlyhavenomajorindicatorsofimminentfinancialunsustainability,thoughwedonotesomeissuesofconcerninthisreport.

Wemakeanumberofrecommendationsinthisreport.BecausetheVenturaCountyEMSsystemhassuchasolidfundamentalstructureandisfunctioningwell,theserecommendationsshouldbeseenas“nextlevel”recommendationsdesignedtohelptheEMSsystemprosperevenmoreinthecomingdecade.Ourrecommendationsshouldmostdefinitelynotbeseenasimplyinganycriticismsoftheexistingexcellentsystem. Asequentialsummaryofallrecommendationsiscontainedinthefinalsectionofthisreport.However,themajorrecommendationsare:

‐ Negotiatenewcontractswiththeexisting,grandfatheredprovidersinsteadofundertakingacompetitiveprocurementprocess;

‐ ImplementaBLSresponseandtransporttier;‐ Expandtheexistingresponsetime‐basedpenaltysystemtoinclude

evidence‐basedclinicalperformancestandardsandsafety;‐ EstablishasingleEOAforCriticalCareTransports;‐ ImplementCriticalCareParamedics;‐ ApplyresponsetimepenaltyreductionprovisionstoEOA4initsentirety

insteadofitssub‐zones;‐ EliminatetheLevelI/LevelIIparamedicpolicy‐ Eliminatenon‐emergencyrateregulation

SummaryofMajorRecommendations

Acompletelistoftherecommendationscontainedinthisreportisincludedinthefinalsectionofthisdocument.However,thefollowingisasummaryofthemajorrecommendationsthataremadeinthisreport.Pleasenotethatthesearenottheonlyoptions,buttheoneschosenforpresentationinthisreportarebasedonstakeholderinput,thepresentEMSsystemdesign,andanalysisofpertinentdocuments.Belowwesummarizemajorrecommendationsthatarediscussedinthereportandprovidepagereferencestowherethecompletediscussionscanbefound.Again,thecompletelistofrecommendationscanbefoundonpp.100‐102.

1. ContractingOptionsforNextCycle–werecommendthatVCEMSAnegotiaterenewedcontractswiththeexistingproviderswhoareeligiblefor“grandfathering.”Thisrecommendationisbasedonseveralconclusions.Firstandforemost,theincumbentprovidersaresubstantiallymeetingexistingperformanceexpectationsandnostakeholdersinterviewedrecommendedabandoningthegrandfatheredprovidersinfavorofacompetitiveprocurementprocess.AnothersignificantfactoristhattheCaliforniaEMSsystemonastatewidebasisispresentlyinastateofsignificantupheavalanduncertainty,andrecentcompetitiveprocurementsundertakenbyotherlocalEMSagencieshaveincurredsignificantoppositionandunexpectedaddedexpenseduetothisunsettledenvironment.Inaddition,inanEMSsystemthatisfunctioningwell,asVentura’sis,thetimeandcostofacompetitiveprocesswillnotresultinabettersystemthanwhatVCEMSAcanachievebynegotiatingnewcontractswiththeexistingproviders.Finally,onceanEOAinCaliforniaiscompetitivelybid,itislikelythatgrandfatheredeligibilityisthereafterlostandcannoteverberestoredinthefuture,andthisassessmentrevealednocompellingreasonstoforeverabandonthegrandfatheredstatusthattheVenturaCountyEMSsystemenjoys.

2. EliminationofLevelI/LevelIIParamedicPolicy–werecommendeliminatingtheVCEMSALevelI/LevelIIparamedicpolicyandinsteadadoptingamoreconventional,employer‐basedpreceptorshipsystemforensuringnecessaryanddesiredlevelsofparamedicexperienceamongpractitioners.Acombinationoffactorsmakethisrequirementduplicative,costlyandburdensome.Theexisting,robustQA/QIprogram,coupledwithstakeholderreportsoffrequentexceptionsbeinggrantedundertheexistingpolicy,aswellascostanddelayinbringingpersonnelintothesystem,suggestthattheeliminationofthispolicyisappropriate.

3. ApplythePenaltyReductionProvisionstoEOA4asaWholeInsteadofitsSub‐Zones–werecommendtheeliminationoftheindividualsub‐zoneresponsetimecompliancestandardswithinEOA4thatthepercentagereductioninpenaltiesforachievingresponsetimecomplianceat92.5%and

Seepp.100‐102

Seepp.20‐21

Seepp.53‐54

higherbeappliedtoEOA4initsentiretyinsteadoftoeachofitssubzonesseparately.NootherEOAintheCountyisdividedintosub‐zones,andconsideringthatthepurposeofanEOAistoawardanexclusivecontractforapopulatedareainexchangeforarequirementtoserveless‐populatedareas,theseparatecalculationofresponsetimecomplianceforsub‐zonesthataremoreandlessprofitableforanEOAprovidertoserviceisanomalous.Werecommendthattheincentiveforachievingaresponsetimecompliancerateof92.5%orhigherbeearnedonlyifitisachievedfortheEOAasawholeasisthecasewithotherEOAsintheCounty.

4. ImplementaBLSResponseandTransportTier‐werecommendthatVCEMSAimplementaBLSemergencyresponsetierforitsambulancetransportcontractors.BecauseVenturaCountycurrentlybenefitsfromcentralized,priority‐basedemergencymedicaldispatch(EMD)viatheVenturaCountyFireCommunicationsCenter(FCC),ithasthecapabilitytosafelyandeffectivelydistinguishbetween911callswhichrequireALStransportcapabilitiesandthosethatcanbeappropriatelyhandledbyaBLSambulance.All‐ALSdeploymentiscostly,canleadtoparamedicfatigueand“burnout,”andcanresultindissatisfactionamongEMTswhoseskillsareoftenunderutilized.Ifitimplementsthisrecommendation,VCEMSAmaywishtoprovideadditionaltrainingforEMTs,monitorBLS‐onlycallsthroughitsQA/QIprogram,andimplementotherstepstoevaluatethesafetyandefficacyofaBLStier.

5. SupplementtheResponseTimePenaltySystemtoIncludePenaltiesforFailingtoSatisfyClinicalMetrics–werecommendthatVCEMSAsupplementitsambulancecontractorpenaltysystemtoincludetheimplementationofpenaltyprovisionsbasedonclinicalperformancemetricsthathaveaprovenimpactonpatientcare.Thereareanumberofclinicalmetrics,suchasthosepresentlyincorporatedintoVCEMSA’sQIPlan,whichwouldserveasappropriatedisincentivesforpoorperformanceinareaswhichareshowntodirectlyimpactpatientcare.Researchandpublishedliteraturedemonstratesthatambulanceresponsetimesdonotmakeadifferenceinpatientoutcomesforthevastmajorityofcases,yetdeploymenttomeetthesestandardsisthesinglebiggestcostdriverfortheambulancetransportcomponentofanEMSsystem.TotheextentVCEMSArequiresproviderfeestosustaincertainaspectsofLEMSAoperations,werecommendthatconsiderationbegiventohavingtheassessmentsbeintheformofcost‐basedannualassessmentsforcostsdirectlyrelatedtosystemoversight,contractadministrationand/orthatdirectlybenefitthecontractedproviders,andthatthesepaymentsbeintheformofpre‐establishedandpredictableassessmentssoastoeliminateanyfinancialincentiveforVCEMSAtoimposepenaltiesuponitscontractedproviders.

Seepp.56‐58

Seepp.87‐88

6. ConsiderEstablishingaSingleEOAforCriticalCareTransports–becauseCCTsrepresentalow‐volume,high‐costlevelofservice,theirongoingeconomicsustainabilityisaconcern.ThisisparticularlytruebecausenoneoftheproviderswhichfurnishCCTsinVenturaCountyareunderanycontractualobligationtomaintainorcontinuetooperatethoseprogramsindefinitelyandarefreetodiscontinuethosevitalprogramsessentiallyatanytime.GrantinganEOAforCCTstoasingleproviderwouldensuregreatervolumeagainstwhichtooffsettheexpenseofCCToperations,whichhelpstomaintaineconomicviabilityofaCCTprogramonanongoingbasis.Forthisreason,werecommendthatthisoptionbeconsidered.

7. ImplementCriticalCareParamedicsforCCTs–inadditionto,orasanalternativeto,therecommendationtoconsiderCCTexclusivity,werecommendthatVCEMSAconsiderimplementingCriticalCareParamedics(CCPs)asaminimumlevelofstaffingforCCTs.Thereisnodataspecifictothecriticalcaretransportenvironmentdemonstratingbetterpatientoutcomeswithnurse‐levelCCTs,andCCPsarenowrecognizedbytheStateofCaliforniaforstaffingCCTs.Inaddition,theuseofCCPsdoesnotinanywayprecludetheuseofadditionaladvancedpractitioners,suchasnurses,physicians,respiratorytherapistsorotherproviders,duringCCTswhenthepatientconditionrequiresit.Importantly,theuseofCCPswouldsignificantlyimprovethepotentialforeconomicsustainabilityofCCTprogramsintothefuture.

8. EliminateNon‐EmergencyRateRegulation–becausetheEOAsintheCountyarelimitedtoemergencyambulanceservices,itisappropriatethattheCounty’srate‐settingpolicyaddressthoseexclusiveservices.However,becausethenon‐emergencymarketisopenandcompetitive,wedonotseearationaleforincludingnon‐emergencyratesintheCounty’srateregulationpolicy.Inorderforacompetitivemarkettotrulyfunctioninacompetitivemanner,thoseratesshouldbetheresultofnegotiationsbetweentheprovidersandconsumersofthoseservices.

Seepp.90‐91

Seepp.92‐93

Seepp.30‐31

Introduction

OnJanuary18,2019,theCountyofVentura(County)onbehalfoftheVenturaCountyEmergencyMedicalServicesAgency(VCEMSAorthe“EMSAgency”)enteredintoacontractwithPage,Wolfberg&Wirth,LLC(PWW),anationalEMSindustrylawandconsultingfirm,toassesstheCounty’sEMSSystem.PursuanttothisengagementPWWistoconducttheanalysisbyfacilitatingfocusgroupdiscussions,interviewingstakeholdersandreviewingdataanddocumentationprovidedbytheCountyandEMSSystemstakeholders.Whenappropriate,PWWistoalsocomparenational,state,andregionalbenchmarks,aswellasbestpractices,totheCounty’scoreEMSSystemelements.

PWWisrequiredtoassess,ataminimum,thefollowinganditssubcomponents:

CountyDemographics SystemFinancials EMSSystemDeployment EMSSystemCommunications(EmergencyandNon‐Emergency) ResponseTimes CriticalCareTransports Non‐EmergencyTransports

PWWwasalsorequestedtoprovideitsrecommendationsonwhethertheEMSAgencyshouldpursuenewcontractswithitsexistingExclusiveOperatingArea(EOA)providerspursuanttothe“grandfather”provisionsofthestateEMSlaworwhethertheCountyshouldundertakeacompetitiveprocessfortheawardofnewcontractsfortheEOAs.

AlthoughPWWhasnotbeenengagedtoconductafocusedreviewoftheCounty’sSTEMI,Stroke,Trauma,CardiacArrestRegistrytoEnhanceSurvival(CARES)fortheSuddenCardiacArrest,andCardiacArrestManagement(CAM)SpecialtyCarePrograms,itistoaddresstheseprogramsinthecontextoftheCounty’sEMSSystem.

PWWistoprovideanon‐sitepresentationtotheBoardofSupervisorsofitsSWOTanalysisandrecommendationsforEMSSystemenhancements.

Methodology

Themethodologyforthisprojectincludedthefollowing:

‐ On‐sitefocusgroupmeetings;‐ Remotefocusgroupmeetings(viaphone/video);‐ On‐siteindividualstakeholderinterviews;‐ Remotestakeholdermeetings(viaphone/video);‐ ReviewofdataanddocumentationsubmittedbyEMSSystem

stakeholders;‐ ReviewofdataanddocumentationsubmittedbyVCEMSA;and‐ Researchofcomparativedataanddocumentationfromexternalsources

AlistofthedocumentsandinformationinitiallyrequestedfromtheCountyandEMSSystemstakeholdersisattachedasAppendixA.

DocumentanddatacollectionandreviewbyPWWwasinitiatedonMarch28,2019andcontinuedasnewdataanddocumentswerereceived.DocumentswerecollectedfromVCESMA,theprovidersassignedanexclusiveoperatingarea(EOA)intheCounty(EOAproviders)andfiredepartmentsthatprovidefirstresponseservices.Thedocumentswerecollectedviaasecurefiletransfersite.AdditionaldatawasprovidedtoPWWontheCounty’sbehalfthroughitsEMSdataanalyticsvendor,FirstWatch.

PWWaccesseddatafromsourcessuchasUnitedStatesCensusBureaureportsandQuickFacts,otherInternetresources,the2017AnnualReportoftheVenturaCountyPublicHealthEmergencyMedicalServicesAgency,the2016‐17AnnualReportoftheCountyofVenturaHumanServicesAgency,andotherpublicdatasourcestogathercurrentandprojecteddemographicdataregardingtheCountyanditspopulation.

OnMarch8,2019,PWWprovidedanon‐sitepresentationtoEMSSystemstakeholderstoexplainhowitintendedtoconducttheEMSSystemassessmentandtoobtaininputfromthisfocusgroup.Thatwasimmediatelyfollowedbyone‐on‐oneinterviewsofEMSSystemstakeholdersbythreePWWstaffmembersseparatelyconductinginterviewsin30‐minuteincrementsthroughouttheday.Stakeholderrepresentativeswhosigneduptobeinterviewed,butwerenotavailableonMarch8,werelaterinterviewedbytelephoneorvideoconference.

OnApril3,2019,PWWconductedanadditionalstakeholderfocusgroupmeetingwithmembersoftheVenturaCountyEMSAdvisoryCommitteeviavideoconference.

AsummaryofselectedstakeholdercommentsisincludedinAppendixB.

Additionally,weconductedextensiveliteraturesearchesandresearchregardingcomparativedatasources.FootnotestosourcematerialareincludedinthetextofthisreportandaProjectBibliographyisincludedinAppendixC.

LimitationsandDisclaimers

Ourfirmwasengagedinaconsultingcapacity,notinalegalcapacity.Accordingly,itisbeyondthescopeofthisengagementforustoprovidealegalanalysisofissuespresented.

Methodologiesemployedtoconductthisreview(i.e.,stakeholdermeetingsandreviewofcertainavailabledata)haveinherentlimitations.Stakeholderinput,whileimportanttoanyEMSsystemassessment,naturallytendstoreflectbuilt‐inbiasesandpoliticalconsiderationsofthestakeholders.Inaddition,anyassumptionsoroptionspresentedbasedonavailabledatawillinevitablydependupontheaccuracy,completenessandsuitabilityofthedataprovided.

Thisreportisprovidedwiththeexpectationthatitwillbecomeapublicrecord.

1CountyDemographics

TheCountyhasatotalareaof2208squaremiles,whichincludes43milesof

coastline,twooffshoreislands,twomilitaryinstallations,severallakes,andalargeareaofnationalforestandstateparkland.2Approximately53%ofthisareaisoccupiedbytheLosPadresNationalForestandothernationalforestland.3365squaremilesarewaterarea,1,843squaremilesareland,areaand675milesarerurallandarea.

EstimatedpopulationofVenturaCountyis850,967people.Populationinthe

Countygrewapproximately3.3%betweenApril1,2010andJuly1,2018,whichislessthanthe6.2%rateofgrowthinCaliforniagenerallyoverthattimeperiod.MostofthepopulationresidesintheCounty’scities.ThecitypopulationcentersoftheCounty,whichtogethercompriseapproximately87.8%oftheCounty’spopulation,arefoundinTable1below.

Table1:VenturaCountyCityPopulations

City PopulationEstimates4CityofOxnard 209,879

CityofThousandOaks 129,557CityofSimiValley 127,716

CityofSanBuenaventura 108,170CityofCamarillo 69,880CityofMoorpark 37,020CityofSantaPaula 30,779CityofPortHueneme 23,526

CityofFilmore 15,925CityofOjai 7,769

1Unlessotherwiseindicated,thedataunderthistopicistakenfromtheU.S.CensusBureautablesasofJuly1,2018.2VenturaCountyPublicHealthEmergencyMedicalServicesAgency2017AnnualReport.3Wikipedia.4ThesepopulationestimatesarebaseduponworksheetspreparedbytheDemographicResearchUnitoftheCaliforniaDepartmentofFinance.TheyarepopulationestimatesasofJanuary1,2019releasedbytheCaliforniaDepartmentofFinanceonMay1,2019.TheDepartment’spopulationestimatefortheCountyasofJanuary1,2019is856,598.

BackgroundandDiscussion

Personsunder18yearsofagecomprised23.2%ofthepopulation,whichisslightlyabovethestatewide22.9%.Personsover65yearsofagecomprised15%ofthepopulation,whichisahigherpercentagethanthestatewide13.9%.Approximately50.5%ofthepopulationwasfemale.Thestatewidefigureis50.3%.ThewhitepopulationoftheCountywas84.3%whichwasconsiderablyhigherthanthe72.4%statewide.Ofthesepercentages,intheCounty45.2%werenotHispanicorLatino,andinCaliforniathepercentwas37.2%.ThenexthighestpercentagebyracewasAsian,whichwasapproximately7.8%intheCountycomparedto15.2%statewide.

Withrespecttohousingandfamilylivingarrangements,63.2%oftheCounty’s

populationlivedinowner‐occupiedhousingcomparedto54.5%statewide.Personsperhouseholdwere3.09intheCountyand2.96statewide.

Between2013and2017,themedianhouseholdincomeintheCountywas

approximately$81,972.Thatwas12.2%abovethestatemedian.Itisestimatedthat9.5%oftheCounty’sresidentshadincomesbelowtheFederalPovertyLevel(FPL),whilethestatewidefigurewas13.3%.Forpersons25yearsofage,84%ofCountyresidentshadatleastahighschooleducation,comparedto82.5%statewide,andinbothVenturaCountyandstatewide,32.6%ofthepopulationhadabachelor’sorhigherdegree.Forpersonsover16yearsofage65.6%wereinthecivilianlaborforcecomparedto63.0%statewide.

MajoremployersintheCountyareAmgen,Inc.,BaxterHealthcare,CityofSimi

Valley,CommunityMemorialHealthSystem,DoleBerryCompany,HaasAutomation,Inc.,HarborFreightToolsUSA,Inc.,KaiserPermanenteVentura,LosRoblesHospital&MedicalCenter,MoorparkCollege,MuranakaFarm,Inc.,NancyReaganBreastCenter,NationalGuard,NavalBaseVenturaCounty,OjaiValleyInn&Spa,OxnardCollege,PentairAquaticSystems,VenturaSheriff’sDepartment,SimiValleyHospital,St.John’sRegionalMedicalCenter,SullstarTechnologies,VenturaCountyMedicalCenter,andVenturaCountyOfficeofEducation,amongothers.5

InascertainingwhichcountiesmightbesimilartoVenturaCountyforpurposesof

comparativeanalysis,itisreadilyapparentthatVenturaCountyisratheruniqueandthatdirectcomparisonsaredifficult.SantaBarbara,LosAngeles,andKernCountiesaregeographicallyadjacenttoVenturaCounty.CountieswithpopulationscomparabletothatofVenturaCountywithinarangeof+/‐20%includeKern,SanFrancisco,SanMateo,FresnoandSanJoaquinCounties.Countieswithpopulationdensities(i.e.,personspersquaremile)comparabletothatofVenturaCountywithinarangeof+/‐20%includeSolano,SanJoaquinandMarinCounties.CountieswithlandareascomparabletothatofVenturaCountywithinarangeof+/‐20%includeMadera,Merced,ElDorado,Butte,

5StateofCaliforniaEmploymentDevelopmentDepartment,extractedfromtheAmerica’sLaborMarketInformationSystem(ALMIS)EmployerDatabase,20191stEdition.

SonomaandStanislausCounties.6Unfortunately,thereisnocountyinCaliforniacomparabletoVenturaCountywithina+/‐20%rangeacrossallthreeofthesemetrics(population,populationdensityandlandarea).

BecauseofthelackofdirectlycomparablecountiesinCaliforniaacrossallthreeof

thesecomparabilitymetrics,thisreportwill,asappropriate,utilizedataandfindingsfromdifferentcountiesfordifferentpurposes.Wewillthroughoutthisreportclearlystatethecountiesandthedatasourcesutilizedwheresuchcomparisonsaremade.

ForpurposesofEMSsystemsustainability,thekeydemographictrendsofnotein

VenturaCountyarethosepertainingtoincomeandsocioeconomicstatus.BecauseVenturaCountyhasasignificantlyhighermedianhouseholdincomeandalowerpercentageofindividualslivingbelowthepovertylineascomparedtoCaliforniastatewide,healthcareprovidersintheCounty,includingEMSproviders,shouldenjoyahigherrevenue‐per‐transportandfeweruncollectableaccountsascomparedtoprovidersinmanyothercountiesinCalifornia.WhilethisdoesnotassureEMSsystemfinancialsustainabilitythroughoutfutureEOAcontractingcycles,itisworthnotingthattheVenturaCountyEMSSystemdoesnothavethesamebuilt‐indisadvantagesasconfrontmoreeconomicallydepressedareasofthestate.

6AcoupleofstakeholdersaskedwhywedidnotuseContraCostaforcomparisonpurposes.Wedidnotdosobecauseitisnotacountythatsatisfiedthe+/‐20%rangesofVenturaCounty’spopulation,landareaorpopulationdensitywefeltweremostappropriatetochooseothercountiesforcomparisonpurposes.OurpurposewasnottomakedirectcomparisonsofotherEMSsystemconfigurationsormodels,whichpresumablywasthepointofthosestakeholderinquiries.

Strengths•MedianincomeaboveCAaverage•PercentageofpersonsinpovertyisbelowCAaverage•VCEMSAstaffrunaresponsiveandthoroughprogramwhichreceiveshighmarksfromstakeholdersdespiteastaffinglevellowerthanmostotherLEMSAsonaperpopulationbasis

Weaknesses•PopulationgrowthratebelowCAaverage

Opportunities•Higher%of65+populationthanstatewideaverage•Slightlyhigher%ofpopulationincivilianlaborforcethanCAaverage

Threats•Higher%ofpopulationwithouthealthinsurancethanCAaverage

SWOTAnalysis–CountyDemographics

LocalEMSAgency/SystemOverview VCEMSA7istheleadagencyfortheVenturaCountyEMSSystem.Itsresponsibilitiesinclude:

Coordinatingallsystemparticipantsinitsjurisdiction,encompassingboththepublicandprivatesectors.

Monitoringandevaluatingthequalityofadvancedlifesupport(ALS)andbasiclifesupport(BLS)emergencymedicalcareprovidedtotheresidentsofandvisitorsoftheCountythroughacomprehensivequalityimprovementprogram

ProvidingEMSsystemguidanceanddirectionthroughpolicydevelopment Ensuringmedicaldisasterpreparedness Ensuringprehospitalpersonnelexcellencethroughtraining,certification,

accreditationandcontinuingeducationprogramreview

VCEMSAisaDivisionoftheVenturaCountyDepartmentofHealthandisstaffedwitheight(8)fulltimepersonnel,ahalf‐timemedicaldirectorandanassistantmedicaldirector.OtherpositionsincludeanEMSAdministrator,aDeputyAdministrator,aSeniorSpecialtyCareSystemsCoordinator,anEMSProgramCoordinator,anAdministrativeAssistant,andEMSCertificationSpecialistandtwo(2)ProgramAdministrators,AdministrativeAssistantsandone(1)EMSCertificationSpecialist.

WhencomparedtootherLocalEMSAgenciesinselectedcountiesinCalifornia,

VCEMSA’slevelofstaffingislowerthanthestatewideaverageofLEMSAstaff‐per‐populationserved.VCEMSAhas1LEMSAstaffmemberforevery99,172personsserved.Accordingtoourresearch,thenumberofLEMSAstaff(includingcontractedmedicaldirectors)isapproximately1staffmemberper77,735personsservedstatewide,amongallLEMSAtypes(i.e.,singlecountiesandmulti‐countyJPAs).Theratiois1:76,648forsingle‐countyLEMSAs.Theratiois1:81,359formulti‐countyJPA‐modelLEMSAs.VCEMSAcomparesunfavorablyintermsofLEMSAstaffingwhencomparedbothtosingle‐countyandmulti‐countyJPAmodelLEMSAsinCalifornia.8

7TheinformationprovidedunderthisheadingwastakenfromtheVenturaCountyPublicHealthEmergencyMedicalServicesAgency2017AnnualReport.8ThisresearchisbasedonLocalEMSAgencywebsitesforsinglecountiesandmulti‐countyJPA‐modelLEMSAsthatreporttheirstaffinformationonawebsite(mostcommonlyina“staffdirectory”).StaffingnumbersincludeLEMSA‐contractedand/oremployedmedicaldirectors.SomeLEMSAstaffingfiguresmayalsoincludeEmergencyPreparednessOffice(EPO)staff.However,itisourunderstandingthatmostLEMSAEPOstaffingisinaseparategovernmentunit.

VCEMSAOrganizationandStaffing

StateStructure TheCaliforniaEMSAuthority(EMSA)hasdevelopedastatewideEMSQualityImprovementProgram.9TheEMSQIProgrammeansthemethodsofevaluationofprehospitalEMSthatarecomposedofstructure,process,andoutcomeevaluationswhichfocusonimprovementeffortstoidentifyrootcausesofproblemsinprehospitalEMS,intervenetoreduceoreliminatethosecauses,andtakestepstocorrecttheprocessandrecognizeexcellenceinperformanceanddeliveryofprehospitalEMS.10 TherearefourprimarylevelsofEMSprehospitalQIresponsibility:theEMSA,localEMSagencies(LEMSAs),basehospitalsandalternativebasehospitals,andEMSserviceproviders.TheEMSAhasdevelopedstatewideplanningandimplementationguidelinesforEMSsystemswhichaddressthefollowingcomponents:11

Manpowerandtraining Communications Transportation Assessmentofhospitalsandcriticalcarecenters Systemorganizationandmanagement Datacollectionandevaluation Publicinformationandeducation Disasterresponse

VCEMSAProgramStructure

UndertheCounty’sPrehospitalEmergencyMedicalCareQualityImprovement

Program(VCEMSAPolicy120,June1,2009)eachhospitalprovider,ambulanceproviderandfirstresponseagencyistousetheCounty’sContinuousQualityImprovement(CQI)PlanwithrespecttotheEMSpartoftheiractivities.12TheVCEMSAQIProgramcoversLEMSA,hospitalandEMSproviderresponsibilities.Itrequiresprehospitalcareproviders

9EMSA’sdevelopmentandimplementationofastatewideEMSQualityImprovement(QI)Programisrequiredby22CCR§100405.TheprehospitalEMSQIresponsibilitiesofEMSAandotherentitieswithintheprehospitalEMSQIstructurearesetforthat22CCR§§100400‐100405.1022CCR§100400.11EMSA#166.EmergencyMedicalServicesSystemQualityImprovementProgramModelGuidelines.12CountyofVenturaHealthCareAgencyEmergencyMedicalServices(VCEMSA)PolicyNo.120.PrehospitalEmergencyMedicalCareQualityImprovementProgram.

QualityAssurance/QualityImprovementStructure

toestablishin‐houseprocedureswhichidentifymethodsofimprovingthemethodofpatientcareprovided.

VCEMSAmonitorsandevaluatesthequalityofadvancedlifesupport(ALS)andbasic

lifesupport(BLS)emergencymedicalcareprovidedtotheresidentsofandvisitorstotheCountybyprehospitalpersonnel,provideragencies,andhospitals.13Inthisrole,VCEMSA:

Servesastheleadagencyfortheemergencymedicalservicessysteminthecountyandcoordinatesallsystemparticipantsinitsjurisdiction,encompassingbothpublicandprivatesectors;

Providessystemguidanceanddirectionthroughproviderandcommunitydrivenpolicydevelopmentaimedatestablishingandmaintainingstandardsforcare;

Monitorspatientcarethroughacomprehensivequalityimprovementprogram;

Ensuresmedicaldisasterpreparednessthroughtheemergencyplanningprocessandcoordinatesresponsetolocaldisastersandincidentswithmultiplecasualties;and

Ensuresprehospitalpersonnelexcellencethroughtraining,certification,accreditationandcontinuingeducationprogramreview.14

TheVCEMSACQIProgramusespatientcaredatafromitsstakeholderstoevaluate

systemperformance.HospitalssubmitdatathroughtheOutcomeSciencesRegistryfortheCounty’sStrokeProgram,CardiacArrestRegistrytoEnhanceSurvival(CARES)foritsSuddenCardiacArrestProgram,TraumaRegistrydataforitsTraumaSystem,andusesAmericanHeartAssociation(AHA)programandregistryguidelinesforbothSTEMIandstrokedata.DispatchdataiscollectedthroughtheCountyFireDepartmentTriTechComputerAidedDispatchSystemandMedicalPriorityDispatchSystem(MPDS).Dataiscollectedfromthepre‐hospitalEMSagenciesandhospitalsinordertofollowapatientfroma911calltoactivitiesdoneinthehospital.15

In2018VCEMSAcontinuedaprocessofredefiningitsQIPlanbyreorganizingthe

program’sstructureasitrelatestohowtheprogram’scoremeasuredataiscollectedanddisseminatedtokeystakeholders.Thegoalhasbeentoensurethatthecoremeasuresarepatientfocusedandthatimplementationofchangesforimprovementistimelyandsustainable.EMSAtracksStateCoreMeasures,primarilyfocusedontraumapatientmanagement,STEMIpatientcare,andstrokepatientcare,withadditionalindicatorsfor

13ThisinformationisprovidedbytheVenturaCountyPublicHealthEmergencyMedicalServicesAgency2017AnnualReport.14Id.15VenturaCountyPublicHealthEmergencyMedicalServicesAgency2017AnnualReport.

pediatricrespiratoryassessmentandredlightandsirenusage.In2016VCEMSA’scompliancerateinsatisfyingthoseCoreMeasureswas80%,whilein2017thecomplianceratewas100%.16

SomeproductsofVCEMSA’sQIinitiativesrealizedin2017and2018havebeenthe

additionandchangingofpolicies,accompaniedbythedevelopmentofatrainingprogramforEMTstoadministerEpinephrinebyauto‐injector,administerNaloxoneintranasal,andperformfingerstickbloodglucosetests.TheseadditionalskillswereaddedtoanEMT’sscopeofpracticeinthesecondhalfof2018andthetrainingofEMTsfortheexpandedscopeofpracticebegan.Inaddition,newpoliciesandprocedureswereimplementedtodesignateThrombectomyCapableAcuteStrokeCenters(TCASCs)andtoidentifypatientswithemergencylarge‐vesselocclusion(ELVO)fortransporttotheclosestTCASC.Also,paramedicsarerequiredtoattendfourairwaylabstationsoveratwo‐yearperiodalongwithoneparamedicskillsdayannually.Includedinthelabsareeducationstationscoveringsomelowfrequency,highriskprocedures.VCEMSAhasanelectronicPatientCareReportingSystem.Advancedairway,transcutaneouspacing,andintraosseousinfusionarecriticalproceduresmonitoredregularlybyVCEMSAthroughthissystem.17

ProviderParticipation

EachoftheEOAprovidershaveaQIplanandprogram.TheyhaveaQIteamandtheirCQIprocessescoversuchmattersasnewemployeeorientation,newemployeeEMStraining,newemployeemonitoring,chartreview,continuingeducation,patientcarerecordauditing,incidentreview,aperformanceimprovementplanandperformancerecognition.18

ThethreeEOAproviderspaytheirappropriateshareoffeestotheCountyfortheQIoversight,medicaloversight,andcontractadministrationcostsincurredbyVCEMSArelativetotheoperationandfunctioningoftheemergencygroundambulancesystemintheCounty.TheircollectivefeesfortheseVCEMSAserviceswere$423,076in2016,$432,402in2017,and$447,150in2018.19

Analysis

Onpaper,theVCEMSAQA/QIprogramappearstomeetallapplicablestate

standards.Moreimportantly,stakeholdersinterviewedforthisprojectindicatethattheprogramworksverywell,andthatEMSagencystafftakeacollaborativeapproachtothe

16VenturaCountyEMSPlan2017QualityImprovementProgramAnnualUpdate(August2018).17Id.18AMRandGoldCoastQualityImprovementPlan2019andLifeLineMedicalTransportQualityImprovementCommitteeReport2018.19VCEMSAspreadsheetentitledVCEMSAQualityAssuranceFees2016‐2018.

QA/QIprocess.ManystakeholdersreportedthatthesubstantialandongoinginvolvementofhospitalstakeholdersintheEMSQA/QIprocessmakestheprogramworkverywell.ThiscontinuousdialogueappearstohavealsopaiddividendsinhelpingEMSstakeholdersaddressandmitigateotherproblems,suchaspatientoffloadtime,EMSwaittimeforIFTs,andothersimilarissuesinvolvingtheinterfacebetweenEMSandhospitals.

VCEMSAmeetsregularlywithitsSTEMI,Stroke,TraumaandSuddenCardiacArrest

committeesandEMSsystemstakeholderstoreviewsystemperformance,resolveissuesidentifiedthroughtheQIprocess,andconsideropportunitiesforEMSsystemimprovement.Thecollectionandevaluationofdata,aswellasstakeholderinput,haveresultedinthechangingofpoliciesandtheimplementationofnewprogramssuchasthosewehavealreadymentionedtoexpandthescopeofpracticeofEMTswithadditionaltrainingandeducationrequirements.TheQIprocesshasalsocontributedtotheestablishmentofotherprogramsthatdealwithprehospitalEMSconcerns.suchastheCounty’sstressmanagement,StoptheBleed,HandsOnly“SidewalkCPR”,andPublicAccessDefibrillatorprograms

FourofthefiveLEMSA’soverseeingEMSsystemswithpopulationsorterritorieswithin20%oftheVenturaCountypopulationorterritory—KernCounty,SanMateoCounty,SanFranciscoCountyandSanJuaquinCounty—alsosatisfytheEMSAminimumstandardsandguidelinesforaCQIprogram.20LikeVCEMSAtheyhavedevelopedQIprogramsadheringtotheEMSAstatewideQualityImprovementProgramandtheEMSAQIregulations.TheycollectdatathattheyevaluateforEMSsystemissuesandopportunitiesandhavecommitteescontributingtotheirQIProgramthatworkwiththeirEMSsystemstakeholders.Forexample,theKernCountyEMSSystemusesthefollowingcommitteesandmeetingsaspartofitsQIprogram:EmergencyMedicalDispatchCommittee,TraumaEvaluationCommittee,STElevationMyocardialInfarctionCommittee,StrokeSystemofCareQICommittee,PediatricAdvisoryCommittee,EmergencyMedicalCareAdvisoryBoard,andEMSSystemCollaborativeMeeting.21

TheVenturaCountyCQIPlanandProgramarecomparabletothoseinthesefourcountieswithpopulationsorterritorieswithin20%oftheVenturaCountypopulationorterritory.VCEMSA,throughitsCQIPlanandProgramhasdemonstrateditscommitmentandenthusiasmtothetaskofcontinuousqualityimprovementoftheVenturaCountyEMSSystem.

20ThemostrecentEMSPlanorEMSPlanUpdateforeachoftheseLEMSAs.SolanoCountymayhavealsometthestandardsandguidelines,butthatcouldnotbeascertainedbyreviewingitsmostrecentEMSPlanUpdate.21KernCountyEmergencyMedicalServicesPolicy1002.00.EMSQualityImprovementProgram(EQIP).

EMSpersonnellevelsinCaliforniaareemergencymedicaltechnician(EMT),advancedemergencymedicaltechnician(AEMT),paramedic(EMT‐P),criticalcareparamedic(CCP),mobileintensivecarenurse(MICN)andflightnurses.BasicEMTtraining22mustinvolveatleast170hoursoftraining,includingatleast24hoursofclinicaltrainingand146hoursofdidacticandskilltraining.Thetrainingalsorequiresatleast10patientcontacts.TobecomeanEMTapersonmusthaveahighschooldiplomaorGEDcertificateandbeatleast18yearsofagebytheendofthetrainingprogram.ThescopeofpracticeofanEMTisdefinedinVCEMSAPolicyNo.300.EmergencyMedicalTechnicianScopeofPractice.However,theVCEMSAMedicalDirectorhasestablishedpoliciesandprocedures,includingadditionaltrainingrequirements,forlocalaccreditationofanEMTtoperformthefollowingoptionalskills:

Administrationofepinephrinebyprefilledsyringeand/ordrawingupthe

properdrugdoseintoasyringeforsuspectedanaphylaxisand/orsevereasthma.

AdministrationofAtropineandPralidoximeChloride,utilizingtheDuoDoteautoinjectorfollowinganexposuretoanerve‐agent.23

AEMTtraining24involvesatleast160hoursofadditionaltraining,includingatleast

80hoursindidacticandskillstraining,40hourofclinicaltraining,and40hourstobecompletedinafieldinternship.Thetrainingmustalsoincludeaminimumof15patientcontacts.

Paramedictraining25involvesatleast1,090hoursoftrainingandatleast40ALS

patientcontacts.Ofthetraining,atleast450mustbedidacticandskillstraining,160hoursinhospitalclinicaltraining,and480hoursinafieldinternship.TherearelevelIandIIparamedics.AllALSresponseunitsmustbestaffedbyalevelIIparamedic.AdditionalALSresponseunitstaffmustbealevelIorIIparamedicoranEMTsatisfyingVCEMSAPolicyNo.306.EMT:RequirementsToStaffanALSUnit.CCPtrainingmustinvolveatleast202hoursofadditionaltraining,including108hoursoftrainingindidacticandskillsand94hoursinhospitalclinicaltraining.Anindividualmusthaveatleastthreeyears‐experienceworkingasaparamedicbeforebeginningCCPtraining.

22EMTprogramtrainingrequirementsarefoundat22CCR§100074andVCEMSAPolicyNo.1100.EmergencyMedicalTechnicianTrainingProgramApproval.23VCEMSAPolicyNo.303.EMTOptionalSkills.24AEMTprogramtrainingrequirementsarefoundat22CCR§100119.25Paramedicprogramtrainingrequirementsarefoundat22CCR§100154andVCEMSAPolicyNo.1135.ParamedicTrainingProgramApproval.

PrehospitalEducationandTraining

Itissomewhatatypicalforacountyorlocal‐levelEMSoversightagencytohavein

placeapolicyimplementingspecific,experience‐basedparamediclevels.ThemoretraditionalapproachisforanEMSoversightagencyorsystemmedicaldirectortoestablishpreceptorshiprequirementspertainingtominimalskillexperienceandproficiency(e.g.,establishingaminimumrequirednumberofsuccessfulintubations,etc.)andthentopermittheindividualEMScompany’smedicaldirectortooverseeeachparamedic’sattainmentoftherequiredskills,resultingina“signoff”foreachqualifyingparamedic.Stakeholdersinterviewedforthisprojecthadavarietyofopinionsonthistopic.SomeindicatedthattheEMSAgency’s“LevelI/LevelII”policyworksfairlywell,andthatVCEMSAhasworkedwithprovideragenciestograntexceptionswhentheyhaveacutehiringneeds,suchasmaybecausedbyunusuallevelsofemployeeturnover,toaccommodatetheirneeds.ButsomestakeholdersalsoassertthattheLevelI/LevelIIpolicyisacostlyandinefficientanachronismfromatimewhenthe“2paramedicvs.1paramedic/1EMT”debatewasraginginCalifornia(andelsewhere)some30+yearsago.

StakeholdersalsonotethatthelocalEMSagencyalsohasothersafeguardsinplace

thatmakemoottheneedfortheLevelI/LevelIIpolicy.Forinstance,theCounty’srobustQIprogramiscapableofdeterminingifpatientcareisbeingjeopardizedbyinexperiencedproviders.Inaddition,EMSemployershaveastrongincentivetoensurethattheydonotdeployinexperiencedproviders,whocanopenthemuptoliability,customerdissatisfactionandotherbusinessconsequences.

ItisourrecommendationthattheCountyeliminatetheLevelI/LevelIIparamedic

policyinfavorofaninternalEMScompanysign‐offprocessinvolvingthecompany’smedicaldirectorinadherencetoestablishedCountyguidelinesregardingskillacquisitionandmaintenance.

ToobtainauthorizationbyVCEMSAtoserveasaMICN26intheCountyaregisterednurse(RN)musthaveaminimumof1040hoursofcriticalcareexperienceasanRN,beemployedinaCountybasehospital,andwithintheprevioussixcalendarmonthperiodbeenassignedfor520hourstoclinicaldutiesinanemergencydepartmentresponsiblefordirectingprehospitalcare,orhadresponsibilityformanagement,coordinationortrainingprehospitalcarepersonnel,orservedasastaffmemberofVCEMSA.Additionally,theRNmusthavesuccessfullycompletedaMobileIntensiveCareNursesDevelopmentCourse.TheRNmustallridewithaCountyparamedicunitforaminimumofeighthoursandobserveatleastoneemergencyresponsepatientcontactorsimulateddrillandthenpassawrittenexaminationapprovedbyVCEMSAandserveaninternship.

26MICNauthorizationrequirementsarefoundinVCEMSAPolicyNo.321.MobileIntensiveCareNurseAuthorizationCriteria.VCEMSAPolicyNo.323.MobileIntensiveCareNurseAuthorizationChallengeprovidesaprocedureforanRNwhoiscurrentlyauthorizedasanMICNinanotherCaliforniacountyorstatetochallengeforMICNauthorizationintheCounty.

ToreceivecertificationasanEMTorAEMT,orlicensureasaparamedic,onemustsuccessfullycompleteapplicableNationalRegistryEMTtests.ToreceivecertificationasaCCPonemustpassthecertificationexamoftheBoardforCriticalCareTransportParamedicCertification.

VCEMSAhasprimaryresponsibilityforapprovingandmonitoringtheperformance

ofemergencymedicalresponder(EMR)trainingprogramsintheCounty.27EMTtrainingprogramsintheCountymaybeapprovedeitherbytheCaliforniaEMSAuthority(CEMSA)orVCEMSA.28AEMTprogramsintheCountyareapprovedbyVCEMSA.29ParamedicandCCPtrainingprogramsmaybeapprovedbyEMSAorVCEMSA.30VenturaCollegeprovidestheonlyfullyaccreditedparamedictrainingprogramintheCounty.31

AllEMSpersonnelneedtosatisfycertainrequirementsfortheiron‐going

authorizationoraccreditationtoprovideprehospitalcareintheCounty.32AllEMSpersonnelmustattendinitialbasicoradvancemasscasualtyincident(MCI)trainingwithinsixmonthsofstartingthecertificationoraccreditationprocessandcompletebi‐annualrefreshers.Also,allsuchpersonnelexcludingEMTs,butincludingEMT‐ALSAssistsearchandrescue(SAR)EMTs,mustannuallyattendmandatoryeducationonupdatestolocalpoliciesandproceduresorcompleteatestontheupdates.

Additionalongoingtrainingrequirementsincludegrieftraining(MICNsare

exempt),emergencyresponsetoterrorismtraining,andAdvancedCardiacLifeSupport(ACLS)(EMTsandSAREMTsareexempt).Paramedicsarerequiredtotakeaparamedicskillsrefreshercourseduringboththefirstandsecondyearoflicensure,paramedicsandSARflightnursesarerequiredtotakeafieldintubationrefreshercoursepersix‐monthperiodbasedupontheirlicensecycle,andparamedicsandMICNsarerequiredtotakeaPediatricAdvancedLifeSupport(PALS)orPediatricEducationforPrehospitalProviders(PEPP)coursewithinsixmonthsofstartingtheaccreditationprocessandthenremaincurrent.MICNsmay,alternatively,taketheEmergencyNursePediatricCourse(ENPC).

VCEMSAalsooffersapprovalsforPublicSafetyFirstAidandCPR,andTactical

CasualtyCaretrainingprograms.33

27VCEMSAPolicyNo.1102.EmergencyMedicalResponder(EMR)TrainingProgramApproval.2822CCR§100057.2922CCR§100101.3022CCR§100137.31www.vchca.org/education‐and‐training32VCEMSAPolicyNo.334.Pre‐HospitalPersonnelMandatoryTrainingRequirements.33VCEMSAPolicyNo.1602.PublicSafety‐FirstAid(PSFA)andCPR/TacticalCasualtyCareTrainingProgramApproval.

FutureConsiderationsandOutlookofEMSTrainingandEducation

TheEMSAgenda2050,publishedbytheU.S.DepartmentofTransportation,NationalHighwayTrafficSafetyAdministration,isapeople‐centeredvisionforthefutureofEMS.ThegoalofthereportwastoexploreandaddresswhatEMScouldbebytheyear2050.AprimarycomponentofthatgoalisforEMSprofessionalstoreceivetheeducationandtrainingtoadequatelypreparethemtonotonlyprovidelifesavinganddisease‐treatingcare,butalsotobecomeanintegralpartofapublichealthandhealthcaresystemthatfocusesonpreventinginjuriesandillnessesaswellascarethatreducesphysical,emotionalandpsychologicalsuffering.Inshort,thevisionisforEMSprofessionalstobeeducated,trainedandpermittedtoplayamuchlargerroleinmanagingthehealthofpatientsincoordinationwithotherhealthcareprofessionals.

TheEMSAgenda2050describessixguidingprinciplestopavethewayforitsvision.EMSsystemsmustbe:

Inherentlysafeandeffective Integratedandseamless Reliableandprepared Sociallyequitable Sustainableandefficient Adaptableandinnovative

EMSprofessionalsintheVenturaCountyEMSSystemareeducatedandtrainedtoperformthetraditionalrolesofEMSproviders—respondtoemergencyandnon‐emergencycalls,assessthepatienttodeterminewhattypeofcarethepatientrequires,andprovidethecaretothepatientuntiltransportedtothepatient’sdestination.TheEMSAgenda2050stressesthateducationandtrainingforEMSprofessionalsneedstocoverallaspectsofclinicianandpatientsafetywithafocusonevidence‐basedmethodsofharmreduction.ThevisionforthefutureisthatEMSprofessionals,particularlyparamedics,alsoreceiveacomprehensiveorientationtopublichealth,socialservices,mentalhealthandsocialdeterminantsofhealthinawaythatempowersthemtoprovidedintegratedcare.

TomaketheEMSagenda2050visionareality,theVenturaCountyEMSSystemneedsto,andtosomeextentalreadyhas,embracedthesixguidingprinciplesoftheEMSAgenda2050.TheCountyhasbeenoutfrontintheCaliforniacommunityparamedicinepilotprogramtotrainparamedicstoservethepublic,incoordinationwithotherhealthprofessionals,innon‐traditionalEMSroles.ThisisastepintherightdirectiontohaveEMSprofessionalsplayamuchlargerroleinmanagingthehealthofpatientsinVenturaCounty.AstheEMSAgenda2050statesinadoptingacommonsaying,“Thebestwaytopredictthefutureistocreateit.”Toachieveby2050thepeople‐centeredvisionoftheEMSAgenda2050,theVenturaCountyEMSSystemplannersneedtocontinuetobeforwardthinkingto

adaptthesystemtoservethechangingneedsofitscitizens,understandthepotentialofitsEMSproviderworkforcetoservethosechangingneeds,andhavethesystemevolvetoharnessthatpotentialtomaximizethecontributionoftheEMSworkforcetothehealthandwellbeingoftheCounty’scitizens.

Strengths•StakeholdersreportgeneralsatisfactionwithLEMSA•RobustQIprograminvolvesanactivecollaborativeprocesswithallclinicalstakeholders,includinghospitals

Weaknesses•LEMSAstaffinglevelbelowCAaverage•Stakeholdersreportstringentandinflexiblestaffingrequirements•Non‐competitiveEMSwagescreateEMSpractitionerretentionissue•LevelI/IIparamedicpolicyreportedascreatinginefficiencyandexpense

Opportunities•Continuemovementtowardpatient‐focusedQImetrics•Potentialimplementationofpreceptorshipmodel

Threats•Needtokeeppaceinprovidereducationandtrainingtoprovideexpandedrangeofintegratedcareservicesinfuture

SWOTAnalysis–LocalEMSAgency/SystemIssues

SystemFinancials

ForFY17‐18,VCEMSAhadanannualbudgetof$3,894,819derivedfromamixof

servicefees,providerchargesandpenalties,trafficfinecollections,andCountygeneralfunds.ItalsoadministeredtheMaddyFund,whichisusedtoreimbursephysiciansandemergencyroomsforaportionofuncompensatedcarewithtrafficfinefunding.Fromthe$3,894,819,theMaddyFunddisbursementswere$1,505,231inFY17‐18tosettlehospitalandphysicianclaimsforuncompensatedcare.34ForFY16‐17theannualbudgetwas$3,588,795,with$1,575,713disbursedfromtheMaddyFund35andforFY15‐16theannualbudgetwas$3,534,742,with$1,585,461disbursedfromtheMaddyFund.36For2016,2017and2018responsetimepenaltyfeespaidtoVCEMSAwere$202,463,$229,251and$221,027respectively.37

Whilerelativelysteadyforthepastthreeyears,theresponsetimepenaltiesarenot

guaranteed.Asforfactorswhichinfluenceambulancefee‐for‐servicerevenuenationally,thereiscurrentlya2%reductioninMedicarepaymentscausedbythe“sequestration”provisionoftheBudgetControlActof2011.Thisisprojectedtocontinueindefinitely.Twopercentmayseemlikeaminoradjustment,howeverbasedonacombined2018revenueofapproximately$45,000,000and50%Medicarepayormix,theresultinglossisinexcessof$450,000peryearforthethreeambulanceserviceprovidersinVenturaCounty.

Thereareseveralissuesthatmayaffectthefutureofreimbursementandtherefore

haveafinancialimpactontheEMSsysteminVenturaCounty,theStateofCaliforniaandtheUnitedStates:

1. PaymentforTreatmentwithoutTransport(“TNT”):Beginningwithdatesof

serviceonorafterSeptember1,2018,AnthemBlueCrossbeganpayingforambulanceserviceresponseandtreatmentofpatientson‐scenewithouttherequirementoftransport.ThisaffectedclaimsinCaliforniaand13otherstates.38Thepaymentforthisisapproximately$380pertransport.ItisunknownatthistimewhethertheambulanceservicesuppliersinVenturaCountyaretakingadvantageofthispaymentpolicyanditisnotknownwhat

34FY2017‐18budgetinformationfromVCEMSA.35.FY2016‐17budgetinformationfromVCEMSA.36FY2015‐16budgetinformationfromVCEMSA. 37VCEMSAResponseTimePenalties2016‐2018spreadsheet.38https://providernews.anthem.com/california/article/update‐regarding‐hcpcs‐code‐a0998‐ambulance‐response‐and‐treatment‐with‐no‐transport

SystemRevenue

percentageofthecommerciallyinsuredpopulationhasAnthemcoverage,butthepotentialimpactofthisistwo‐fold.Firstthismaybeasourceofrevenuetofundsomeoftheclaimsinthe“uncompensatedcare”bucketnotedintheProviderFinancialssectionbelow.Second,itmayallowfortreatmentinplaceinlieuofunnecessarytransports,whichcouldresultintheprovidersbeingbackinservicequickeraftertheinitialpatientencounter.Bothofthesecouldhaveapositivefinancialimpactontheindividualambulanceserviceproviders.

2. TheCMSET3paymentmodel:Beginningin2020,CMSwillbeselectingalimitednumberofambulanceservicesupplierstoparticipateintheEmergencyTriage,Treatment,andTransportprogram.39Ifselected,participantswouldqualifyforMedicarepaymentforpatientstreatedon‐scene(similartotheAnthempolicyoutlinedabove)aswellasfortransporttodestinationsotherthanahospital.Applicationtoenrollinthisfive‐yearpilotprogramisvoluntary.TheimpactofthisprogramonreimbursementisagainsimilartothatoftheAnthemprogram;specificallyitwouldallowforpaymentforsometypesoftransportsortreatmentthatarenotcurrentlycoveredbyinsuranceanditcouldallowEMSresourcestobebackinservicemorequicklyafterthepatientencounter,eitherbytreatingon‐sceneandimmediatelygettingbackinserviceortransportingapatienttoaclinicthatiscloserthanthenearesthospital.Thereshouldbeapositivefinancialimpactontheambulanceserviceproviders,howevertherewillbeareductioninmileage‐basedcharges,sotheoverallnetfinancialimpactmaybedifficulttocalculatewithoutayear’sworthofdatatoanalyze.ItisnotknownwhetheranyofthethreeambulanceserviceprovidersinVenturawillapplyorbechosenforthisprogram.

3. CMSCostDataCollectionRequirement‐Beginningin2020,CMSwillrequireambulanceservicesupplierstocollectandreportcostandrevenuedata.40TheresultsofthisprocesswilldeterminewhetherambulanceservicesuppliersarebeingpaidasufficientamountundertheMedicarefeeschedule.IfthestudyresultsshowthatMedicarepaymentsareinexcessofcosts,thenitislikelythatthecurrent2%urban,3%rural,and22.6%super‐ruralambulanceadd‐onpaymentswillend.However,ifthestudyshowsthatthecurrentMedicareratesarenotsufficienttocovercosts,thenitislikelythatthesebonuseswillbemadepermanentandpotentiallyevenincreased.PriorstudiesbytheGovernmentAccountingOfficehaveshownthatMedicarepaymentsareinfactlowerthanthecostofprovidingthecare41,thereforetheCostDataCollectionprocessshouldnotresultinapaymentdecrease.ItshouldalsobenotedthatCMShasthe

39https://innovation.cms.gov/initiatives/et3/40https://www.cms.gov/Outreach‐and‐Education/Outreach/NPC/Downloads/2018‐06‐28‐Ambulance‐Services‐Transcript.pdf41https://www.gao.gov/assets/650/649018.pdf

authoritytoimposea10%reductiononfuturepaymentsforanyambulanceservicewhichdoesnot“substantially”complywiththecostdatareportingrequirement.TheimpactoftheCostStudywillnotbefeltuntilthefinalreportcomesoutin2022andadeterminationismaderegardingtheratesfor2023.WenotethattheprovidercontractssetforthaChartofAccounts(e.g.,ExhibitD).AfterCMSissuesitsfinalambulancecostdatacollectionregulations(proposedregulationsforambulancecostdatacollectionwereissuedonJuly29,2019),werecommendforfuturecontractsthatVCEMSAincludelanguageadoptingtheCMSambulancecostmethodologyforthispurpose.

4. CommercialInsuranceDeductiblesandCo‐Pays:Thereisatrendtowardhigherdeductiblesandco‐paymentsincommercialhealthinsurance.AccordingtoastudybytheKaiserFamilyFoundation42thatcompareddatafrom2013to2018,58%ofemployeeshadadeductibleofmorethan$1,000in2018comparedtoonly38%ofemployeesin2013.Similarly,deductiblesofover$2,000rosefrom15%in2013to26%in2018.Thesehigherdeductibleplanscreatealargerself‐paybalancewhichhasalowerrateofcollectionperdollarwhencomparedtootherpayors.

5. RepetitiveNon‐EmergencyPriorAuthorizationProgram:CMSonDecember1,

2019wasscheduledtoconcludeamodelpaymentprogramwhichiscurrentlyineffectin8statesandtheDistrictofColumbia.CMShasindicatedthatthisprogramcouldgonationwide.However,onSeptember16,2019CMSpublisheditsdecisiontoextendtheprogramthroughDecember1,2020forjustthe8statesandtheDistrictofColumbiawheretheprogramiscurrentlyineffect.ThoughCMS’sfuturesplansforthismodelpaymentprogramarecurrentlynotknown,itispossiblethatthisprogramcouldgonationwideduringthenextcontractingcycleforprovidersinVenturaCounty.Inthestateswhererepetitivepriorauthorizationhasbeenimplemented,therehasbeenadenialrateofapproximately1/3ofallscheduled,repetitivenon‐emergencytransports.Inaddition,CMSbeginninginOctober2018reducedbyatotalof23%itsreimbursementamountforBLSnon‐emergencytransportsforpatientsgoingtoandcomingfromdialysisvisits.WhilethesepoliciesdonotdirectlyaffectreimbursementforALS‐levelandemergency911calls,manyambulanceprovidersineffect“subsidize”theircostsofreadinessfortheprovisionofemergencyambulanceserviceswiththerevenuesgeneratedbynon‐emergencyambulancetransports,includingdialysisandotherrepetitivenon‐emergencytransports.ThesefactorshavethepotentialtocreateadditionalfinancialpressuresforprovidersinVenturaCountyandnationwide.

42http://files.kff.org/attachment/Summary‐of‐Findings‐Employer‐Health‐Benefits‐2018

Theextenttowhichthesefactorsmayinfluencefuturepaymentshouldbemonitored,howevernoneareexpectedtohaveanimpactthatwouldrequiremajorsystemchange.

FortheproviderofEOAs2,3,4,5and7,overthefive‐yearperiod2014‐2018,Medicarewasthepredominantpayorofambulanceserviceclaims,accountingineachyearforslightlymorethan50%ofthepaidclaims.In2018thefigurewas53.1%,whichisthelargestpercentofpaidclaimsattributabletoMedicareoverthefive‐yearperiod.ThecombinationofMedicareandMedi‐Calpaidclaimsoverthatperiodrangedfrom65%in2014to71.9%ofpaidclaimsin2017.In2018thepercentagewas71.2%. CommercialandSelf‐Paywerethenexthighestcategoriesofpaidclaimsoverthefive‐yearperiod,withthetwoswitchingpositionsinrank.In2014,combined,theyaccountedfor29.6%ofpaidclaims,thehighestpercentofpaidclaimsattributabletothesetwopayorclassificationsoverthefive‐yearperiod,whilein2018theyaccountedfor24.8%ofpaidclaims,thelowestpercentofpaidclaimsoverthefive‐yearperiod.Duringthisperiodthepercentofpaidclaimsattributabletocommercialpayorsdroppedfrom13.9%to13.0%.ThedeclineinpaidclaimsattributabletoSelf‐Payorswasmorepronounced.In2014itwas15.7%;in2018,11.8%.Thatwasactuallyahigherpercentagethanin2017,whichwasonly10.9%.TheremainingsourcesofpaidclaimswereattributabletoFacilityContracts,ContractedInsuranceandHMOs,CapitatedandVA,whichcollectivelymadeup5.4%ofpaidclaimsattheirhighestin2014. Intermsofdollars,between2014and2018thepercentageofreimbursementattributabletoMedicareandMedi‐Calrosefromapproximated65%to70%andbetween2014and2018thepercentageofreimbursementfromCommercialandSelf‐Paypayorsdroppedfromaround30%to25%.

PayorMix

Table2:VenturaCountyAmbulanceProviderPayorMix,2018*PercentageofTransports

[*Provider‐SuppliedData]

Payor AMR GoldCoast LifeLine(9‐1‐1)

Medicare 53.1% 44.2% 54.8%Medi‐Cal 18.1% 25.8% 21.7%Commercial/Contract 17.0% 19.2% 18.6%Self‐Pay 11.8% 10.8% 4.9%

Table3:ComparativeAmbulancePayorMixesforSelectedCaliforniaCounties

Payor Monterey43 Alameda44 Stanislaus45

Medicare 39.43% 33% 41.6%Medi‐Cal 27.99% 34% 34.5%Commercial 17.78% 16% 14.6%Self‐Pay 14.31% 17% 9.4%

Ascanbeseenfromthetablesabove,VenturaCounty’spayormixisgenerallymorefavorablethanthatoftheselectedcounties,asitrepresentsalowerproportionofMedi‐Calrecipientsandofself‐paypatientsinthepayormix,andahigherpercentageofcommercially‐insuredpatients,forwhomreimbursementamountsaregenerallyhigherthanthosepaidbygovernmenthealthcareprograms.

WenotethatthepayormixreportedbytheambulanceprovidersservingVentura

Countyalsocomparesfavorablytothatreportedin2018bytheCaliforniaHealthCareFoundation.TheEDpayormixforhospitalsintheCentralCoastofCalifornia(whichincludesVenturaCountyinthisstudy)isreportedas23%Medicare,42%Medi‐Cal,25%privateinsurance,and6%self‐pay.46

43MontereyCountyRFPpublished1/10/1944RFP#EMS‐900616forbidon1/6/201745RFP#MVEMS‐2018‐12(2017data)46CaliforniaHealthCareFoundation,CaliforniaEmergencyDepartments:UseGrowsasCoverageExpands,August2018.Thesepayormixdataarereportedfrom2016.Wealsonotethatthesepayormixdataare

PursuanttoVenturaCountyOrdinanceCodeSection2423‐3,ambulanceratesareapprovedbytheCountyBoardofSupervisorsandareestablishedbaseduponthecosttotheambulanceoperatorstoprovideemergencyambulanceservicetothecitizensofVenturaCounty.TherateslistedarerevisedannuallyasneededandarethemaximumratesthatmaybechargedintheCountybyallambulancecompanies.ThemaximumratesthatmaybechargedeffectiveJuly1,2019areasfollows:47

Table4:CurrentVCEMSA‐ApprovedAmbulanceRates

LevelofService Charge DefinitionNon‐EmergencyBaseRate

$940.50

Transportfromsiteofillnessorinjurytohospitalorfromhospitaltohomeorotherfacilityresultingfromanon‐emergencyrequest

ALSBaseRate

$1,795.00

TransportfromsiteofillnessorinjurytohospitalastheresultofanemergencyrequestorforprovisionofALSlevelservicesduringtherequestforservice

SCTNurseHourlyRate(two‐hourminimum)

$277.00

Rateperhourforprovidingaspeciallytrainednursetoaccompanyacriticallyinjuredorillpatientduringtransportbyagroundambulancevehicle,whichincludestheprovisionofmedicallynecessarysuppliesandservices,atalevelofservicebeyondthescopeoftheEMT‐Paramedic

Mileage

$37.25

Ratepermilefrompointofpickuptohospital.Thischargeisproratedamongthepatientsifmorethanone(1)patientistransported

OxygenAdministration $117.50 Chargemadetopatientforadministrationofoxygenandrelatedadjuncts

Nochargeispermittedforadispatchthatiscancelledorthatresultsinnoprovision

ofprehospitalcare.48WenotethatVCEMSApolicyestablishesratesfornon‐emergencytransports.BecausetheEOAcontractsestablishexclusivityforemergencyambulanceserviceonly,non‐emergencyservicesareprovidedtofacilities,patientsandconsumersonacompetitivebasiswithintheCounty.Forthatreason,includingscheduledratesforcompetitiveservicesasaconditionofexclusivityfortheEOAcontractsisatypicaland

basedonnumberofvisits,comparedwithpayorasapercentageofrevenueasreportedbytheambulanceprovidersinVenturaCounty.47VCEMSAPolicyNo.112.AmbulanceRates.48ThispolicyshouldberevisitedintheeventthatacontractorisselectedforparticipationintheCMSET3programorsimilarinitiativeforlow‐acuitypatients.

Rates/Billing

appearstoustobeinconsistentwithhavinganopenmarketfornon‐emergencytransports.WerecommendthatVCEMSAconsidereliminatingnon‐emergencyratesfromitsmaximumrateschedulepolicysothatthenon‐emergencymarketcanfunctioninthecompetitivemanneritwasintended. AMRandGoldCoasthaveaCompassionateCareProgram(CCP).49Theyprovidereducedcostambulanceservicestopatientswhoareuninsuredorunderinsured,andabletoprovidedocumentationofhardship.AccountsthathavenotbeenreferredtoanoutsidecollectionagencyandarenoolderthanoneyearfromthedateoftransportatthetimethepatientorresponsiblepersonrequestsparticipationintheCCPwillbeconsideredforreducedcosts.IftheaccountisolderthanoneyearitmayalsobeconsideredforparticipationintheCCPifrequestedbytheoperationssiteormanagement.Otherwise,accountsthatareoverdueafterrepeatedrequestsforpaymentarereferredtoacollectionagencytoresolvetheoutstandingbalance. AMRandGoldCoastwillprovideaCCPapplicationtoanapplicantiftheapplicant’shouseholdincomeforthepreviousyear(orcurrentincome)lessmedicalexpensesisequaltoorlessthan125%ofthefederalpovertylevel,unlessthecountyinwhichthetransporttookplaceotherwisedefinedhardshiplevels,providedthedefinedlevelsarenolowerthanthefederalpovertylevel.Thisdeterminationwillbemadebasedontheapplicant’smostrecenttaxreturnorotherdocumentation.InthediscretionoftheAMRpatientadvocate,approvalforreducedpaymentcanbevalidforsixmonths. Thedocumentationrequiredtoestablishfinancialhardshipdependsuponthestatusoftheapplicantasfollows:employed,unemployedorretired,self‐employed,studentwithnoproofofincome,non‐USresident,Medicaidactive,orapplicantwithahospitalcharityapprovalletter.Aslidingscaleisusedtodeterminethewaiverpercentagebaseduponvariousfactors.Waiversofapplicantcostmaybepartialorfull. LifeLinealsohasahardshiprequestpolicy.RequestsforaccommodationforfinancialhardshipareinitiallyreceivedbyLifeLine’scontractedbillingcompany.Thebillingcompanyrequeststhatthepatientsubmitawrittenappeal,alongwithdocumentationoffinancialstatus.Afteritreceivestherequesteddocumentation,thebillingcompanyisauthorizedtoofferapaymentplanoption,butisnotpermittedtowriteofthebalance.Iftheapplicantrequestssomethingotherthanapaymentplan,theapplicantisdirectedtocontactLifeLinedirectlyforadditionaloptions.IftheapplicantcontactsLifeLine,therequestisconsideredonanindividualbasisbyadministrativestaffforpartialorcompletewrite‐off,orforotheroptionsthatmightbeavailableforresolution.

49BaseduponthedocumentationprovidedbyGoldCoastitappearsthattheCCPforbothorganizationsisadministeredbyAMR.

Asseeninthetablesbelow,VenturaCountyambulanceratesaresignificantlylowerthansomeothercounties.However,theMedicareandMedicaidfeeschedulesand“usualandcustomary”ratelimitsappliedbymostpayorsmaynotallowfullpaymentoftheserates,relegatingbalancestobewritten‐offorshiftedtoprivatepaystatus.Table5:ComparativeAmbulanceRateSchedulesforSelectedCaliforniaCounties

LevelofService Monterey50 Alameda51 Stanislaus52Non‐EmergencyBaseRate $2,327.84 $2,001.03 $2,584.21(ALS)

$1,445.65(BLS)EmergencyBaseRate $2,327.84 $2,001.03 $2,811.61(ALS)

$1,927.00(BLS)SCTBaseRate $3,682.03 NotListed $4,816.59

Mileage $50.21 $47.54 NotListed

OxygenAdministration $150.08 $157.40 NotListed

Finally,wenotedsomepotentiallyaberrantpatternswithinsomeoftheservicemixdatasubmittedbysomeoftheproviders.Servicemixreferstothespecifictypesandlevelsofservicebilledtopayorsforambulanceservicesprovided,stratifiedbyHCPCScode.Inparticular,wenotedaparticularlyhighpercentageofbilledALS‐levelclaimscomparedtoBLS‐levelclaims whencomparedtotheratioofALStoBLSclaimsbaseduponMedicarenationalclaimsdata.AccordingtoMedicare’smostrecentnationalclaimsdata,thisratioisapproximately63%ALS‐to‐37%BLSforemergencyresponsesnationwide.53

AlthoughcontractorsaremandatedtorespondattheALSlevelonallemergencycalls,thisdoesnotmeanthatallclaimsareeligibletobebilledattheALSlevel.Forexample,numerouscallsaredispatchedattheBLSlevel,andthosearenoteligibleforapplicationoftheCMS“paramedicassessment”rule.Althoughaspecificbillingandcodingauditofproviderclaimswasbeyondthescopeofthisreview,werecommendthatfutureambulanceprovidercontractsincludearequirementforanannualbilling/codingaudit,ateachcontractor’sexpense,ofarandomsampleofclaimsbyaqualifiedoutsideclaimauditingfirmselectedbyVCEMSA.WealsorecommendarequirementthateachcontractorhaveacomplianceprogramadheringtotheOIG’sComplianceProgramGuidanceforAmbulanceSuppliers,aswellasarequirementthatcontractorshavepersonnelcertifiedinambulancecodingontheirbilling,codingand/orrevenuecyclestaff.

50Source:MontereyCountyRFPpublished1/10/1951Source:RFP#EMS‐900616forbidon1/6/201752SourceRFP#MVEMS‐2018‐12(2017dataaverageof5providers) 53MedicareProviderUtilizationandPaymentData:PhysicianandOtherSupplier,CY2017,https://www.cms.gov/research‐statistics‐data‐and‐systems/statistics‐trends‐and‐reports/medicare‐provider‐charge‐data/physician‐and‐other‐supplier.html

Notethatproviderfinancialsdiscussedinthissectionarebasedonself‐reportedinformationfromthecontractedproviders.Wewerenotengagedto,nordidwe,performindependentauditsofproviderfinancialstatements.

AccordingtoAMRfinancialstatements,forcalendaryear2016,itstotaloperating

expenseforitsoperationsintheCountywas$25,717,210,anditsrevenuenetofcontractualprovisionswas$26,438,864,leavingitwithnetincomebeforetaxesandinterestof$721,654.Thefourlargestcomponentsofitsoperatingexpensewere$8,272,851inuncompensatedcare,$8,857,103insalaryexpense,$1,764,418inbenefitsandpayrolltaxes,and$1,124,523infirstresponderfees.Thenetprofitmarginfor2016was+2.8%

Forcalendaryear2017itstotaloperatingexpenseandrevenuenetofcontractualprovisionswas$25,812,737and$26,440,527respectively,leavingitnetincomebeforetaxesandinterestof$627,790.Thefourlargestcomponentsofitsoperatingexpenseswerethesameasforcalendaryear2016,withincreasesineachofthoseexpensesexceptforuncompensatedcare.Theuncompensatedcareexpensedecreasedsignificantlyto$7,121,985.Thenetprofitmarginfor2017was+2.4%

Forcalendaryear2018itsrecordsreflectthatithadanetlossofincomebefore

taxesandinterestof$770,909baseduponrevenuenetofcontractualprovisionsof$26,009,715andatotaloperatingexpenseof$26,780,624.Onceagaintherewasareductionintheexpenseforuncompensatedcare,thistimebyapproximately$20,000.Therewasalsoanapproximate$50,000increaseinitsbenefitandpayrolltaxesexpense.Overthethree‐yearperiodthelargestexpenseincreasewasthesalaryexpense,whichincreasedfrom$8,857,103in2016to$10,057,022in2018.The2018netlossmarginwas‐3%. WenotethatAMRreportsapproximately$2millionperyearin“sharedsupportservices,”whichpresumablyarefeespaidbyregionalAMRaffiliatestoacentralizedAMRentityforserviceswhichbenefitthelocaloperation.

ProviderFinancials

GoldCoast54

AccordingtoGoldCoast’sfinancialstatements,forcalendaryear2016,itstotaloperatingexpenseforitsoperationsintheCountywas$10,734,932,anditsrevenuenetofcontractualprovisionswas$11,111,175,leavingitnetincomebeforetaxesandinterestof$376,244.Thethreelargestcomponentsofitsoperatingexpenseswere$4,309,791inuncompensatedcare,$3,200,914insalaryexpense,and$476,285inbenefitsandpayrolltaxes.UnlikeAMR,ithadnofirstresponderfeesexpense.Thatisalsothecaseforcalendaryears2017and2018.The2016netprofitmarginwas3.4%.

Forcalendaryear2017itstotaloperatingexpenseandrevenuenetofcontractualprovisionswas$10,446,298and$11,404,768respectively,leavingitnetincomebeforetaxesandinterestof$958,470.Theuncompensatedcareandsalaryexpenseremaineditstwolargestoperatingexpenses,butitsthirdlargestexpensebecameitsmanagementexpenseunderdirectsharedsupportservices,increasingfrom$350,025to$529,806.AsforAMR,itsawasignificantreductioninitsuncompensatedcareexpense.Itdecreasedfrom$4,309,791to$3,669,136.The2017netprofitmarginwas8.4%.

Forcalendaryear2018itsrecordsreflectthatitagainhadanetincomebeforetaxes

andinterest,forthisyear,of$1,315,010baseduponrevenuenetofcontractualprovisionsof$13,225,805andatotaloperatingexpenseof$11,910,795.Forthiscalendaryear,however,itsuncompensatedcareexpenseincreasedto$4,696,180,anditsbenefitsandpayrolltaxesexpenseagainbecameoneofitsthreelargestoperatingexpenses.Thenetprofitmarginfor2018was9.9%

WenotethatGoldCoastreportsapproximately$1.1millionperyearin“sharedsupportservices,”whichpresumablyarefeespaidbyregionalAMRaffiliatestoacentralizedAMRentityforserviceswhichbenefitthelocaloperation.

LifeLine

AccordingtoLifeLine’sfinancialstatements,forcalendaryear2016itstotaloperatingexpenseforitsoperationsintheCountywas$4,265,640,anditsrevenuefromthoseoperationswas$4,551,310,leavingitnetoperatingincomeof$285,670.Withotherincomeandexpenses,itsnetincomewas$262,595.Itslargestoperatingexpenseswereassociatedwithitspayroll,whichwasbrokendownintodifferentcategoriesandcollectivelywerewellover$2million.ThethreelargestsourcesofitsrevenueswereBLS‐NE($1,764,856),911emergency($800,304),itsKaisercontract($753,094)andALS‐NE($630,9443).AMR’sandGoldCoast’sfinancialstatementsdidnotspecifythesourcesofits

54GoldCoast,whileacorporationseparatefromAMR,isanaffiliateofAMRandoperatesunderAMR’smanagement.

revenue.UnlikeAMR,ithadnofirstresponderfeesexpense.Thenetprofitmarginfor2016was6.3%

Forcalendaryear2017itstotaloperatingexpenseforitsoperationsintheCounty

was$5,227,768,anditsrevenuefromthoseoperationswas$5,542,845,leavingitnetoperatingincomeof$315,078.Withotherincomeandexpenses,itsnetincomewas$315,203.Again,itslargestoperatingexpenseswereassociatedwithitspayroll,whichwasbrokendownintodifferentcategories.Collectively,theywerewellover$2millionandwereasignificantincreasefromthatin2016.Thethreelargestsourcesofitsrevenueswerenon‐911($3,835,253),BLS‐NE($443,025),and911emergency($934,835),The2017netprofitmarginwas5.7%.

Forcalendaryear2018,itstotaloperatingexpenseforitsoperationsintheCountywas$5,612,291,anditsrevenuefromthoseoperationswas$5,772,252,leavingitnetoperatingincomeof$159,961.Withotherincomeandexpenses,itsnetincomewas$223,894.Again,itslargestoperatingexpenseswereassociatedwithitspayroll,whichwasbrokendownintodifferentcategoriesandcollectivelywerewellover$2million.Thethreelargestsourcesofitsrevenueswere911emergency($1,010,209),non‐911($4,293,358)andCCTRN($369,117).The2018netprofitmarginwas2.8%

SummaryandDiscussion–ProviderFinancials ThefollowingtablesummarizeskeyaspectsofthefinancialreportsofthethreecontractedEOAprovidersinVenturaCounty.Inthistable,“Revenue”istotalrevenuenetofcontractualallowancesasreportedbyeachprovider.“P/L”referstonetprofit(orloss).“Netπ”referstothepercentageprofitmarginasreportedbyeachprovider.

Table6:VenturaCountyProviders‐FinancialComparison,2016‐2018

DataBasedonProvider‐ReportedFinancials

Entity

GOLDCOAST

LIFELINE

Year Revenue P/L Netπ Revenue P/L Netπ Revenue P/L Netπ2016 26,438,864 721,654 2.8% 11,111,175 376,244 3.4% 4,551,310 285,670 6.3%2017 26,440,527 627,790 2.4% 11,404,768 958,470 8.4% 5,542,845 315,078 5.7%2018 26,009,715 ‐770,909 ‐3% 13,225,805 1,315,010 9.9% 5,772,252 159,961 2.8%

Thetrendsinprofitandlossmarginsbetweenthethreeambulanceserviceprovidersarenotconsistent.WhileAMRandLifeLinehaveshownaconsistentdownwardtrendinmargin,GoldCoasthasshownannualgrowthovereachofthelastthreeyears.Thecauseofthisdisparityisnotreadilyapparent.

Thereportingbyanyproviderofanegativenetprofit(aswasthecasein2018by

AMR55)shouldbeacauseforconcern.AlthoughthereisgenerallyminimumfinancialregulationbyLEMSAsoftheircontractedEOAproviders,alocalEMSagencyshouldensurethatitmonitorsthefinancialpositionofacontractedEOAproviderforanysignsoffinancialunsustainabilitythatmayarise.Itappearsthatin2018AMRreportedarevenuedropof$431,000comparedwith2017,andanincreaseinoperatingcostsof$1.2million,ofwhich$900,000oftheincreasewasattributedtosalaryexpense.

TheRealityofAmbulanceRevenues.Itisimportanttoframetheissuethat

underlieseveryEMSsystemdesign:anEMSsystemcanperformonlytotheleveloftherevenuesthatsupportit.AnEMSsystemthatplacesmobileemergencydepartmentswithanemergencyphysicianandcriticalcarenurseevery3milesthroughoutacountywouldbepubliclyandpoliticallydesirable,bututterlyunaffordable.Ontheotherhand,asystemwithoneBLSambulanceserving100,000peoplewouldbehighlyaffordable,butcompletelyundesirablefromapublichealthandsafetyperspective.

SomewherebetweenthoseextremeexamplesliestheoptimumEMSsystemconfigurationforeachcounty.EMSsystemdesignisalwaysanaccommodationofnecessitybetweenthepublic’sdesireforthefastestEMSresponseandthehighestlevelofcarewiththerealityoftheresourcesavailabletosupportthatsystem.ThechallengeineveryEMSsystemistofindthatbalance,thatequilibrium.

ToPayers,EMSisaTransportCommodity.ThoughMedicareisundertakingthefive‐yearET3model,asdiscussedabove,andsomecommercialinsurersarereimbursingfornon‐transportservices,EMSisstill,unfortunately,viewedprimarilyasatransportcommoditybyhealthcarepayers.Insurerspayforambulancetransports,notEMSsystems.Thus,revenuesareavailableonlyforcallsthatresultincoveredtransports.Mostpayercriteriarequirethatthetransportmeetmedicalnecessityguidelines,thatthepatientbetransportedtoacovereddestination,thatthepatientreceivecoveredservicesattheoriginordestination,andotherstringentcriteria.Unfortunately,reimbursementisinsignificantforcancelledcalls,“treatnotransport”responses,standbys,patientrefusalsofcare,waitingtime,extracrewmemberswhenneeded,non‐transportinterceptservicesandotherservices.PatienttransportisonlypartofwhatanEMSsystemdoes,butitcomprisesnearlyalltherevenueavailabletosupportallofthevitalEMSsystemactivitiesapartfrompatienttransport.

EvenwhenanEMSresponsedoesresultinapatienttransport,itisimportanttonotethatmanypayersarelimiting,denyingorretrospectivelyrecoupingreimbursementfortransportsthatthepayerbelievesfailtomeetmedicalnecessityandotherpaymentcriteria.ItisvitaltounderstandthatwhileEMSsystemsmustrespondtoall911calls,not

55WerecognizethatwhileAMRshoweda3%lossitsaffiliate,GoldCoast,showeda9.9%profit.

everyambulanceresponsetoa911patientwillresultinreimbursement–evenwhenthepatientistransported.ThisisbecauseMedicare,Medi‐Cal,andcommercialpayersoftenrefusepaymentfortransportswheretheyunilaterallydeterminethatthepatientcouldhavebeensafelytransportedbymeansotherthananambulance.Thesimplefactinmostcommunitiesisthatanumberofpatientswhocall911donothavetrueemergenciesanddonotgenuinelyrequiretransportbyambulancefromaclinicalperspective.Yet,legaldutiesofcareobligateEMSsystemstorespondtoall911calls(withinthemandatedresponsetimes,ofcourse)andtransportthevastmajorityofthesepatients.So,eventhoughEMSsystemreimbursementisavailableonlyforpatienttransports,thereisasubsetofpatienttransportsthatsimplyarenotreimbursable.

Therefore,mostdirectrevenueavailabletoanEMSsystemisstrictlytransport‐related,despitethefactthatmanyresponses–andevensometransports–donotresultinreimbursement.Manyresponsesarenotreimbursable,eventhoughthecostofreadinessforthoseresponsesissubstantial.Thefederalgovernmentisthesinglelargestpayerforambulanceservices,yetfederalstudieshavedemonstratedthatambulancetransportrevenuesfallshortofcompensatingmostambulanceservicesfortheirtransportcosts.Andagain,reimbursementisgenerallynotevenavailableforthemultitudeofresponsesthatdonotresultinpatienttransport.Putsimply,anon‐subsidizedEMSsystemmustsurviveonlyontherevenuesgeneratedbyasubsetofthatEMSsystem’sresponses.

MostEMSReimbursementFallsShortofCosts.AstudybytheUnitedStates

GovernmentAccountabilityOffice(GAO)56foundthatMedicarereimbursementresultsinanaverageMedicaremarginofnegative6percentforambulanceproviderswithoutsharedcosts.57Putanotherway,theratespaidbyMedicare,whichisthesinglelargestpayerinthepayermixformostambulanceservicesintheUnitedStates,fallsshortofcoveringcostsbyanaverageof6%.Again,reimbursementfromMedicareandmostotherpayersisavailableonlyforcallswhichresultinamedicallynecessaryambulancetransport,notforresponseswhichterminatewithouttransport,orfortransportsdeemedtobemedicallyunnecessary.Byextension,thecostsformostresponsesthatterminatewithouttransportorthatresultinnon‐coveredtransportsmustthereforenecessarilybeshiftedontothosepatientswhoreceivecoveredtransports.

InCalifornia,theaveragelossesfromthetransportreimbursementofferedbygovernmentalpayerslikeMedicareandMedi‐Calareevenmorepronounced.Onestudy

56AmbulanceProviders:CostsandExpectedMedicareMarginsVaryGreatly.UnitedStatesGovernmentAccountabilityOffice,ReportGAO‐07‐383,May2007.57InthecontextoftheGAOreport,“providerswithoutsharedcosts”meantthoseambulanceservicesthatwerenotpartofahospitaloramunicipality.TheGAOconcludedthatitwasimpracticaltoevaluatecostsinEMSagenciesthatwereoperatedasdepartmentsoflargerentitieslikehospitalsorcities.Accordingly,theGAOreportfocusedonindependentambulanceserviceswhoserevenuesandcostscouldbeallocatedonlyamongambulancetransportservicesandnotother,unrelatedproductsorservices.

identifiedtheaveragecostsofaprivatesectorambulancetransporttobe$589.58Medi‐Calpaysanaverageof$124to$135pertransport.Medicarepaysabout$507foranaverageALStransportandcomprisesbetween44‐54%ofthepayormixforEOAprovidersinVenturaCounty,asreportedbythoseproviders.

TheRealityof“Zero‐Subsidy”EMSSystems.Thechallengeofoperatingahigh‐performanceEMSsystemisparticularlyacutein“zerosubsidy”systems;thatis,systemsinwhichtheambulancetransportproviderisrequiredtosubsistentirelyonthetransportrevenuescollectedfrompatientsandthird‐partypayers.59EMSagenciesinCaliforniathatwishtosustainoneormoreEOAsmustrecognizethatanEMSsystemischallengedtosustainitselfinthenewhealthcareenvironmentwhenitmustsubsistsolelyontransportrevenuesandsomeofthoserevenuesgotopenaltiesorfeesforthelocalEMSagency,andsomegotosubsidiesorarereallocatedtoothercomponentsoftheEMSsystem(i.e.,firstresponderagencies).ArecentwhitepaperfocusedonEMSreimbursementinCaliforniapointedlyconcluded,“EMSsystemsinCaliforniamayrequiresubsidies,mayhavetosignificantlyrestructuretheiroperationsorwillbecomeinsolvent.”60AlthoughtheoverallpayormixandfinancialstrengthoftheEOAprovidersinVenturaCountyappearstobesound,anegativemarginreportedinoneofthoseyearsbyoneofthoseprovidersshouldbemonitoredcloselybyVCEMSA.ALEMSAmustlookforwardandgiveseriousconsiderationastowhatmeasuresneedtobetakentopreventsysteminsolvencyfrombecomingarealityinitscounty.

IthasbeensuggestedthattheimplementationoftheAffordableCareActshouldbeincreasingproviderrevenues,asmoreindividualsbecomeinsured.However,thewhitepaper61onEMSreimbursementinCaliforniastatedthenatureofthisfallacysuccinctly:

_____________________________________________________________________________“ThesignificantgrowthinthenumberofMedi‐Calinsured,Medi‐Cal’s

exceptionallylowreimbursementrate,andMedi‐Cal’sprohibitionagainstbalancebillingsuggeststhatEMSsystemthathavehighproportionsofMedi‐Calinsuredarenotfinanciallysolventnow,orwillnotbefinanciallysolvent,if:(1)theproportionofhighpayingcommercialinsuranceplans

decreases;or(2)theaverageamountpaidbycommercialplansdecreases;or,(3)populationstransitionfromhigher‐payingcommercialinsurancetoMedi‐Cal.Conversely,inthoseEMSsystemswheretheproportionofuninsuredandprivatepaydecreases,whilethe

58CaliforniaAmbulanceAssociation,California’sGroundEmergencyAmbulanceTransportation(GEMT)CertifiedPublicExpenditure,July17,2013.59WenotethattheproviderforEOA1,LifeLineMedicalTransport,doesreceiveanannualsubsidyof$48,000aswellasaper‐call“helicopterdryrun”feeincaseswheregroundEMSisdispatchedbutanairambulanceultimatelytransportsthepatient,whichismorelikelyinthemoreruralgeographyofEOA1.Forallintentsandpurposes,however,theVenturaCountyEMSSystemisprimarilya“zerosubsidy”system.60Petrie,M.,EMSReimbursementinCalifornia:DiscerningtheFacts,April2016.61Petrie,M.,EMSReimbursementinCalifornia:DiscerningtheFacts,April2016.

proportionofMedi‐Calinsuredincreases,andtheproportionandreimbursementofotherpayergroupsremainunchanged,

averagenetrevenuemayincrease.”_____________________________________________________________________________

MeetingOperatingExpensesisOneThing,MakingCapitalInvestmentsis

Another.Evenwhenacontractorcancoveroperatingexpenseswithitstransportrevenues,otherneededinvestmentsinpeopleandcapitalmaylag.Partofeverydollarearnedoughttogotothereplacementofvehicles,medicalequipmentandothercapitalexpenditures,andpartshouldideallybeinvestedincashreservestocovercontingencies.Asdiscussedinmoredetailbelow,theselonger‐terminvestmentsalsoneedtobetakenintoaccountwhendesigninganEMSsystemthatrequiresthecontractortobeself‐sufficientinrelianceonitstransportrevenues.

Tworecentcasesareparticularlynoteworthy:

‐ InAlamedaCountyin2015,thesystemwasdeemedtobeunsustainableandthecontractorwaspaidanoutrightcashsubsidyof$4millionduringthetermofthecontract.

‐ InSantaClaraCountyin2016,concessionsgivenduringthetermofthe

contractsuchaseliminationoffranchisefeesanddispatchfees,eliminationofcontractornegativesubsidyrequirementssuchasfundingcountysoftwareandequipmentpurchases,eliminationoflatepenaltiesandothersuchmodificationswereestimatedatavalueof$7millionincontractorsubsidies.

Notably,theSantaClaraCountyExecutive,inhismemostotheBoardofSupervisors

regardingthesecontractualchanges,wrotethefollowingrevealingpassages:____________________________________________ _______________________________________________

“Wecontinuetobeconcernedaboutthe “Whiletherehavebeencriticismsregardingsustainabilityofthesystemand[the [thecontractor’s]originalbid…wemustfocuscontractamendment]attemptsto onthecurrentstateoftheEMSsystemandthecontinuebalancingcostsandresponse needtotakestepstoassurethecontinuitytimesisawaythatwebelievestillyields ofeffectiveemergencymedicalservicesintoahighquality,costeffectiveproduct thefuture.”foreveryoneinvolved.”

‐SantaClaraCountyExecutive62

62May5,2015andFebruary9,2016memorandafromJeffreyV.Smith,CountyExecutive,totheSantaClaraCountyBoardofSupervisors.

InvestmentintheEMSSystem.Onethemeraisedbysomeofthestakeholdersinterviewedforthisassessmentcenteredon“investmentintheEMSsystem”bytheEOAproviders.StakeholderswhoraisedthisissuewereprimarilyrepresentativesoffireserviceorganizationswithintheCounty.WhileabovewediscussthelessonslearnedfromEMSsystemfailures,near‐failuresandbailoutsinotherCaliforniacounties,whichinsomecaseshave,atleastinpart,beenattributabletounsustainablefinancialburdensplacedoncontractorsbylocalEMSagencies,thereisanotherrealitythatmeritsdiscussionaswell.Thatis,fireservicestakeholdersindicatedthattheyholdacoreexpectationthatVenturaCounty’sambulancecontractorsmakeappropriatelevelsofinvestmentinthelocalEMSsystemandthatcornersarenotcutintermsofserviceinordertomaximizeprofitsforshareholders,ownersorparentcompanies.CoupledwiththatexpectationwascommunicationofthefactthatfireserviceorganizationswouldreservetherighttoseektoentertheEMSmarketandtodisplacecontractorsshouldthelevelofinvestmentinthesystembycontractorsbedeemedinsufficientbyfireserviceleadership.63

Ofcourse,thereisafundamentaldifferencebetweenapublicandprivateentityintermsof“profit,”andtheremustbeasufficientprofitincentiveforanyprivatecompanywhenitoffersanyserviceorproducttothepublic.ButonerealitythatalocalEMSagencymustconfrontinthisdayandageinCaliforniaistheevolvingroleofthefireserviceandtheincreasinginvolvementandinfluencethatstatewidefireorganizations(representingbothchiefsandunions)arehavingonlocalEMSsystems.Whenallissaidanddone,bothlocalandstatewidefireserviceorganizationsarewellwithintheirrightsasparticipantsinthesystemtoask–andtoexpect–thatinvestmentinalocalEMSsystembyambulancecontractorsissufficienttotimelydeliverthelevelandtypeofservicesdeemedtobeappropriateforthatsystem.64

Duringthestakeholderinterviewstheconsultingteamaskedsomeofthefireservicerepresentativestoprovideexamplesorspecificsregardingcontractors’systeminvestmenttheywoulddeemtobesufficient.Nostakeholdersrespondedtotheconsultants’requestformorespecificinformationinthisregard.

ItisthereforevitalthatVCEMSA–aspartofanyEMSsystemchoicesitmakesforthefuture–continuetoengageinfacilitateddiscussionswithallstakeholderstodeterminetheirdegreeofsatisfactionwithcontractorinvestmentinthesystem.Werecommend

63WedonotexpressalegalopinionontherightofanysuchentitiestoentertheEMStransportmarket.64 Wenotethateveninpublic‐sectorEMSsystems,resourcesarenotlimitless.Justasfireservicerepresentativeshavejustifiablyindicatedtheirconcernregardingsysteminvestmentbycontractedproviders,tax‐supportedpublicEMSagenciesalsofacepressuresfromlocaltaxpayerstodeliverservicesasefficientlyaspossibleandtoavoidunnecessarylocaltaxincreases.Notably,somestudieshavelookedquitecriticallyatcostly,outdatedandofteninefficientresponsemodelsoffiredepartmentsthathavebecomeentrenchedinmanycommunitiesinCalifornia.Notableamongtheseisthe2010‐2011SantaClaraCountyCivilGrandJuryReport,FightingFireorFightingChange?RethinkingFireDepartmentResponseProtocolandConsolidationOpportunities,http://www.scscourt.org/court_divisions/civil/cgj/2011/FDResponse.pdf

continued,focuseddialoguetoaddresstheseconcernsexpressedbyfireservicestakeholders.Ultimatelythe“levelofinvestment”isadeterminationthatmustbemadeonacontinuousbasisafterbalancingtherealitiesofEMSsystemsustainabilityandinvestmentaswehavediscussed.

ResponsetimerequirementsimposedupontheEOAprovidersarediscussedlaterinthisreport.TheCounty’scontractswiththoseprovidersprovideforfinesandpenaltiestobeassessedagainstthemforfailingtosatisfythoserequirements.

VariousmonetarypenaltiesmaybeimposedupontheEOAprovideronaper‐callbasis.Theyincludepenaltiesforthefollowing:

Eachminuteorfractionthereofexceedingtheresponsetimestandard. Eachcallovertheresponsetime.Ifanon‐scenetimeisnotdocumented,the

callisconsideredtohaveexceededthemaximumresponsetime. Ifadelayinresponsetoa9‐1‐1callisduetonon‐availabilityofaunitin

violationofVCEMSAPolicyNo.605.InterfacilityTransferofPatients.65However,therearealsocontractualincentivesfortheEOAprovidersintheformof

percentagedecreasesintotalpenaltiesthatareorwouldbeassessedagainstthembasedupontheabove‐referencedviolations.IftheEOAproviderexceedsresponsetimestandardsinacalendarmonththemonetarypenaltieswillbereducedbeginningwitha92.5%compliancerate(20%ofthetotalpenaltyamount)upto98‐100%(100%ofthetotalpenaltyamount).

BetweenJanuary1,2016andDecember31,2018,AMRhadanoverallcompliance

rateof93.32%inEOA2,92.09%inEOA3,90.43%inEOA4,92.37%inEOA5,and93.93%inEOA7,GoldCoasthadanoverallcompliancerateof94.58%inEOA6,andLifeLinehadanoverallcompliancerateof96.07%inEOA1.66

Afterreceivingmonthlypercentagedeductionsforexceedingresponsetime

standardsproviders’netfinesareasfollows:

65Thispolicyrequiresthatnon‐emergencytransfersbetransportedinamannerwhichallowstheprovidertocomplywithresponsetimerequirements.66FirstWatchdata.

FinesandPenalties

Table7:VenturaCountyProviderResponseTimeCompliance

andPenaltiesPaid2016‐2018

BasedonVCEMSAFirstWatchData

Entity

(AllEOAs)

GOLDCOAST

LIFELINE

Year Compliance Fines Compliance Fines Compliance Fines2016 91.92% 157,851 94.75% 39,159 96.18% 4,8642017 91.84% 168,214 93.96% 48,898 94.99% 11,6892018 91.81% 178,076 95.06% 40,412 97.04% 2,735Total 91.86% 504,141 94.59% 128,468 96.07% 19,288

TheannualaverageofcollectedfinesbyVCEMSAisthereforeapproximately$217,299peryear.AlthoughtherearenoaggregatedorreportedstatewidedataonpenaltiespaidtolocalEMSagenciesforresponsetimedeficiencies,anecdotallythisamountislessthanamountscollectedbyLEMSAsinmanyothercounties.Forinstance,in2017‐18,theYoloCountyEMSAgencyreportedfinestotaling$355,000wereleveledagainstitscontractedprovider.67ItisreportedthatfinesinStanislausCountytotaledmorethan$4millionoverthefiveyearperiodfrom2013‐17,averagingover$800,000peryear.68Asof2017,penaltiesassessedagainsttheEOAproviderinMercedCountyexceeded$100,000permonth.69Ofcourse,tothecontrary,penaltieswerefarlessinsomecounties,ornonexistentinothers.However,wenotethatnopenaltiesareassessedinsomecountiessimplybecauseofthecontractor’sperformance,thoughthosesystemstypicallyhavepenaltyprovisionsintheirprovidercontracts.Forexample,penaltiesareauthorizedinSolanoCounty,thoughnonehavebeenassessedduetothecontractor’scompliancewithitsperformanceobligations.70

Belowforcomparisonpurposesareexamplesofpenaltyprovisionsfromother

CaliforniacountiesalongsidethoseofVenturaCounty:

67YoloCountyEMSAgency,2017‐18AnnualReport,https://www.yolocounty.org/home/showdocument?id=5577368Why$4millioninfinesnotfixingproblemwithambulanceresponsetimesincounty,ModestoBeeApril23,2018,www.modbee.com/news/article209628224.html69See,however,arecentarticleindicatingasignificantreductioninassessedpenaltiesinMercedCountyduetoitsimplementationofarecommendation,madeina2017reportpreparedbyPWW,toimplementatieredresponseandtransportsystem.MurphyandTaigman,Responsetimeperformanceimprovementthroughsystemre‐design,June20,2019,EMS1.com,https://www.ems1.com/response‐performance/articles/394171048‐Response‐time‐performance‐improvement‐through‐system‐re‐design/70EMSSystemReviewandBlueprintReport,SolanoEmergencyMedicalServicesCooperative,October11,2018,https://www.solanocounty.com/civicax/filebank/blobdload.aspx?BlobID=29305

Table8

ResponseTimePenalties:SelectedCountyComparisons

AlamedaCounty71 StanislausCounty72 VenturaCounty73Onthefirstoccurrenceoffailuretomeetresponsetimerequirements,theEMSAgencywillrequirethecontractordevelopmentandimplementacorrectiveactionplan

ExtendedResponseTimeoverspecificzonerequirement:$500between10‐15:59min$750forgreaterthan16:00min

$20foreachminuteorfractionthereofexceedingtheresponsetimerequirementnottoexceed$250perincident

$30,000Ifwithin30daysofimplementingthecorrectiveactionplanthereisanotherresponsetimeviolation

Failuretomeet90%requirement89‐89.99%$1,00088‐88.99%$1,50087‐87.99%$2,50086‐86.99%$4,00085‐85.99%$6,000<85%$8,000

$250foreachcalloverthemaximumresponsetime,includingcallswereresponsetimewasnotdocumented

$60,000Ifwithin60‐calendar‐dayperiod,andtheviolationsarerepetitive

$250ifthecrewfailstodocumentresponsetimesonsceneandonscenetimeisnotverifiablebyotherpre‐agreedreliablemeans

$250Ifthecrewfailstodocumentonscenetime

$120,000ifthereisathreeconsecutivemonthlyrepetitivepatternofresponsetimeviolations

$250,000ifthereisafourconsecutivemonthlyrepetitivepatternofresponsetimeviolationsandpossiblefindingofmaterialbreachofthecontract

$500everytimeanemergencyambulanceisdispatched,andtheambulancecrewfailstoreportanddocumenton‐scenetime.

$50,000failuretorespond.Definedasfailureofanambulancetoarrivewithin250%oftheresponsetimerequirement

71DatafromtheAlamedaEMSRFPNo.EMS‐901017Section1672DatafromtheMountain‐ValleyStanislausRFPNo.MVEMS‐2018‐12Enclosure773DatafromCountyofVenturaEOAcontractssection5.2

Imposingpenaltiesforinstancesofnon‐compliance–primarilywithresponsetimestandards–onambulancecontractorsservingexclusiveoperatingareasismostcommoninCalifornia.Althoughthatanecdotallyseemstobethestateinwhichpenaltyprovisionsaremostutilizedatthecountylevel,theyareutilizedinotherEMSsystemconfigurationsaswell,oftenbyindividualcitieswithexclusiveorprimaryambulancecontractsinplace.7475

AlthoughcontractorfinepaymentinVenturaCountyismodestcomparedtosomeotherCaliforniacounties,itismorethanothers.WenotethatinsomeEMSsystems,penaltyrevenuehasbecomeabudgetedsourceofrevenueonwhichsomelocalEMSagenciesdependtosustaintheirprogramsandpersonnel.WhilenothingsuggeststhatisthecaseinVenturaCounty,itisourbeliefthatEMSsystemoversightauthoritiesshouldworkcloselywiththeircontractedproviderstomake“zeropenalties”areality.Thatisintheinterestbothofprovidersandoversightagencies,becauseononehanditmeansproviderscanavoidwastefulspendingonpenaltypaymentsandlocalEMSagenciesareassuredthattheirprovidersaremeetingtheexpectationssetoutfortheirEMSsystem.AswediscussbelowintheResponseTimessectionofthisreport,werecommendthetransitionoffinancialdisincentives(i.e.,penalties)awayfromresponsetimecomplianceandmoretowardclinicalperformancestandardswithadocumentedeffectonpatientcareandoutcomes.

Accordingly,totheextentthatalocalEMSagencyrequiresproviderfeestosustaincertainaspectsofLEMSAoperations,werecommendthattheseassessmentsbeintheformofcost‐basedannualassessmentsforcostsdirectlyrelatedtosystemoversight,contractadministrationand/orthatdirectlybenefitthecontractedproviders,andthatthesepaymentsbeintheformofpre‐establishedandpredictableassessmentssoastoeliminateanyfinancialincentiveforalocalEMSagencytoimposepenaltiesupontheircontractedproviders.76

74Ala.cityconsidersfinesforslowambulanceresponsetimes,TheDecaturDaily,March31,2019,https://www.ems1.com/response‐times/articles/393678048‐Ala‐city‐considers‐fines‐for‐slow‐ambulance‐response‐times/75Ambulancecompanytopay$2Minfines,serviceforslowresponsetimes,https://www.11alive.com/article/news/ambulance‐company‐to‐pay‐2m‐in‐fines‐service‐for‐slow‐response‐times/85‐581527848,August7,201876VCEMSAcurrentlyimposesadministrativefeesuponitscontractedproviderforQIandrelatedactivities.

Strengths•FavorablepayormixcomparedtootherCaliforniacounties• Lowerproviderchargesthaninmanycounties•LowerassessedfinesthanmanyotherCaliforniacounties

Weaknesses•Commercialplansmovingtohigherdedudctibles,creatingmorenon‐insuredpatienthealthcaredebt•Regulationofnon‐emergencyrateswhensystemexclusivityislimitedtoemergencyambulanceservices

Opportunities•Generallypositiveprofitmarginsamongthethreeproviders•NewpaymentmodelssuchasET3andcostcollection

Threats•Pressureforrateincreaseslilelytogrow•Oneproviderreportednegativeprofitmarginin2018•Impactofproviderfeesandongoingsystemsustainabilityneedstobekeptintheforefront•ProvidersusceptibilitytoMedicareoverpaymentdemands

SWOTAnalysis–SystemFinancials

EMSSystemDeployment

ExclusiveOperatingAreas(EOAs)

VenturaCountyisdividedintoseven(7)AmbulanceServiceAreas(ASAs),eachof

whichisassignedtoanambulanceserviceproviderasanexclusiveoperatingarea(EOA)for911emergencyambulancecallsonly.ASA1isassignedtoLifeLineMedicalTransport(LifeLineorLMT)andincludesacombinationofmetropolitan/urban,suburban/ruralandwildernessareas,includingtheCityofOjai.ASAs2,3,4,5,7areassignedtoAmericanMedicalResponse(AMR)andincludeacombinationofmetropolitan/urban,suburban/ruralandwildernessareasincludingtheCitiesofFillmore,SantaPaula,SimiValley,Moorpark,ThousandOaks,Camarillo,andVentura.ASA6isassignedtoGoldCoastAmbulance(GoldCoastorGCA,anAMRsubsidiary)andincludesacombinationofmetropolitan/urban,suburban/ruralandwildernessareasincludingtheCitiesofOxnardandPortHueneme.77,78

Eachoftheseassignmentswasmadeunderthe“grandfatherprovision”ofSection1797.224oftheCaliforniaHealthandSafetyCode.79Section1797.224confersuponaLEMSAtherighttograntanEOAtoanambulanceserviceproviderbydevelopingandimplementinganEMSplanthatcontinuestheuseofanexistingproviderwithinalocalEMSareatoprovideambulanceservicesinthesamemannerandscopeinwhichithasprovidedthoseserviceswithoutinterruptionsinceJanuary1,1981.VCEMSAhasdonethatandimplementedtheEOAassignmentsbyenteringEOAcontractswithAMR,GoldCoastandLifeLine.ThosecontractsbeganJanuary1,200580,andwithextensionswillexpireonJuly1,2021.

TheCountyenteredintocontractswitheachoftheEOAprovidersforeachofthe

EOAsassignedtothem,andthosecontractswereamendedseveraltimesovertheyears,thelastcontractamendmentsoccurringonJuly1,2015.

ExclusiveoperatingareasaredefinedinSections1797.85and1797.224oftheCaliforniaHealthandSafetyCode,andtheStateofCaliforniahasrecognizedthefollowingtypesofservicesaseligibleforinclusioninEOAsinCalifornia:911EmergencyResponse,7‐

77VenturaCounty2017EMSPlanUpdate.78Inaddition,theFederalFireDepartment–VenturacoversallareasoftheNavalBaseVenturaCounty,includingSanNicholasIslandwithBLSfirstresponseandBLSambulanceservice.79VenturaCounty2017EMSPlanUpdate.80VenturaCounty2013EMSPlan.

ReviewofCurrentStructure

DigitEmergencyResponse,ALSAmbulance,InterfacilityTransport(IFT),ALSIFT,BLSNon‐EmergencyandIFT,BLSNon‐Transport,StandbyService,StandbyServicewithTransportAuthorization,andSpecialtyCareTransport(SCT).81

PublicPrivatePartnerships

VenturaCountyFireProtectionDistrict.82OnDecember14,2004,AMRentered

intoacontractwiththeVenturaCountyFireProtectionDistrict(VCFPD),whichisstillineffect.UndertheagreementVCFPDistoprovideALSfirstresponseserviceinconcertwithAMRanditsbackupprovider’sauthority(i.e.,mutualaidagreementswithLifeLineandGoldCoast)inEOAs2,3,4,5&7.VCFPDisalsotoprovideBLSfirstresponseservicesinthoseEOAs,includingEMTdefibrillationservicesintheurbanareasofthoseEOAs,sothatVCFPDandAMRmeetVCEMSA’sresponsetimestandardsforthedeliveryofthoseservices.

TocompensateVCFPDforitsfirstresponseserviceAMRwastopaya$450,000base

paymenttoVCFPDinthefirstyearofthecontract.ThiscompensationwasbasedontheanticipatedemergencycallvolumeforVCFPD’sEngineCompanies36and40,whichthepartiesagreewas845forthetimeperiodbetweenJune1,2003andMay31,2004.83

Afterthefirstyear,ifVCFPD’sEngineCompanies36and40emergencycallvolume

increasesordecreasesby3%ormore,thebaserateistoincreaseordecreasebythesamepercent.However,innoyearmaytheamountpaidbyAMRtoVCFPDbebelow$450,000unlessthecompensationtoVCFPDexceedsitsactualcostinprovidingfirstresponseservice.ThepartiesagreedthatVCFPD’scompensationforitsservicesundertheagreementshallatnotimebegreaterthanitscost.

Also,ifbothpartiesdeterminethatincreasesinVCFPDALSstaffingortheaddition

ofVCFPDALSenginecompaniesinotherareasoftheCountywillresultinareductionofAMRexpenses,theincreasesmayoccur,andcompensationbyAMRtoVCFPDforthoseALSresourceincreaseswillincreaseasmutuallyagreedbytheparties.AMRagreedtoprovideVCFPDwithfinancialinformationthatmaybeusedforanindependentevaluationoftheAMRcost‐savingsattributabletotheadditionalVCFPDstaffingorengines.

VariouspenaltiesmaybeimposedonVCFPDifitdoesnotsatisfytimeperformance

requirementsinAMR’sservicearea(FS40&36).Thetimeperformancerequirementsand

81AmbulanceZones,GroundExclusiveOperatingAreas(EOA)StatusDeterminationsbyEMSAasofAugust2018.82TheinformationprovidedunderthisheadingistakenfromtheDecember14,2004EmergencyAmbulanceTransportationServicesSubcontractAgreementbetweenAMRandVCFPD.83Asdiscussedbelow,therewasalsoa$450,000basefeepaidtotheCityofVentura.However,therelativevolumecoveredbythisbasefeediffersmarkedlybetweenVCFPD(845projectedresponses)andCOV(6023projectedresponses).

thepenaltiesfornotmeetingthoserequirements,aswellasincentivesforexceedingthoserequirements,arediscussedlaterundertheResponseTimeheading.

InadditiontothePPParrangement,AMRreplacesVCFPD’sdisposablesuppliesand

nonregulateddrugsdisposedofduringVCFPD’sALSandBLSfirstresponseserviceatAMR’sowncost.Also,theagreementprovidesthatallprovisionsofapreviousagreementbetweenAMRandVCFPDrelatingtoVCFPD’sprovisionofdispatchservices,andpaymentforsuchservices,shallcontinueinfullforceandeffect.Underthatagreement,AMRistopayVCFPD$15.45percallVCFPDdispatchestoAMR,butthatratecanbeadjustedupordownannuallytoreflectsavingsoractualnetcostincreasesrealizedbyVCFPD,asmutuallyagreedbytheparties.A$15.45percallratefor22,400calls(theinitialexpectedcallvolume)amountsto$346,080.

CityofVentura.84AMRalsoenteredintoanagreementwiththeCityofVentura

(Buenaventura)(“COV”)onDecember20,2004,containingmanyofthesamePPPprovisionsasAMR’sagreementwithVCFPD.PursuanttothisagreementCOVwillprovideALSfirstresponseservicesintheincorporatedpartofEOA7inconcertwithAMRanditsbackupprovider’sauthorityandistorespondelsewhereinEOA7whenrequestedbyAMR.COVisalsotoprovideBLSfirstresponseservicesintheincorporatedpartofEOA7,includingEMTdefibrillationservices,sothatCOVandAMRmeetresponsetimestandardsfordeliveryofthoseservices.

AswithVCFPDvariouspenaltiesmaybeimposedonCOVifitdoesnotsatisfytime

performancerequirements,inthiscaseinEOA7.Here,too,thetimeperformancerequirementsandthepenaltiesfornotmeetingthoserequirements,aswellasincentivesforexceedingthoserequirements,arediscussedlaterundertheResponseTimeheading.

Basecompensationforitsfirstresponseserviceisalso$450,000inthefirstyearof

thecontract.ThatisbasedupontheanticipatedemergencycallvolumeintheincorporatedareaofEOA7,whichthepartiesagreedwas6,023forthetimeperiodJune1,2003throughMay31,2004.ChangesinthebaserateinsubsequentyearsaresubjecttothesamecriteriaasagreeduponbyVCFPDandAMR.Again,thepartiesagreedthatCOV’scompensationforitsservicesundertheagreementshallatnotimebegreaterthanitscost.

InadditiontothePPParrangement,AMRistoreplaceatAMR’scostCOV’s

disposablesuppliesandnonregulateddrugsdisposedofduringCOV’sALSandBLSfirstresponseservice.

84TheInformationprovidedunderthisheadingistakenfromtheDecember20,2004EmergencyAmbulanceTransportationServicesSubcontractAgreementbetweenAMRandtheCityofVentura(CityofSanBuenaventura).

Hospitals85

Thereareeight(8)acutecarehospitalswithinVenturaCountythathaveemergencydepartmentsandserveasreceivingfacilitiestowhichpatientsmaybetransportedbyambulanceorotherwise.TheyareCommunityMemorialHospital,LosRoblesRegionalMedicalCenter,St.John’sPleasantValleyHospital,St.John’sRegionalMedicalCenter,SimiValleyHospital,VenturaCountyMedicalCenter,andVCMCSantaPaulaHospital.OjaiValleyCommunityHospitalhasastandbyemergencydepartmentandisastandbyreceivingfacility.TheircapabilitiesareshowninTable9.

Table9:HospitalCapabilities

HospitalStandby Receiving Facility

Receiving Facility

Base Hospital

STEMI Receiving Center

Acute Stroke Center

Thrombectomy Capable ASC (TCASC)

Level II Trauma Center

Adventist Health Simi Valley

(SVH) X X X X

Community Memorial

Hospital (CMH) X X X

Los Robles Regional

Medical Center (LRH)

X X X X X X

Ojai Valley Community

Hospital (OVH)X

Santa Paula Hospital (SPH) X

St. John’s Pleasant Valley Hospital (PVH)

St. John’s Regional

Medical Center (SJO)

X X X X X

Ventura County Medical Center

(VMC) X X

* Pending X

85Unlessotherwisenoted,theinformationprovidedunderthisheadingistakenfromtheVenturaCounty2017EMSPlanUpdate.

WenotethatCaliforniapopulationgrowthisgenerallyexceedinghospitalbedcapacity,andthathospitalbeds‐per1,000population–astandardmetricforfacilitycapacity–isthelowestinCaliforniaamongthemostpopulatedstates.Californiareports1.9bedsper1,000population,comparedtoaU.S.averageof2.5bedsper1,000population.86Inaddition,whileEDvisitsincreased35%between2005and2014,andEDbedsduringthisperiodincreasedby29.8%,ametricdevelopedbyChow,etal.,EDbedspervisit,showsthatthisnumberdecreasedbynearly4%inthattimeperiodinCalifornia.87TheauthorsconcludethatthesupplyofEDbedsinCaliforniacannotkeeppacewiththegrowthinEDdemand.Inaddition,theseauthorsnotedastatewidereductioninpsychiatricbeds.88Thisisechoedina2018reportfromtheCaliforniaHospitalAssociation,whichnotedspecificallyadeficitof425inpatientpsychiatricbedsinVenturaCounty.89,90JointlyaddressingtheissuesofEDutilizationandpsychiatriccareresources,onepapernotedthat10‐12%ofallEDutilizationisdirectlyattributabletomentalhealthemergencies,andthatthese“frequentvisitorstoEDsduetopoorlycontrolledbehavioralhealthrequiretheirownurgenttreatmentpathwaystopreserveEDcapacity.”91

AmbulancesaredeployedcountywidebasedonestablishedSystemStatusManagementplans.Table10shows,byEOAnumber,theSystemStatusManagementPlansforstationingALSemergencyambulancesthroughouttheCounty.

86HospitalBedsper1,000PopulationbyOwnershipType,KaiserFamilyFoundation,2017,https://www.kff.org/other/state‐indicator/beds‐by‐ownership/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D87Chow,JL,etal.,TrendsinthesupplyofCalifornia’semergencydepartmentsandinpatientservices,2005‐2014:aretrospectiveanalysis,BMJOpen,2017;7(5),https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5566591/88Id.89CaliforniaHospitalAssociation,California’sAcutePsychiatricBedLoss,March28,2018.https://www.calhospital.org/sites/main/files/file‐attachments/psychbeddata.pdf90Wenotethatafour‐bedpsychiatriccrisisunitopenedinApril2019atVenturaCountyMedicalCenter.SeeKisken,T.,Psychcareshortagegetsboostfromnewcrisisunitatcountyhospital,VCStar,April18,2019,https://www.vcstar.com/story/news/local/2019/04/18/psych‐care‐shortage‐gets‐boost‐new‐crisis‐unit‐county‐hospital/3453619002/91Fields,W.,TheAcuteCareContinuuminCalifornia,Rev.Med.Clin.Condes,2017;28(2),https://www.sciencedirect.com/science/article/pii/S0716864017300317

SystemStatusPlan

Table10:

VenturaCountyEMSStationLocationsandStaffingByEOAEOA1

Ojai 11544N.VenturaAve.,Ojai,CA93023

MED501,24‐hr,7days,0700‐0700MED503,24‐hr,7days0700‐0700

Ventura 632E.ThompsonBlvd.,Ventura,CA93001

MED502,12‐hr,7days,0800‐2000

ThousandOaks 88LongCourt,ThousandOaks,CA91360

MED506,24‐hr,7days,0700‐0700

SantaPaula 623E.MainSt.,SantaPaula,CA93060

MED421,24‐hr,7days,0700‐0700

Fillmore 743SespePlace,Fillmore,CA93015

MED422,24‐hr,7days,0700‐0700

HungryValley 49680GormanPostRoad,Gorman,CA93243

MED423,12‐hr,7days,0900‐2100

SimiValleyEast 4322EileenSt,SimiValley,CA93063

MED431,24‐hr,7days,0700‐0700

SimiValleyWest 665‐CLosAngelesAve,SimiValley,CA93065

MED432,24‐hr,7days,0700‐0700

ThousandOaks,South 166N.MoorparkRoad#101,ThousandOaks,CA91360

MED441,24‐hr,7days,0700‐0700

OakPark 652ALinderoCanyonRoad,OakPark,CA91377

MED442,24‐hr,7days,0700‐0700

NewburyPark 700WendyDr.#24,NewburyPark,CA91320

MED443,24‐hr,7days,0700‐0700

Moorpark 616FitchAve,Moorpark,CA93021

MED444,24‐hr,7days,0700‐0700MED491,12‐hr,7days,0730‐1930MED433,12‐hr,7days,0900‐2100MED494,8‐hr,5days,1400‐2200

ThousandOaks,North 2667N.MoorparkRd#103,ThousandOaks,CA91362

MED445,24‐hr,7days,0700‐0700

Camarillo,West 109SGlennDrive,Camarillo,CA93010

MED451,24‐hr,7days,0700‐0700MED453,12‐hr,7days,0800‐2000

Camarillo,East 5800SantaRosaRd,#115,Camarillo,CA93012___

MED452‐24‐hr,7days,0700‐0700

Oxnard 200BernoulliCircle,Oxnard,CA93030

Oxnard 401NorthAStreet,Oxnard,CA93030

PortHueneme 2675SouthVenturaRdPortHueneme,CA93033

MED664,24‐hr,7days,0700‐0700

Oxnard 4225SaviersRd#7,Oxnard,CA93033

MED665,24‐hr,7days,0700‐0700

Ventura,Central 3418LomaVistaRd#2a,Ventura,CA93003

Ventura,East 1593LosAngeles,Ave#9,Ventura,CA93004

MED483,24‐hr,7days,0700‐0700

ThethreeEOAprovidersalsohaveestablishedambulancemove‐upplanswhenunitsassignedtoastationarecommittedtoresponses.Ambulancesnotcurrentlycommittedtoaresponsearerepositionedtoalocationwheretheyaremostlikelytobeneeded.92

Responsetimeswillbediscussedinmoredetailbelow.However,forpurposesofassessingdeploymentwithintheVenturaCountyEMSSystem,itishelpfultolookatresponsetimecompliancedatafromtheVCEMSAEOAzonesandsub‐zones.

92OnefiredepartmentinformedusthattheEOAprovidersrevisetheirmove‐upplanswithoutfirstsharingadraftwiththefiredepartmentsothattheEOAproviderhasthebenefitofitsfeedback.WebelievetheEMSsystemwouldbebetterservediftheEOAproviderssharedtheirdraftrevisedmove‐upplanswithrelevantfiredepartmentstoreceivetheirinputbeforefinalizingrevisionstotheirmove‐upplans.Werecommendthatsucharequirementbeincludedtothenextcycleofprovidercontracts.

Discussion–Structure/SystemStatusPlan

InreviewingVenturaCountyresponsetimedatafortheyears2016–2018providedtousbyFirstWatch,therearenoindividualmonthsreportedinwhichresponsetimecompliancefellbelow90%inEOA1(LMT),EOA2(AMR),EOA4(AMR),EOA6(GCA)andEOA7(AMR).93Therearetwo(2)individualmonthsinthissame36‐monthperiodinwhichresponsetimeswerebelow90%inEOA3(AMR),andinbothinstancesthoseshortfallswerelessthan1%.InEOA5(AMR),thereisonemonth(January2016)inthis3‐yearperiodwereresponsetimesfellbelow90%(andthatwasalsoadeficiencyoflessthan1%).Collectively,thesedatashowthatdeploymentisgenerallysufficienttomeettheresponsetimeperformancestandardssetforthinthecontractsforEOAs1,2,3,4,5,6,and7.

However,EOA4isdividedintofoursub‐zones.Becausemonthlyreportsare

providedforeachsub‐zone,wewereabletoconsiderthedatanotonlyforEOA4initsentirety,butforeachsub‐zone.Ourreviewrevealedthatforthreeofthefoursub‐zonesdeploymentwasoftennotsufficienttomeetresponsetimerequirements.Thecollective108reportsforthosethreesub‐zonesoverthethree‐yearperiodshowedthaton40occasionsthe90%monthlyresponsetimerequirementwasnotsatisfied.Ofthose40occasions,20wereattributabletoonesub‐zone.

The2005EOA4providercontractprovidedthatapenaltywouldbeimposedforeachindividualfailuretomeettheresponsetimerequirementbut,ifthemonthlyrateofsatisfyingtheresponsetimerequirementmetorexceeded92.5%inanEOA4sub‐zone,theproviderwouldbecreditedapercentagediscountofthetotalmonth’spenaltyforthatsub‐zone.Aswereadthe2011amendmenttothecontract,thatchanged,sothattheproviderwouldbecreditedapercentagediscountbaseduponachievinga92.5%compliancerateforEOA4initsentirety,andcomplianceratesforindividualsub‐zoneswouldnolongerbeconsidered.However,wewereadvisedbytheEMSAdministratorthatthecontractforEOA4hascontinuedtobeadministeredtograntapercentagediscountformeetingthe92.5%compliancerateonasub‐zonebysub‐zonebasis,suchthatnopercentagediscountisappliedtothepenaltiesincurredinasub‐zoneifthecompliancerateinthatsub‐zonedoesnotreachatleast92.5%forthemonth.

TheEOA4deficienciesareparticularlyapparentintheMoorparksub‐zone(n=13deficientmonths)andOakParksub‐zone(n=20deficientmonths).TheNewburyParksub‐zonehadatotalof7deficientmonthsinthe3‐yearperiod.Thislevelofdataanalysissuggeststhatthecontractor’sdeploymentisinsufficientwithinthesesub‐zonestomeetresponsetimeobligationswithinthreeofthefourEOA4sub‐zonesapproximately2/3ofthemonthsintheprecedingthree‐yearperiod.TheThousandOakssub‐zonehadnodeficientmonths.

93DataforEOA4wascompiledfromthe2016and2017VEMSAnnualReports.

ItisalsoworthnotingthatinnootherVenturaCountyEOAsareresponsetimesmeasuredinseparatesub‐zones,andsurelyitispossiblethatcontractordeploymentinotherEOAswouldappeartobeinsufficientifdiscretesub‐zoneswithinthoseEOAswereanalyzedseparately.ItisalsoimportanttonotethattheEOA4callvolumeisconcentratedintheThousandOakssub‐zone;infact,thissub‐zonebyitselfhasmorecallsthaneveryotherfullEOAinVenturaCountyexceptEOA7.Inaddition,thecallvolumeoftheotherthreeEOA4sub‐zones,takentogether,islessthanmostotherEOAsinVenturaCounty.94Thus,thefactthattheEOA4volumeisconcentratedintheThousandOakssub‐zone,coupledwiththefactthattheresponsetimedatashownodeficienciesinthissub‐zoneduringtheperiod2016‐2018,meansthatoverallEOA4responsetimecomplianceismet.

Nevertheless,itisunclearwhythisEOAisdividedintosub‐zonesforpercentage

discountpurposesbaseduponsatisfyingresponsetimerequirementsatleast92.5%ofthetimeinasub‐zone,particularlywhensomeofthosesub‐zoneshaverelativelylowercallvolumescomparedtothepopulationcenteroftheThousandOakssub‐zone.Sometimesthisisreflectiveoflocal,municipalconcernsregardingresponsetimeswithindiscreteareasofalargerEOA.StakeholdersinterviewedforthisprojectindicatedthatthisdivisionofEOA4intosub‐zoneswasalongstandingpracticegoingbackseveraldecades.

TheEOA4contractanditsamendmentswhichimposethebreachconditiononlyfor

non‐complianceinthewholeEOAmeansthattheprovidercanessentiallyassurecontractcompliancebyupholdingresponsetimesintheThousandOaksEOA–andsolongasthepenaltiesincurredfornon‐complianceintheotherthreesub‐zonesarelessthantheunithourcostofdeployingadditionalambulancesatalevelsufficienttoavoidthepenalties,theprovidercancontinuetounder‐deployinthosesub‐zoneswithoutconsequence.Thisessentiallymerelybecomesarecurringandmorepredictablestreamofpenaltyrevenueasopposedtocreatingarealincentiveforpromptserviceinthosesub‐zones.

However,theprimaryobjectiveofEOAdevelopmentistorequirecoverageinless‐populatedareasasaconditionofgrantingprovidersexclusiveaccesstothecallsinthemoreheavilypopulatedareasofanEOA.Itseemsanomaloustoseparatelymeasureresponsetimeperformanceintheless‐populatedareasofanEOAwhen(1)nootherEOAsareevaluatedinthismanner,and(2)mostsystemsinCaliforniarecognizedifferentresponsetimestandardsformoreandless‐denselypopulatedareasofEOAsasawhole.Accordingly,werecommendthatVCESMAconsidereliminatingtheEOA4sub‐zonesfor

94Wenote,however,thatpopulationdensityinMoorpark(2830p/sm)andOakPark(2810p/sm)rankcomparablywiththatofThousandOaks(2330p/sm),though,ofcourse,thepopulationdiffersconsiderably.

responsetimeincentivepurposes,particularlygiventhediscussionregardingthetrueeffectivenessofresponsetimes,laterinthisreport.95,96

TherearemanytypesoftieredEMSresponsesystemsthatareusedtorespondtoemergencycalls.Somerequirearesponsebyanon‐transportingBLSfirstresponderunitandanALSambulancetoascene.OtherssendanALSfirstresponderunitandaBLSambulancetoascene,whileothershaveALSfirstresponsecoupledwithALStransport.Somearehybridsystemsthatuseamixtureoftheseresources.StillothersdonotrelyonfirstresponderresourcesatallandsendaBLSambulanceorALSambulancedependingontheconditionofthepatientasreportedinthecall‐intakeprocess.

TheCounty’sEMSresponsesystemisahybrid.Forall911callsthecurrentEOA

providersmustrespondwithanALSambulancetoalldispatches.Foreachofthesecallsafiredepartmentfirstresponderunitisalsodispatchedandresponds.Somefire

95Aswithotherlegalissues,weexpressnoopiniononwhethertheeliminationoftheEOA4sub‐zoneswouldaffectgrandfatheringeligibilityunderCal.Health&SafetyCode§1797.224.96Somestakeholdersrecommendedthatwenoteliminatethesub‐zonesinEOA4.Wearenotrecommendingeliminatingthesub‐zonesinEOA4.Dataiscollectedeachmonthforeachsub‐zoneregardingthepercentageofcallsforwhichresponsetimerequirementsaremet.Wearenotrecommendingthatthisdatacollectionbysub‐zonebediscontinued.Whatwearerecommendingisthediscontinuationineachsubzoneoftheapplicationofaresponsetimecompliancerateof92.5%andhighertoreducebyatleast20%themonthlypenaltyinthesub‐zonethatisbaseduponindividualresponsetimeviolations.WebelievethisincentiveshouldapplyonlyifresponsetimecomplianceforEOA4initsentiretymeetsorexceeds92.5%.

TheproviderassignedEOA4,liketheprovidersassignedtheothersixEOAs,iscontractuallyresponsibleformeetingresponsetimerequirements90%ofthetimefortheentireEOA.Failuretosatisfythatrequirementforthreeconsecutivemonthsorforfourmonthsinafiscalyearconstitutesabreachofcontract.TheproviderassignedEOA4hasmetthe90%compliancerateeverymonthofthe36‐monthperiodfrom2016through2018.

However,unlikethepenalty‐reductionincentivegrantedtheprovidersassignedtheothersixEOAs,whichappliesonlyiftheymeetorexceeda92.5%monthlyresponsetimecomplianceratefortheentireEOA,theproviderservingEOA4doesnotneedtomeetorexceeda92.5%complianceratefortheentireEOAtoreceiveapercentagereductioninpenalties.Underthecurrentarrangement,itreceivessomereductioninpenaltiesifitsresponsetimecomplianceratemeetsorexceeds92.5%inatleastoneofthesubzones.Wedonotbelievetheprovidershouldreceiveanypercentagereductioninmonthlypenaltiessimplybymeetingorexceedinga92.5%responsetimecompliancerateinasub‐zone.Forthisreasonwearerecommendingthatthepercentagereductioninpenaltiesformeetingorexceedinga92.5%responsetimecompliancerateapplyinEOA4,asitdoesintheothersixEOAs,onlyiftheprovidermeetsorexceedsthatresponsetimecomplianceratefortheentireEOA.

ConfigurationOptions

departmentsrespondattheALSlevelandsomerespondattheBLSlevel.Itdependsuponwhichfiredepartmentisdispatchedandthatfiredepartment’sresourcesandlevelofserviceprovided.

ThereareseveralfiredepartmentsinVenturaCountythatprovide911first

responseservices.TheVCFPDFireDepartmentprovidesbothALSandBLSfirstresponseservicesdependinguponthedispatch.TheVenturaCityFireDepartmentandtheFillmoreFireDepartmentprovideALSfirstresponse.97TheOxnardFireDepartmenthadprovidedonlyBLSfirstresponseuntilNovember15,2018,butthenincreaseditsleveloffirstresponsetoALSfirstresponseforhighacuityemergencies.98TheVenturaCountySheriff’sOfficeprovidesbothALSandBLSairrescueservicesaspartoftheEMSsystem.99

All‐ALStransportsystemshaveevolvedtobecomeacommon,perhapsevenapredominant,modelinCaliforniaEMSsystems.IntheearlydevelopmentofEMSsystems,theimplementationofALSwasuniversallyseenasanaspirationalsystemdesigngoal.Overtime,all‐ALSEMStransportsystemsbecamethedefactostandardinCalifornia.However,all‐ALSambulancedeploymentisunquestionablymorecostlythanatieredBLS‐ALSsystem,anditnegatesthebuilt‐inadvantagesthatcancomewithimplementationofamedicalprioritydispatchsystem(MPDS).MPDS,whenimplementedproperly,caneffectivelydistinguishbetweenthosecallswhichrequireALS,andthosewhichcansafelybehandledwithalesscostlybutmoreappropriateBLSresponse.Additionally,MPDScandistinguishbetweencallsinwhichfirstrespondersupportisnecessaryinadditiontoambulanceresponse,andthosecallsforwhichthereisnodemonstratedpatientbenefittodeploymentoffirstresponders.

PWWwasengagedin2016‐2017toperformanEMSsystemassessmentinMercedCounty,California.Merced’sEMSsystemcanbedescribedasfinanciallydistressed,owinglargelytothedemographicsanddepressedsocioeconomicsofpartsoftheCentralValleyofCalifornia,withapayormixfarlessfavorablethanthatenjoyedbyprovidersinVenturaCounty.Inour2017report,werecommendedimplementationofaBLS‐onlyoptionforlow‐acuitycallsproperlytriagedthroughanMPDSsystem.Accordingtoanewly‐publishedarticle,100thisrecommendationwasimplementedin2018throughafour‐stepprocess(newpolicies,newtraining,supervisedpracticeandfulllaunch)andthenevaluatedcloselyforthesubsequentyear.WithassistanceofFirstWatch,MercedCounty’sEMSagencyevaluatedtheresultsofthistiereddeploymentimplementationandfoundthefollowing:

‐ Quickadaptationbyfirefirstresponseagencies;

972017VenturaEMSPlanUpdate.98https://www.oxnard.org/advanced‐life‐support‐als/.992017VenturaEMSPlanUpdate.100MurphyandTaigman,Responsetimeperformanceimprovementthroughsystemre‐design,EMS1.com,June20,2019,https://www.ems1.com/response‐performance/articles/394171048‐Response‐time‐performance‐improvement‐through‐system‐re‐design/

‐ Improvementfrom87%to92%inresponsetimesforhigh‐prioritypatientsduetoimproveddeployment;

‐ Decreaseinassessedaverageresponsetimepenaltiesfromover$109,000permonthto$12,000permonth,includingmonthswithzeropenalties;

‐ Noadversepatientevents;‐ Improvedsatisfactionamongparamedics(runningfewercalls)and

amongEMTs(expandedopportunitytoutilizetheirskills)

Clearly,similarbenefitscanbeexpectedinEMSsystemsthatcurrentlyrequireall‐ALSambulancedeployment.AlthoughVenturaCountyisnotburdenedwiththesamepayormixandsocioeconomicchallengesthatprecipitatedthechangesinMercedCounty,nosystem’sresourcesarelimitless,andtieredsystemconfigurationoptionswhichutilizeBLS‐onlydeploymentwhenappropriatecangenerateefficienciesandadvantagesbothclinically(throughoptimizedavailabilityofALSforthosecallsinwhichthereisademonstratedclinicalbenefit)andeconomically(throughreducedpenaltiesanddeploymentcosts,aswellasthepotentialforincreasedjobsatisfactionamongEMTsandreductionoffatigueforparamedics).

Ithasbeenrecognizedintheliteraturethatthevastmajorityof911callsdonotrequireanALSintervention(lessthan5%),thatpatientsincardiacarrestaccountforfewerthan1‐2%ofcalls,andthatfewerthan15%ofpatientsrequireanytypeofALSprocedureorevenALS‐levelmonitoringbyALSpersonnel.101,102

SomestakeholdersinterviewedforthisprojectindicatedthatimplementingaBLStiermakessense,butquestionedwhetheranassociatedreductioninrevenuewouldbedamagingtothesystem(MedicareandmostotherpayorspaylessforBLStransportsthanforALScalls).Tothecontrary,whereproperbillingrulesarefollowed,usingparamedicstorespondtoacallwhenonlyBLSservicesarerequireddoesnotgenerateanymorerevenuethaniftheresponsewashandledbyEMTsonly.MedicareandMedi‐Calarepredominantpayorsformostambulanceservices.RegardlessofwhetherthereisanALSresponse,ifonlyaBLSresponseisrequiredbasedonthedispatchedconditionofthepatient,theypayattheBLSrateofreimbursement,notthehigherALSrateofreimbursement.103

ThecostsofemployingparamedicsanddeployingALSambulancesaregreaterthanthecostsofemployingEMTsanddeployingBLSambulances.Becausetheyuseparamedics

101PepePE,MattoxKL,FischerRP,MatsumotoCM.Geographicalpatternsofurbantraumaaccordingtomechanismandseverityofinjury.JTrauma.1990;30:1125‐32.102ForadiscussionoftheadvantagesanddisadvantagesofbothanallALSandatieredresponseambulancesystemseeStoutJ,PepePEandMosessoVN.All‐AdvancedLifeSupportvsTiered‐ResponseAmbulanceSystem.PrehospitalEmergencyCare.January/March2000,Vol.1,No.4.103SeediscussionunderRates/Billingsectionabove,p.32,forfurtherdiscussionoftheALS‐vs.‐BLSbillingissue.

torespondtocallswhereonlyBLSskillsarerequired,ambulanceservicesareincurringgreatercoststhanwarrantedfromaclinicalperspective.And,asmentionedabove,reimbursementisnotbaseduponthelevelofvehicle(BLSvs.ALS)thatisdeployed;itisbasedupontheinformationcommunicatedtothedispatcherandtheservicesrequiredbythepatient.Therefore,thereisalargesubsetofresponsesforwhichcomparativelyexpensiveALSunitsaredeployedwhenonlyBLS‐levelreimbursementcanproperlybereceived.

IthaslongbeenrecognizedasanindustrystandardofcarethatmedicallyvalidateddispatchprotocolswithdifferentialALS‐BLSresponsedeterminantscansafelyandeffectivelysupporttieredEMSsystemdeployment.Accordingly,werecommendthatVCEMSAshouldconsiderimplementationofaBLSresponseandtransporttierforthosecallsinwhichtheFCC’sdispatchprotocolspermitaBLS‐levelresponse.104Althoughtiereddeploymentisalong‐recognizedstandardofcareinEMS,VCEMSAmaywishtorequiresomeadditionaltrainingforEMTsandtoincorporatefocusedreviewofBLS‐onlyemergencyresponsesintoitssystemwideQIplanforaprescribedtimeperiodtoensurethatthedispatchresponsedeterminantsareresultinginappropriateBLSresponses.105

TheVCEMSA’sgoalforapatientwhoishavingaSTEMIisforthepatienttohaverapidassessmentandtransporttoaSTEMICentertoreceiveaPercutaneousCardiacIntervention(PCI)toquicklyrestorebloodflowtotheheart.UndertheCountySTEMISystemparamedicsusefieldtransmissionof12‐LeadECGsand“STEMIAlerts”toprovideearlynotificationofcardiacinterventionteams.GoalsdevelopedbytheAmericanCollege

104ItisimportanttonotethatimplementingaBLS‐tierintoanexisting,“grandfathered”ALSsystemunderCal.Health&SafetyCode§1797.224raisesthequestionofwhetherthatcanbeaccomplishedviacontractwithexisting“grandfathered”EOAproviders,withoutcompromisingthegrandfatheredexclusivity,orwhetherimplementationofaBLStierwouldnecessitateacompetitiveprocess.Aswithotherlegalissuesraisedinthisreport,providingalegalopiniononthisquestionisbeyondthescopeofthisproject.WerecommendthatVCEMSAaddressthisseparatelywithqualifiedlegalcounsel,andwewouldbehappytoassistinworkingwithCountyCounseltoprovidefurtheranalysisofthatlegalquestionunderanattorney‐clientconsultationshouldthatbesomethingthatVCEMSAdesires.105IncommentswereceivedtoVersion1.0oftheEMSSystemAssessmentReportastakeholderaskedwhetherourrecommendationforaddingaBLSresponseandtransporttierappliedtonotonlytheEOAproviders,butfiredepartmentfirstresponders.OurrecommendationtoaddaBLStierappliestothesystemasawhole.Inotherwords,ifacallisforanALS‐levelpatient,anALSfirstresponse,whereavailable(oraBLSfirstresponsewhenanALSfirstresponsecapabilityisnotavailable)andanALSambulancewouldbeappropriate.Ifitwasforalow‐acuity,BLSpatient,onlyaBLSambulanceresponsemaybewarranted,and,insomecases,anaccompanyingBLSfirstresponse.Butthatisallsubjecttothechoicesmadeinthesystemdesignphase,eitherthrougharenegotiatedsetofcontractsorRFPprocessastheCountydecides.

SpecialtyCare

ofCardiology,theAmericanHeartAssociationandtheCaliforniaDepartmentofPublicHealtharetoachievethefollowing,inlessthan90minutes:

911calltoPCI FirstMedicalContacttoPCI PositiveEMSSTEMI12‐LeadtoPCI ArrivalatSTEMIhospitaltoPCI

TheCountyroutinelyexceedsthesegoals.Also,in2017,theVenturaCountySTEMI

SystemreceivedGoldPlusLevelrecognitionfromtheAmericanHeartAssociation’sMissionLifeLineProgram,whichwasthethirdyearinarowthatitreceivedGoldlevelorhigherrecognition.TheMissionLifeLineProgramrecognizesSystemsofCarethatmeetthefollowingperformancemeasures:FirstMedicalContacttoInterventioninlessthan90minutes75%ofthetime,and12‐LeadECGsobtainedonpatientshavingchestpain75%ofthetime.In2017,109EMSSTEMIpatientsreceivedPCI.

Stroke

In2017theCountyhad1397patientswhowerediagnosedwithstrokesandwho

weretreatedatoneoftheCounty’sStrokeCenters.ParamedicsaretrainedtoevaluatepatientsusingtheCincinnatiPrehospitalStrokeScale(CPSS)andprovideearlynotificationbycallingina“strokealert”tothehospitalsoresourcescanbemobilizedtoprovideimmediatetreatmentofapossiblestrokepatientuponarrival.Theprimaryobjectiveofastrokesystemistocoordinatecarebetweentheemergencymedicalsystemandhospitalssopatientspossiblysufferingfromastrokewillreceivecarewithin3to4½hoursoftheirfirstsymptoms.Amongotherstandardsofperformance,theCountyStokeProgramachievedthefollowingpercentages:

12%ofischemicstrokepatientstreatedwithIVTissuePlasminogenActivator

(tPA)whoarrivedwithin4.5hoursoftimelastknowntobewell(nationalaverage,1‐7%)

92%ofpatientstreatedwithIVtPAwithin60minutes(nationalaverage,50%) 59%ofpatientstreatedwithIVtPAwithin45minutes(nationalaverage,50%)

TheEMSAgencytracksapatient’scarefromthe911callthroughtheirhospitalstay.

Oneintervaltrackedisthetimedispatchisnotifiedtothetimeaneurologistreceivesthebrainimagereport.In2017themediantimeforthisintervalwas52minutes.Theon‐scenetimewas13minutes.Thetimeofarrivalatthehospitaltothetimetheclot‐bustingmedicationtPAwasadministeredwas42minutes.Thebenchmarkgoaliswithin60minutes.

ThereareaVenturaCountyStrokeCommitteeandtheVenturaSTEMICommitteethatprovideinputtotheVCEMSAMedicalDirectorandVCEMSAAdministrationonmatterspertainingtotheCountyStrokeSpecialtySystemandtheCountySTEMISpecialtySystem.

Withfewexceptions,novehiclemaybeoperatedasanambulanceunlessitisundertheimmediatesupervisionanddirectionoftwopeople,oneofwhommustbeatleastanEMT‐1A106certifiedandauthorizedbyVenturaCounty.107IntheCounty,allALSResponseUnits(FirstResponseALSUnits,ParamedicSupportVehicles,ALSAmbulances),withtheexceptionofParamedicSupportVehicles,mustgenerallybestaffedwithaminimumofoneLevelIIparamedicandeitheranEMToraLevelIorIIparamedic.AnALSResponseUnitmayalsobestaffedwithanon‐accreditedparamedicifitisalsostaffedwithanauthorizedFieldTrainingOfficer(FTO)orParamedicPreceptor,unlessthenon‐accreditedparamedicisfunctioninginaBLScapacity.AParamedicSupportVehiclemaybestaffedwithasingleLevelIIparamedic.108

ALevelIparamedicisaparamediclicensedbyEMSAwhohascurrentaccreditationasaLevelIparamedicbyVCEMSA.TomaintainLevelIaccreditationtheparamedicmustmaintainemploymentwithaCountyapprovedALSserviceproviderandcompleteatleast288hoursofpracticeasaparamedicorhaveatleast30patientcontacts,including15ALSpatientcontacts,everysixmonths.However,inlieuofthesehourandpatientcontactrequirements,withtheapprovaloftheEMSMedicalDirector,thoseparamedicswithaminimumof1yearoffieldexperienceintheCounty,whoareemployedasafieldparamedicinanothercountyorworkinanacutecaresetting(registeredorlicensedvocationalnurse)onafull‐timebasis,mayqualifybycompletingaminimumof144hoursofpractice,or20patientcontacts(minimum10ALSpatientcontacts),intheprevious6‐monthperiodintheCounty.TomaintainLevelIparamedicstatustheparamedicmustcompleteVCEMSAcontinuingeducation.

ALevelIIparamedicisaparamedicwhohascompletedtheLevelIparamedic

requirementsandaminimumof240hoursofdirectfieldobservationbyaCountyParamedicFieldTrainingOfficer(FTO).Duringthistimetheparamedicmusthaveatleast30patientcontactsincludingatleast15ALSpatientcontacts.However,inlieuofthesehourandpatientcontactrequirements,withtheapprovaloftheFTOandprehospitalcarecoordinator(PCC)thehourandpatientcontactrequirements,underdirectfieldobservation,maybereducedto144hoursor20patientcontactswithatleast10ALS

106AnEMT‐1AisapersonwhohassuccessfullycompletedabasicEMT‐1AcoursethatmeetsEMSArequirementsandhasbeencertifiedassuchbytheVCEMSAMedicalDirector.107VenturaCountyOrdinanceCode§§2423‐1.3and2423‐2.108VCEMSAPolicyNo.506.ParamedicSupportVehicles.

Staffing

patientcontacts.Theparamedicmustalsocompletecompetencyassessmentsinvolvingscenariobaseskills,andwrittenpolicyandarrhythmiarecognitionandtreatmentassessmentadministeredbyVCEMSA.

TomaintainLevelIIstatustheparamedicmustmaintainemploymentwithaCounty

approvedALSserviceproviderandcompleteatleast576hoursofpracticeasaparamedicorhaveatleast60patientcontacts,including30ALSpatientcontacts,everysixmonths.Forparamedicswithaminimumofthreeyearsfieldexperience,nomorethan144hoursofthisrequirementmaybemetbydocumentationofactualinstructionatapprovedPALS,PEPP,ACLS,PrehospitalTraumaLifeSupport(PHTLS),BasicTraumaLifeSupport(BTLS),EMTorparamedictrainingprograms.However,inlieuofthesehourandpatientcontactrequirements,withtheapprovaloftheVCEMSAMedicalDirector,therearealternativestomeetingthesehourandpatientcontactrequirements.

ThecontinuingeducationrequirementsforLevelIandIIparamedicsincludeACLS

certificationwithinthreemonthsandeitherPALSorPEPPcertificationwithinsixmonths,tobekeptcurrent;12‐hourfieldcareauditseverytwoyearswithatleastsixofthehoursintheCounty;oneskillsrefreshersessioninthefirstyearofthelicenseperiodandoneeveryyearthereafter;educationortestingonupdatestolocalpoliciesandprocedures;completionoftheCountyMulti‐CasualtyIncidenttraining;andsuccessfulcompletionofanyadditionalVCEMSA‐prescribedtraining.

AswediscussedaboveintheLocalEMSAgency/SystemOverviewsectionofthis

report,underthe“PrehospitalEducationandTraining”subheading,werecommendthattheLevelI/LevelIIVCEMSApolicybeeliminated,asissuesofproviderexperiencearemoretypicallyleftuptoEMScompanyemployersasanindustrystandard. Wealsonotethatexistingprovidercontractsstipulatethatparamedicsmayberequiredtoworkadditionalconsecutivehoursthatareequaltoonenormalshiftlength,butmaynotworkmorethan72consecutivehours.109Thereisincreasingconcernthatlongershiftlengthscontributetoproviderfatigueandincreasethepotentialformedicalerrors,ambulancecrashesandotherpotentiallycatastrophicevents.110Accordingly,werecommendthatVCEMSAamendfuturecontractssothatEMSpractitioners’shiftlengthsarenomorethan24hoursinlength,andincludeothershiftrequirementsinaccordancewithpublishednationalstandardsreasonablydesignedtoeliminateEMSpractitionerfatigueasasignificantworkimpediment.

109See,e.g.,ScheduleB,Section11.1ofexistingprovidercontracts.110Patterson,P.D.Etal(2018).2018FatigueRiskManagementGuidelinesforEmergencyMedicalServices.FallsChurch:NationalAssociationofStateEMSOfficials.

EmergencyDepartmentDiversion

AcrossCalifornia,emergencydepartmentdiversionreachedapeakintheearly‐to‐mid2000s.Subsequently,manyjurisdictionshavesignificantlylimitedoreliminatedEDdiversionpractices.111DatasuggestthatEDdiversionofinboundambulanceshasbeenmarkedlyreducedintheperiodbetween2006and2016.IntheAugust2018CaliforniaHealthCareFoundationEDstudydiscussedabove,itwasalsoreportedthatstatewideambulancediversionhoursfellfrom182,642in2006to94,687in2016,ora48%decrease.IntheCentralCoastcounties,whichincludesVentura,ambulancediversionhoursdecreasedby79%duringthesameperiod,fromahighof13,327hoursin2006to2,754in2016. StakeholderinterviewsalsosuggestedthatambulancediversionhoursinVenturaCountywerenotamongthemorepressingconcernsaffectingtheEMSsystem.Nevertheless,continuedvigilanceandmonitoringregardingEDdiversionshouldremainafocus,asdiversionandoffloaddelays,discussedinmoredetailbelow,bothhaveasignificantnegativeimpactonunithourcosts,deployment,responsetimesandpatientcare.

AmbulancePatientOffloadTimes(APOT)

CEMSAwasmandatedbystatute112todevelopaStatewidemethodologyforLEMSA’stocalculateandreportAPOTathospitals.Ithasdonethat.ThestatutedefinesAPOTasthetimeinterval(inminutesandseconds)betweenthearrivalofanambulancepatientatanemergencydepartmentandthetimethepatientistransferredtotheemergencydepartmentgurney,bed,chairorotheracceptablelocationandtheemergencydepartmentassumestheresponsibilityforcareofthepatient.113Thisappliestoall911emergencytransportstoanemergencydepartmentwithavailabletimedata.LEMSAsarealsogiventhediscretiontomonitorAPOTforIFTs,7‐digitandothertransportstoanemergencydepartment.114BaseduponthedataprovidedtousbyVCEMSAitappearsthatVCEMSAiscollectingandreportingAPOTdataonlyfor911emergencytransports.

111Backer,etal.,StatewideMethodofMeasuringAmbulancePatientOffloadTimes,Prehosp.Emerg.Care,2019May‐Jun;23(3):319‐326,onlinepublicationdateOctober25,2018. 112Cal.Health&SafetyCode§1797.120.113Cal.Health&SafetyCode§1797.120(b).114AmbulancePatientOffloadTime(APOT)StandardizedMethodsforDataCollectionandReporting,asrevisedbytheEMSCommissiononNovember21,2016.

InfluencingFactors

Beginningthefirstquarterof2017,andcontinuingonaquarterlybasis,VCEMSAhasgatheredtherequiredinformationandreportedittoEMSA.TherequiredreportsareforAPOT1andAPOT2.Theseareasfollows:

APOT1–anambulancepatientoffloadtimeintervalmeasure.Thismetricis

acontinuousvariablemeasuredinminutesandsecondsthenaggregatedandreportedatthe90thpercentile.

APOT2–anambulancepatientoffloadtimeintervalprocessmeasure.ThismetricdemonstratestheincidenceofambulancepatientoffloadtimesexpressedasapercentageoftotalEMSpatienttransportswithinatwenty(20)minutetargetandexceedingthattimeinreferenceto60,120and180minutetimeintervals.

VCEMSAcollectsthisdatafromitsprovidersthroughImageTrendfromtheeight

acutecarehospitalsintheCounty.Inthefirstmonthof2017,forAPOT1,VCEMSAcollecteddataon3,278transports.The90thpercentileAPOTfortheeighthospitalscollectivelywas18.16minuteswiththelowesthospital90thpercentileAPOTbeing09.43minutesandthehighestbeing23.34minutes.Forthelastmonthof2018,forAPOT1,VCEMSAcollecteddataon3,751transports.The90thpercentileAPOTfortheeighthospitalscollectivelywas18.15minuteswiththelowesthospital90thpercentileAPOTbeing12.42minutesandthehighestbeing21.38minutes.

ThetargetforAPOTtimeestablishedbytheCommissiononEMSisthatitnot

exceed20minutes,thoughlocalEMSagenciesarefreetosettheirownbenchmarks,withsomechoosinglongerones.Beginningthesecondquarterof2017,VCEMSAbeganreportingthemedianAPOTtimeforeachofthehospitalsandforthehospitalscollectively.ForanindividualhospitalthelowestmedianAPOTwas2.55minutesandhighestmedianwas14.26minutes.ForthehospitalscollectivelythelowestmedianAPOTwas8.45minutesandthehighestmedianAPOTwas10.41minutes.

TheAPOT2reportsreflectthatfortheeighthospitalscollectivelyover90%of

patientstransportedtoanemergencydepartmentbyambulancepursuanttoa911dispatchexperienceatransferofcaretothehospitalwithin20minutesofarrivalattheemergencydepartment,andlessthan10%experienceatransferofcaretothehospitalbetween21and60minutesofarrival.OverthecourseoftheAPOT2datacollectionperiodfor2017and2018,onlyaveryfewsuchpatients(muchlessthan1%)experiencedatransferofpatientcaretothehospitalwithin61to120minutesofarrivalattheemergencydepartment,andevenfewersuchpatientsexperiencedatransferofpatientcaretothehospitalwithin121to180minutes.Nosuchpatientexperiencedatransferofpatientcaretothehospitalmorethan180minutesafterarrivalatahospitalemergencydepartment.In2018nopatienttransportedtoanemergencydepartmentbyambulancepursuanttoa911

dispatchexperiencedatransferofcaretothehospitalmorethan120minutesafterarrivalattheemergencydepartment.

Asofthecompilingofthisreport,thereisstillnocentralized,statewidedatabaseof

APOTdatainCalifornia,asreportingbylocalEMSagenciesisstillgenerallyrampingup.Inaddition,apaperpublishedin2018indicatedthatthereis“substantialvariation”inAPOTtimesacrossCalifornia.115Nevertheless,somecomparativedataareilluminating.

The2018Backerstudy,whichutilizeddatafromlocalEMSagencieswhichreported

afullyearofAPOTdatain2017,showedameanoffloadtimeof36minutes.Thisreportalsorevealedthatthemajorityofhospitalsintheareasreportingcomplete2017datahada90thfractileAPOTbetween15–45minutes.116

AnApril2019reportinSanJoaquinCountyshowed90thpercentileAPOTsranging

fromapproximately26–49minutesduringthefourthquarterof2018.117InFebruary2019,theRiversideCountyEMSAgencyreportedAPOT1timesbetween11minutesandnearlytwohours.TheSantaClaraCountyEMSAgencyreported90thpercentileAPOTsforthefirsthalfof2018rangingfrom10–56minutes,and,interestingly,thosetimesrangedfrom10–37minutesinthesecondhalfof2018.118BetweenJanuaryandMay2019,thereported90thpercentilerangewas9–52minutes.119

ThoughdirectcomparisonswithotherCaliforniacountiesaredubious,itappears

fromavailablestatewidedataandsomecomparativelocaldatathatVenturaCountyatpresentcomparesfavorablyintermsofambulancepatientoffloadtimes.Anecdotally,stakeholdersreportedoverallsatisfactionwithAPOTinVenturaCounty,especiallycomparedtowhatothercountieshaveexperienced.Inaddition,theviewsexpressedbystakeholdersinourinterviewsconfirmswhatstudiesinCaliforniaareshowing;i.e.,thattotheextenttherewasaproblem,itisimprovinginVenturaCountyasithaselsewhereinthestate.SomestakeholdersnotedthatAPOTtendstoincreaseinperiodsoflowEDstaffing,which,ofcourse,constitutesahospitalsubsidyattheexpenseoftheEMSsystem.Fortunately,thisisnotreportedtobeacommonoccurrence.

SomewhatproblematicforAPOTisthattheactualtransferofcaretimefromthe

ambulancecrewtothehospitalismanuallyentered.Thiscancreateinconsistenciesinthe

115Backer,etal.,StatewideMethodofMeasuringAmbulancePatientOffloadTimes,Prehosp.Emerg.Care,2019May‐Jun;23(3):319‐326,onlinepublicationdateOctober25,2018116Id.117SanJoaquinCountyEMSAgency,April11,2019EMSLiaisonCommitteeReport,https://www.sjgov.org/ems/pdf/liaison_committee_meeting_agenda_apr2019.pdf118SantaClaraCountyEMSSystemReports,APOTReports,2018Summary,https://www.sjgov.org/ems/pdf/liaison_committee_meeting_agenda_apr2019.pdf119SantaClaraCountyEMSSystemReports,APOTReports,December2018throughMay2019,https://www.sjgov.org/ems/pdf/liaison_committee_meeting_agenda_apr2019.pdf

reportingofAPOT.Inorderforthetransferofcaretimetobemorereliable,anautomatedprocessforoffloadtimecaptureneedstobepursued.

Finally,itshouldbenotedthatstakeholdersreportahighoveralllevelof

satisfactionintermsofcoordinationbetweenthehospitalsandtheEMSprovidersinaddressingAPOTproblemswhentheydoarise,andalsowithVCEMSAinmediatingthoseissuesasnecessary.ThatisapositiveandconstructiveroleforthelocalEMSagencytoplay.Continuedvigilanceshouldbeexercisedonthisissue,asitcanhavesignificantnegativeconsequencesfordeployment,wastedunithours,costsandpatientcare.But,again,thisappearstobeanareawhereVenturaCountycomparesfavorablytoothercountiesinCalifornia.

InNovemberof2014theCaliforniaOfficeofStatewideHealthPlanningandDevelopment(OSHPD),aCaliforniaOfficethatwaivesscopeofpracticelawstotestnewandinnovativemodelsofcare,approvedHealthWorkforcePilotProject(HWPP#173),apilotprojecttotestsixdifferentconceptsforthepracticeofcommunityparamedicineinten(10)geographicareasacrossCalifornia.Two(2)ofthoseprojectsweresponsoredbytheCaliforniaEMSAuthorityforVenturaCounty.OnewasaTuberculosisPilotProjectimplementedJune1,2015andtheotherwasaHospicePilotProjectimplementedAugust1,2015.120

Toparticipateinacommunityparamedicpilotprojectaparamedicrequiresspecialtraining.Aparamediciseligibletobetrainedtoperformnewrolesasacommunityparamediciftheparamedichasatleastfour(4)yearsofexperience,volunteerstoparticipateinthepilot,andissponsoredbyitslocalEMSagency.TheCaliforniaCommunityParamedicEducationalTaskforcedevelopedacorecurriculumthatOSHPDreviewedandapproved.ThecurriculumwasadaptedfromtheParamedicFoundation’sNationalCommunityParamedicCurriculumtobetteralignwiththestandardsandrequirementsofpracticeinCalifornia.Thecurriculumincludes48hoursofdidactic,classroom‐basedinstructionand48hoursofclinical,hands‐ontraining,foratotalof96hoursofinstruction.Communityparamedictraineesarealsorequiredtocomplete56hoursofstudyoutsidetheclassroom,whichincludesrequiredreadingsandotherassignments.121

120UniversityofCaliforniaSanFranciscoReportonImplementationofHWPP#173‐CommunityParamedicine–Quarter12018(June29,2018).121HealthforceCenteratUniversityofCaliforniaSanFranciscoUpdateofEvaluationofCalifornia’sCommunityParamedicinePilotProgram(February7,2018).

CommunityParamedicine/MobileIntegratedHealthcare

TuberculosisPilotProject122‐TheTuberculosisProjectisdesignedtoimprovethe

treatmentforpeoplewithtuberculosis(TB)byprovidingdirectlyobservedtreatmenttoTBpatientsinthefield,insupportoftheVenturaCountyPublicHealthDepartment’sTBSpecialtyClinicandthepatientstheyserve.Thisisbeingaccomplishedbyimprovingpatientcompliancewithdirectlyobservedtreatment(DOT),increasingthepercentageofpatientswhocompletethefullcourseoftreatmentforTB,andidentifyingandtreatingside‐effectsandmal‐absorptionissuesearly,withphysicianinvolvementasneeded.In2017,communityparamedicsassistedanaverageof6patientspermonth(somepatientswereseenmultipletimesaday).Thisnumberincluded11newpatientswhoenteredtheprogramthroughouttheyear.

Thispilotprojectwaslaunchedin2015andiscontinuing.AllthreeoftheEOAprovidersparticipateinthisproject.TheywereaskedtoparticipatebecausetheVenturaCountyTBclinicdoesnothavesufficientstafftomonitorDOTforallTBpatientsintheCounty.Becauseofthelengthoftimethatittakesforthemedicationtorenderthepatientnon‐communicable,andbecausethetreatmentregimendiffersdependinguponwhetherthepatientisdrug‐resistant,thelengthoftimeTBpatientsareenrolledintheDOTprogramvaries,butgenerallyenrollmentisformultiplemonths.123CommunityparamedicsarestationedthroughouttheCountyandcanusuallyreachpatientswithin15minutes.124

HospicePilotProject‐TheHospiceProjectisdesignedtoprovidehospicepatientswiththemedicalcareandthesupportnecessarytoremainintheirlocationofchoice,ratherthanbeingtransportedtoanemergencymedicalfacility.Ifthe911dispatcherorafirstresponderorscenedeterminesthatapatientisunderthecareofahospiceagency,acommunityparamedicisdispatchedtothepatient’sresidence.Thecommunityparamedicwillassessthepatient,talktoanyfamilymemberspresent,andcontactahospiceagencyregisterednursefordirectiononthecaretoprovideforthepatientuntilthehospiceteamarrives.Inamajorityofcases,thepatient’swishtostayoutofahospitalenvironmentcanbemaintained.125

Communityparamedicsrespondedtoassist148hospicepatientsin2017,withonly31ofthesepatientcontactsresultinginatransporttothehospital.126Itisprojectedthatthissavedanaverageof$755perpatientbyreducingambulancetransportsandemergencydepartmentvisits.127

122Unlessotherwiseindicated,theinformationprovidedunderthisheadingistakenfromtheVenturaCountyPublicHealthEmergencyMedicalServicesAgency2017AnnualReport.123UniversityofCaliforniaSanFranciscoReportonImplementationofHWPP#173‐CommunityParamedicine–Quarter12018(June29,2018)124Overview:CommunityParamedicine—California’sCommunityParamedicinePilotProjects(April2018).https://www.chcf.org/wp‐content/uploads/2018/05/CommunityParamedicinePilotProjects.pdf125Id.126VenturaCountyPublicHealthEmergencyMedicalServicesAgency2017AnnualReportat12.127Overview:CommunityParamedicine—California’sCommunityParamedicinePilotProjects(April2018),https://www.chcf.org/wp‐content/uploads/2018/05/CommunityParamedicinePilotProjects.pdf.

ApreliminarystatewidereviewofCalifornia’scommunityparamedicinepilot

programsreleasedin2019concluded:

Californiansbenefitfromtheseinnovativemodelsofhealthcarethatleverageanexistingworkforceoperatingatalltimesundermedicalcontrol–eitherdirectlyorbyprotocolsdevelopedbyphysiciansexperiencedinemergencycare.Theprojectshaveimprovedcoordinationamongprovidersofmedical,behavioralhealth,andsocialservicesandreducedpreventableambulancetransports,emergencydepartmentvisits,andhospitalreadmissions.Theyhavenotresultedinanyadverseoutcomesforpatients.128

Potentialsavingsperpatientrangedfrom$975‐$2619inotherprogramssummarizedinthestatewidereview.129 Clearly,communityparamedicineprogramshavethepotentialtobenefitpatientsandEMSsystems,bothclinicallyandfinancially.Theseprogramscanreduce911andemergencydepartmentdemandforconditionswhichdonotrequireemergencyresponseoremergencytreatment,improveunithourutilization,reducedeploymentcosts,andpromotelesscostlycareinmoreappropriatecaresettings.VCEMSAhastakenpositivefirststepstobeontheleadingedgeofcommunityparamedicineimplementationinCaliforniathroughparticipationintheearlypilotprocess.Werecognizethattheseprogramsarelikelytotransitionoutascurrentlyadministered,butsupportthecontinuationofcommunityparamedicineprogramswhereresearchidentifiescommunityneedsthatcanbeeffectivelyaddressedbysuchprograms.130VCEMSAshouldcontinueassessmentofCountyneedsthatcanbeservedbycommunityparamedicineprogramsandalsointegratelessonslearnedinparamedicpracticewherefeasible.

TheuseofElectronicHealthRecordsisrequiredforallEMSprovidersinCalifornia,

makingitpossibleforallEMSagenciesintheStatetoexchangeelectronicpatient

128Coffman,etal.,129Id.130Asofthewritingofthisreport,itshouldbenotedthatlegislativeinitiativesinCaliforniamightaffecttheimplementationofcommunityparamedicineprogramsonastatewidebasis,includingproposedlegislationthatwouldessentiallygivefiredepartmentsa“rightoffirstrefusal”inCPprogramimplementationatalocallevel.Regardlessofwhethersuchlegislationisenacted,includingallstakeholdersinacommunity‐basedCPprogramdesignthatreflectslocalneedsandhealthcareprioritiesisadvised.

TechnologyinEMS

informationacrosshealthcareproviders.131AlthoughfewEMSagenciesnationwidearecurrentlyconnectedtoahealthinformationexchange(HIE),132HIEparticipationissteadilyrisinginCalifornia.

TheintegrationofEMSagenciesintothe

HIEworldhasbeenslowduetoalackoffunding,disparateproprietarysystems,insufficientcollaborationbetweenEMSandotherhealthcareproviders,andprivacyconcerns.133But,thesechallengesarebeingovercomeasmoregrantsbecomeavailable,benefitsarerealizedfromEMS/HIEpilotprojects,andprovidersareincreasinglyincentivized(primarilybyreadmissionpenalties)toimproveintegrationwithEMSpartners.WebelievethatEMSagenciesinVenturaCountycouldtakeadvantageofexpandedHIEinitiativesintheStateofCaliforniainthenextambulancecontractingcycle.WealsobelievethatparticipationinHIEincouldoffermanybenefitsfortheVenturaCountyEMSsystem,itsstakeholders,andthepatientsoftheCounty.

HealthInformationExchangeor“HIE”isthe

exchangeofhealthinformationamongorganizationsaccordingtonationallyrecognizedstandards.ThegoalofHIEprogramsistofacilitatesecureaccesstohealthcaredatabyappropriateindividualstoprovideeffective,equitable,patient‐centeredcare.AnHIEorganizationisanentitythatoverseesorfacilitatestheexchangeofhealthinformationamonghealthcarestakeholders.

131See,“ImplementingHIEinEMS,”availableat:https://emsa.ca.gov/wp‐content/uploads/sites/71/2017/07/Adopting‐HIE‐For‐EMS‐Providers.pdf.132See,https://emsa.ca.gov/hie/.133Id.

HIEcanencompassallaspectsoftheEMSpatientcarecontinuum,includingdispatch,scenecare,transport,transfertotheemergencydepartmentorotherdestination,hospitaladmission,hospitaldischarge,andotherpractitionercare.Forthatreason,HIEcanbenefitEMSinmanyways.Havingaccesstorelevanthealthdata(suchaspastmedicalproblems,medications,allergies,andend‐of‐lifedecisions)isvaluable,andsometimescritical,forEMSprovidersandtheirpatientsatthetimeofthecall.Sometimespatientsortheircaregiversmaybeunabletoprovidebasic,reliablehealthinformationaboutthepatient.Indisastersituations,anHIEorganizationconnectedwithEMScanhelptoensurepatienttrackingandresourcecoordinationisavailabletothosewhomaybedisplacedfromtheirnormallocationorhealthcareteam.Inaddition,EMSagenciesincreasinglyprovideschedulednonemergentcareinpartnershipwithlocalhealthsystems.Conveyinginformationgatheredatthescenecanbevitaltothereceivingfacilityandimpactpatientcaredecisionsandtheabilitytobilltheproperpayer.HIEalsoenablesEMSagenciesandEMSsystemstoconductmorerobustqualityimprovementandqualityassurancebecausefacilityadmission,treatmentanddischargedatacouldrevealissueswiththeprehospitalcareprovided.ItcanalsoenhanceEMSeducation,protocols,andprovidertrainingbecauseaccesstooutcomedatacanexposewhatproceduresandinterventionsareeffectiveorineffective.HIEcanalsocultivatemorecollaborativerelationshipsbetweenhospitalsandprovidersthatfunctionwithintheEMSsystem,andcanfacilitatemoreeffectivecommunityparamedicineprogramsatsuchtimeastheybecomefullyimplemented.

TheFederalgovernmentrecognizesthebenefitsof,andstronglyendorsestheintegrationofEMSdataintoHIEsystems.TheFederalHealthITStrategicPlan2015‐2020noted:

“EMSpractitionersprovidestabilizingcareandtransportationservices;havingaccesstoapatient’ssalientclinicalinformationasafirstrespondercanimprovepatienthealthandsafety.AccesstolinkedoutcomesdatafromhospitalscanhelpEMSsystemsmeasureperformance,improvetheirprovisionofcare,andprovidetimelyfeedbacktoproviders.”134

TheOfficeoftheNationalCoordinatorforHealthInformationTechnology(ONC)toutstheelectronicprehospitalcarerecord(ePCR)as“animportantpartofthepatient’soverall

134See,https://www.healthit.gov/sites/default/files/9‐5‐federalhealthitstratplanfinal_0.pdf.

healthrecord[that]shouldbeintegratedwiththepatient’slongitudinalhealthrecord.”135InteroperabilitybetweenEMSprovidersandhospitalsleadstoimprovedmeasurementofEMSsystemperformanceandpopulationhealth.

Inaddition,FederalprivacylawsdonotstandasanobstacletotheuseofHIEin

EMS.TheDepartmentofHealthandHumanServices(HHS)OfficeforCivilRights(OCR)issuedexplicitguidancemakingitclearthatEMSprovidersareproviding“treatment”withinthemeaningoftheHealthInsurancePortabilityandAccountabilityAct(HIPAA)whenexchanginghealthcareinformationwithprovidersinvolvedinthepatient’scare.136Assuch,disclosuresortransmissionsofpatientinformationtoorfromotherprovidersarepermissiblewithouttheneedtoobtainpatientconsent.137EMSprovidersmayparticipateinanHIEarrangementandutilizeanHIEorganizationtoexchangepatientinformationforHIPAA‐permittedactivities,suchastreatment,paymentorhealthcareoperations.138

HealthInformationExchangeinCalifornia

In2013,EMSAbeganexploringwaystoimprovetechnologyforEMSproviderswho

werenoteligibleprofessionalsundertheIncentiveProgramsundertheHITECHAct.139EMSAreceivedfundingfromtheCaliforniaOfficeofInformationIntegritytostudyEMSHIEintegration(EMSADispatch).InitialresearchrevealedthatmanyCaliforniaEMSagencieswerenotyetawareanddidnotunderstandtheconceptofHIEandthepotentialandbenefitsforEMS.Then,inJuly2015EMSAwasawardeda$2.75milliongrantunderacooperativeagreementfromONCtodeveloptechnology,infrastructure,policiesandagreementsthatenableinteroperableHIE

135EmergencyMedicalServices(EMS)DataIntegrationtoOptimizePatientCareTHESEARCH,ALERT,FILE,RECONCILE(SAFR)MODELOFHEALTHINFORMATIONEXCHANGE,availableat:https://nasemso.org/wp‐content/uploads/emr_safr_knowledge_product_final.pdf.136https://www.hhs.gov/hipaa/for‐professionals/faq/273/when‐an‐ambulance‐delivers‐a‐patient‐can‐it‐report‐its‐treatment‐without‐authorization/index.html;Seealso,45CFR§164.506.13745CFR§164.506.138DependingonthenatureoftherelationshipwithbetweentheproviderandHIEpartner,abusinessassociateagreementmayberequired.139HealthInformationTechnologyforEconomicandClinicalHealth(HITECH)Act,TitleXIIIofDivisionAandTitleIVofDivisionBoftheAmericanRecoveryandReinvestmentActof2009(ARRA),Pub.L.No.111‐5,123Stat.226(Feb.17,2009)(full‐text),codifiedat42U.S.C.§§300jjetseq.;§§17901etseq.

betweenmultipleEMSandotherhealthcareproviders.Thiswasatwo‐yearinitiative.ThefundingalsoenabledEMSAtopilotnewEMSHIEworkflowsintwolocalregionsbyconnectingEMSproviderswithhospitalsusingtwodifferentHIEorganizations’vendors.UndertheONCgrant,EMSAdevelopedtheSearch,Alert,File,Reconcile(SAFR)modeltodescribetheminimumfunctionalaspectsofEMSHIEdataexchange.

EMSAbegantwopilotSAFRimplementationsthroughSanDiegoHealthConnectand

OrangeCountyPartnershipRegionalHealthInformationOrganization.ThepilotimplementationswerelargelysuccessfulandEMSAcontinuestoendorsethewidespreadintegrationofEMSintoHIE.

MostrecentlyinMay2019,EMSAissueda$4.9millionstategranttoManifestMedEx,aCaliforniaHIEorganization,tofundanotherHIEinitiative.140TheinitiativeinvolvessixlocalEMSagencies,13EMSagenciesand16hospitalsacrosseightcounties—Riverside,SanBernardino,Fresno,Tulare,SanJoaquin,Merced,Amador,StanislausandCalaveras—andwillservemorethan7.6millionCalifornians.141ThedataexchangeframeworkfollowstheONC’sSAFRmodel.142Startingwithatwo‐yearprogram,theinitiativeisdesignedtocreatecapabilitiesthatcanbescaledtootherareasinCaliforniainthefuture.Morethan400healthcareorganizationsinCaliforniaarecurrentlyparticipantsinManifestMedEx.

StepsNecessaryforVenturaCountyforEMSHIEIntegrationThereareseveralstepsthatcanhelpbegintheprocesstowardintegrationin

VenturaCounty:

1. IdentifyaLeadPerson.IdentifyanEMSleaderwhocanengagetheCountystakeholders,articulatethevalueofinformationexchange,andleadthechargeforHIE.

2. AssessePCRCapability.EvaluatetheePCRcapabilitiesoftheePCRssolutionusedintheCountyandensuretheyarecompliantwiththemostrecentNEMSISstandardsandcanbeeasilyintegratedintoanHIE.

140Landi,H.(2019,May).CaliforniaHIEtouse$4.9Mgranttoconnectambulanceswithhospitalpatientdata,availableat:https://www.fiercehealthcare.com/tech/california‐hie‐to‐use‐4‐9m‐grant‐to‐connect‐ambulances‐to‐patient‐data‐hospital‐ehrs.141Id.142EmergencyMedicalServices(EMS)DataIntegrationtoOptimizePatientCareTHESEARCH,ALERT,FILE,RECONCILE(SAFR)MODELOFHEALTHINFORMATIONEXCHANGE,availableat:https://nasemso.org/wp‐content/uploads/emr_safr_knowledge_product_final.pdf.

3. FundingSources.ItispossiblethatEMSAcurrentlyhasadditionalresourcestoallocateforHIEand/orVenturaCountycouldparticipatewithManifestMedEx;or,EMSAmayhaveresourcesavailableinthefuture.

4. AdoptSAFRModel.VenturaCountyparticipantswouldhavetoimplementandincludethecoredataelementsinCalifornia’spilotprojects.

5. OutreachandCooperation.VenturaCountywouldhavetoestablishearlycooperationwithallinvolvedparties,includingcommunityleadersfromEMS,HIEorganizations,localhealthsystems,hospitals,andePCRvendors.

WerecommendthatVCEMSAtaketheleadinestablishingEMS/HIEintegrationfor

providersinVenturaCounty.FutureambulanceprovidercontractsshouldrequireHIEparticipationbyanappropriatetargetdate.Californiahasanexisting,testedHIEmodelandmayhavetheresourcestofundHIEinVenturaCounty.TheCountyshouldreachouttocommunitiesandvendorswhohavealreadybegunEMSHIEintegrationintheStateandusetheresourcesdevelopedbytheEMSAHealthInformationExchangeKnowledgeBank.143

143Availableat:https://emsa.ca.gov/HIE‐Knowledge‐Bank/

Strengths• VenturaCountyhasgrandfatheringeligibilityforallprovidersinallEOAs,givingittheoptiontomaintainsystemcontinutyandavoidtheexpenseofacompetitiveprocurement

• Effectivevoluntarypublic‐privatepartnershipswithfiredepartmentsforEMSfirstresponse

• Goodspecializedfacilitycapabilities• EfficientEMS‐hospitalinterfaceandrelativelylowAPOT

• Leadershipincommunityparamedicineneedsassessment

Weaknesses• Zone4deploymentinthreeoftheless‐populatedsub‐zonesinadequatetocoverdemand

• Inefficientdeploymentofall‐ALSresourcesregardlessofseverityofEMDresponsedeterminant

• NocurrentEMSHIEparticipation

Opportunities• AbilitytoaddaBLSresponseandtransporttiertomoreeffectivelymatchresourceswithdispatchcondition

• Buildoncommunityparamedicinemodelprogramsuccesstofulfillotheridentifiedcommunityneeds

• ImplementHIEparticipationbyEMS

Threats• Populationgrowthexceedinghospitalbedcapacity

SWOTAnalysis–EMSSystemDeployment

EMSSystemCommunications

VenturaCountyhasatwo‐tiereddispatchsystemwhereall9‐1‐1callsareinitiallyreceivedbyaprimarypublicsafetyansweringpoint(PSAP)andthenEMScallsaretransferredtoasecondaryPSAP.

Nine(9)primaryPSAPsservetheCounty.Six(6)oftheprimaryPSAPsarecoveredbytheVenturaCountyEMSPlan:(1)OxnardPoliceDepartment;(2)PortHuenemePoliceDepartment;(3)SantaPaulaPoliceDepartment;(4)SimiValleyPoliceDepartment;(5)VenturaCityPoliceDepartment;and(6)VenturaCountySheriff’sDepartment.Inaddition,theCaliforniaHighwayPatrol,CaliforniaStateUniversityChannelIslands,andNavalBaseVenturaCountyPSAPSserveasprimaryPSAPsinVenturaCounty.

TheVenturaCountyFireCommunicationsCenter(FCC)isasecondaryPSAP.WhenaprimaryPSAPreceivesacallforamedicalorfireemergencyintheCounty,thecallistransferredtoFCC.FCCistheexclusivedispatcherforemergencyambulancecallsintheCounty,whetherinitiatedbya9‐1‐1call,awalk‐inoraseven‐digitemergencycall.

AllEMSresourcesdispatchedinVenturaCountyaredispatchedbyFCCusingCentralSquareTechnologiesCADsoftware.FCCdispatchestheclosestavailableALSambulancetoanemergency,inaccordancewithVCEMSApoliciesandprocedures.AmbulancesaredeployedbasedonestablishedSystemStatusManagementplansandallambulancesareequippedwithmodernmobiledispatchcomputersandanautomaticvehiclelocation(AVL)system.AVLutilizesacombinationofradiocommunicationsandotherhardwarethatisintegratedwiththeVCFPDdispatchcenter’scomputeraideddispatch(CAD)systemtoprovideavisualimageofthelocationofvehicles.TheAVLsystemcommunicatesthegeographiclocationofthevehiclestotheCADsystem.

FCCalsousestheEmergencyMedical

Dispatch(EMD)programwhendispatchingambulances.EMDisaprogramdesignedtoprovidepredeterminedinstructionstovictimsandbystandersbeforethearrivaloffirstresponders.EMDdispatchersuseMedicalPriorityDispatchSystemsProQADispatchSoftwaretomovethroughcaseentryandkeyquestioningtodeterminethelevelofacuityofthecallandtoassessthepotentialconditionofthepatient.Ventura

CountyisfortunatetohaveasecondaryPSAPwithfullEMDcapabilitiestoprovideprioritydispatchservicesforEMSthroughouttheCounty.PerhapsaworthwhileaspirationalgoalisfortheFCCtoobtaintheIAEDACE(AccreditedCenterofExcellence)designationtoaddtoitsalreadyexcellentreputationandservices.Inaddition,thesecondaryPSAPcouldexploreuseoftheNAEDOmegaprotocoland/orEmergencyNurseCommunicationSystem(ECNS)toprovideadditionaloptionsfornon‐EMSresponseoralternativereferralwhenEMSisdeterminedtobeunnecessary.

IfLifeLineorAMR/GoldCoastreceiveacallforanambulanceresponseand/ortransport,theagenciesassesswhetherthecallisforanemergencyornon‐emergencyambulanceservice.If,baseduponcall‐intakeinformationreceived,LifeLineorAMR/GoldCoastdeterminethatthecallrequiresanemergencyresponse,theagencyrefersthecalltoFCC.144Ifbaseduponthecall‐intakeinformationitreceivesitdeterminesthatthecallrequiresanon‐emergency/interfacilitytransport,theagencywilldispatchoneofitsownambulancesandnottransferthecalltoFCC.

AllambulancesareequippedwithmobileandportableradiosprogrammedtotheCounty’suniformchannellisting,whichallowsallfirstrespondersandambulancepersonneltocommunicateoncommonradiofrequencies.Radiosarealsorequiredtoprovidetwo‐waycommunicationbetweenthecrewandbasehospitalsforneededcommunications.Cellularphonesarealsopermittedtobeusedforthispurpose.

Thetwo‐wayradiosfortheambulanceshavepushtotalkfeaturesandmultipleline

andfrequencycapabilitieswithatleast32channels.Mostambulance‐relatedcommunicationsinVenturaCountyaretransmittedoverVHFradiofrequencybandsrangingbetween151–155MHz.EOAprovidersneedtore‐programtheradiochannelstobecompatiblewithapprovedrecommendationsoftheCountyFireChief‘sAssociationandVCEMSA.Theseradiosarealsousedformultipleagencyaccess,operationsinvariedterrain,andcommunicationscapacityindriverandpatientcompartments.Thepatientcompartmentpartoftheradiosystemisrequiredtoincludeaspeaker,microphoneandvolumecontrol.

EOAprovidersmusthaveonehand‐heldradioperambulanceandaradiochargeror

sparebatterypackforeachportableradioandstockasurplusofportableradiossothattheyareavailabletoreplaceportableradiosundergoingrepairs.SurplusradiosarealsoavailableforuseinincidentsrequiringmoreEMSradiosthanotherwiseavailableonambulancesparticipatingintheincidents.AmbulancesthathaveradiospurchasedbytheEOAproviderarethepropertyoftheEOAprovider.IftheCountypurchasedtheradioitisthepropertyoftheCounty.Regardless,theEOAproviderisresponsibleformaintenanceoftheradio.

144March26,2019memofromChrisRosatoPWW.

AsofFebruary2019,communicationequipmentthatVCEMSAhasdeployedasfront‐lineorreserveequipmentisspecifiedinthefollowingtable:145

Table11:CommunicationsEquipmentDeployedByVCEMSA

TYPE MODEL COUNT

PortableRadios MotorolaAPX7000X 2 MotorolaHT1250 71MobileRadios MotorolaCDM1550 16 MotorolaCDM1550LS 6 MotorolaAstro 2 MotorolaAPX1500 6HAMRadio KenwoodTM‐D710 1HAMRadioPacket AlincoDR‐135MK111 2HAMRadio–Portable WouxunKG‐UV3D 10 KenwoodTH‐F6A 12HAMRadio–Mobile MotorolaTM‐D710A 12SatellitePhone Iridium 7

VCEMSAisintheprocessofupgradingitsfront‐linecommunicationsequipmentto

MotorolaAPXmodelradios,someofwhichwillbemulti‐bandorall‐band,andallofwhichwillbeP25compliant.VCEMSAexpectsthetransitionofitsfront‐lineequipmenttobecompletebytheendofFY19‐20.146

TheCountyalsohasanoperationalareadisastercommunicationsystem.147Ituses

154.055astheradioprimaryfrequency.ItparticipatesintheOperationalAreaSatelliteInformationSystem(OASIS)andhasaplantoutilizetheRadioAmateurCivilEmergencyServices(RACES)asaback‐upcommunicationsystem.Also,HAMradiounitsareplacedintheemergencyroomsofallCountyhospitals.148Intheeventofadisaster,membersofRACESrespondtothehospitalstoprovideemergencyradiocommunications.Thereare

145February22,2019memofromVCEMSAtoPWW.146Id.147VenturaCounty2017EMSPlanUpdate.148VenturaCounty2013EMSPlan.

alsoHAMradiosintheCountyEmergencyOperationsCenter,intheHealthDepartment’sOperationsCenterandinDisasterResponseVehicles.AllCountyhospitalshavetheabilitytocommunicatewitheachotherthroughtheReddiNetsystemandsatellitebackupserviceisavailableforthatsystemintheeventofafailureofregularInternetconnections.149

149Id.;VCEMSAPolicyNo.920.ReddiNetCommunicationsPolicy.

Strengths• CentralizedsecondaryPSAPforallEMSdispatch

• EMDonallEMSemergencycalls• StrongpartnershipforEMSdispatchoperations

Weaknesses• EMDresponsedeterminantsnoteffectivelyutilizedsinceallresponseisatALSlevel

Opportunities• ObtainACEaccreditationforsecondaryPSAPthroughIAED

Threats• Interoperabilityinamulti‐jurisdicationalevent

SWOTAnalysis–EMSSystemCommunications

ResponseTimes

TheVenturaCountyEMSsystemiswhatistypicallyreferredtoasa“highperformancesystem,”thatis,itincorporatesresponsetimestandardsandassociatedpenalties.Responsetimeiscalculatedfromthetimeoffirstnotificationoftheambulanceuntilthetimetheambulancenotifiesthedispatcherofitsarrival(wheelsstopped)atthescene.Responsetimecriteriavariesbasedonpopulationdensityandcallpriority.150

Adetailedanalysisofresponsetimecompliancebyzonesandsub‐zonesisdiscussedintheDeploymentsectionofthisreport.Asdiscussedinthatsection,responsetimecomplianceisoverallsatisfactoryforeachEOAwithminimaldeficiencies,withtheexceptionofthreeofthefourless‐populatedsub‐zonesinEOA4. Baseduponcall‐intakeinformationthesecondaryPSAPdispatchesEMSresourcestorespondaseitheranEMDPriorityIResponseoranEMDPriorityIIResponse.AnEMDPriorityIResponseisanEMSresponsetoapatientwhosemedicalcondition,asdeterminedbyEMDprotocol,requiresanemergencyresponse.AnEMDPriorityIResponserequirestheuseoflightsandsirens.AnEMDPriorityIIResponseisanEMSresponsetoapatientwhosemedicalcondition,asdeterminedbyEMDprotocol,requiresapromptbutnotemergencyresponse.AnEMDPriorityIIResponsedoesnotrequiretheuseoflightsandsirens.

Formetropolitan/urbanareas,suburban/ruralareas,lowdensity/remoteareasandwildernessareasEMDPriorityIResponsetimerequirementsaresetforthinthefollowingchart:

150EMDPriorityIandIIResponsesaredefinedinVCEMSAPolicyNo.910.EmergencyMedicalDispatchSystemStandards.

Table12VenturaCountyAmbulanceResponseTimes

Area EmergencyResponse/90%ofTime

Maximum/100%ofTime

Metropolitan/Urban 8.00151,152 15.00153

Suburban/Rural 20.00 40.00LowDensity/Remote 30.00 40.00Wilderness 45.00154 ASAP

AmbulanceresponsetimecomplianceismonitoredthroughtheFirstWatchOnlineComplianceUtilityprogram. Non‐compliantresponses,withoutanapprovedexemption,areassessedafinancialpenaltybasedonthecontractguidelines.Exceptionstotheresponsetimerequirementsinclude,butarenotlimitedto,16reasonslistedinthecontracts.In2018,monthswherethe90%requirementwasnotmetwererare,andwereconfinedtothreeoftheEOA4sub‐zonesasdiscussedaboveintheDeploymentsectionofthisreport.

Also,iftheCountydeterminesthattheEOAproviderhasfailedtomaintaina90%

responsetimeperformancelevelinanEOAassignedtoitforthreeconsecutivemonthsoratotaloffourmonthsduringafiscalyear,theCountymaydeterminethatthereisamaterialbreachofthecontractandpursueitsremediesforthebreach,whichincludeterminationofthecontractandpossibleimmediatecontrolbytheCountyoftheprovider’semergencyambulanceserviceoperationsintheEOAdirectlyorthroughadesignatedoperator.Therehavebeennooccasionswherea90%responsetimeperformancelevelforanEOAhasnotbeensatisfiedforthreeconsecutivemonthsoratotaloffourmonthsduringafiscalyear.

ToaidresponsetimecomplianceEOAproviderambulancesaredeployed

countywidebasedonestablishedSystemStatusManagementplans.TheEOAprovidersalsohaveambulanceback‐upplanstoaddressoccasionswhenthedispatchofambulancesdeployedinanareahaveleftthatareawithanambulanceshortage.

151ForeachEOAprovider,foreachEOAassignedtoit,pursuanttoitscontractswiththeCountyitsresponsetimeformetropolitan/urbanareaPriorityIcallsisincreasedfrom8minutesto10minutesifanALSfirstresponderunitarrivesatthescenepriortotheALSambulanceandwithin8minutes.152Thenon‐emergencyresponsetimerequirementis15minutes90%ofthetime.153NotalloftheEOAcontractsimposedthismaximumresponsetime.In2011thoseEOAcontractsthatdidnotimposethisrequirementwereamendedtoincludeit.154Thisisforreportingpurposesonly.

AllresponsesdispatchedbythesecondaryPSAParedispatchedattheALSlevel.Collectively,betweenAMR,GoldCoastandLifeLine,theyhaverespondedtoemergencycallsandconductedemergencytransportsasfollows:155

Table13EmergencyResponsesandTransportsbyYear,

2013‐2017

Year EmergencyResponses

EmergencyTransports

2013 53,730 38,8902014 53,032 40,2422015 57,987 43,3952016 57,216 43,4152017 58,862 44,739

ResponseTimeRequirementsforOtherCounties

Welookedattheresponsetimerequirementsforthecountieswithpopulations+/‐20%andpopulationdensitypermile+/‐20%ofthepopulationandpopulationdensityofVenturaCounty,forwhichthereweresinglecountyLEMSAs.Thoserequirementswereasfollows:

KernCounty.Thiscountyuses9prioritycodesandappliesthemto5zones—Metro,Urban,Suburban,RuralandWilderness.Only5oftheprioritycodeshaveresponsetimerequirements,andonly3ofthecodesapplytoprehospitaltransports.TheyarePriorityCode1forlife‐threateningemergencies,PriorityCode2fortime‐sensitiveemergencies,andPriorityCode3forurgent.Theresponsetimerequirementsinminutesapplicabletoeachzoneareasfollows:

o PriorityCode1—Metro(8),Urban(15),Suburban(25),Rural(50),Wilderness(75)

SanMateoCounty.Thiscountyuses2prioritycodesandappliesthemto3zones—Urban/Suburban,RuralandRemote.Theresponsetimerequirements

155Exceptfor2018,theseamountsarebasedonthenumbersofemergencyresponsesandemergencytransportslistedinthe2013VenturaCountyEMSSystemPlanandthe2014‐2017EMSSystemPlanUpdates.

inminutesandsecondsapplicabletoeachzoneareasfollows:

o PriorityCode1—Urban/Suburban(12:59),Rural(19:59),Remote(25:59)

o PriorityCode2—Urban/Suburban(59:59),Rural(19:59),Remote(59:59)

SanJoaquinCounty.Thiscountyappliesasingleresponsetimeinminutesandsecondtoeachzoneasfollows:

o Metro/Urban(7.29),Suburban(9.29),Rural(17.29),Wilderness(29.29)

VenturaCountyFireProtectionDistrict156

Pursuanttoitspublic/privatepartnership(PPP)agreementwithAMR,VCFPDistoprovideALSfirstresponseserviceinconcertwithAMRanditsbackupprovider’sauthority(i.e.,mutualaidagreementswithLifeLineandGoldCoast)inEOAs2,3,4,5&7,within8minutes90%ofthetimeonallPriority1callsformetro/urbanareas.Forsuburbanareasitistorespondwithin20minutes,andforruralareasitistorespondwithin30minutes,bothatleast90%ofthetime.ForallotherareasVCFPDistorespondassoonaspossible.JustasfortheEOAproviders,exceptionstothetimerequirementsinclude,butarenotlimitedto,16listedreasons.

ThesamemonetarypenaltiesasimposedupontheEOAprovidersmaybeimposeduponVCFPDonatrip‐bytripbasis.AMRisresponsibletopaytheCountyforfailuretomeetitsresponsetimerequirementswhetherduetoitsownfailureorthefailureofVCFPD,but,underthePPPagreement,ifanyofthosefinesareduetoVCFPDfailingtomeetitsresponsetimerequirements,VCFPDisresponsibletoindemnifyAMRforthosefines.IncentivesforVCFPDintheformofpercentagedecreasesintotalpenaltiesthatwouldbeassessedagainstitaregrantedifVCFPDexceedsresponsetimestandardsinacalendarmonthbeginningwith92.5%(20%ofthetotalpenaltyamount)upto98‐100%(100%ofthetotalpenaltyamount).

IfVCFPDfailstomaintaina90%responsetimeperformancelevelinanEOA

assignedtoAMRforthreeconsecutivemonthsoratotaloffourmonthsduringafiscalyear,AMRmaydeterminethatthereisamaterialbreachofthecontractandpursueitsremediesforthebreach,whichincludeterminationofthecontractandpossibleimmediatecontrolbyAMRofVCFPD’sfirstresponseALSserviceinalloraportionofVCFPD’sfirstresponseALSservicearea.

156TheinformationprovidedunderthisheadingistakenfromVCFPD’scontractwithAMR.

CityofVentura157

AswithAMR’scontractwithVCFPD,AMR’scontractwithCOVimposesresponsetimestandards,butonlyan8minuteresponsetimerequirement90%ofthetimeonallpriority1callsintheincorporatedportionofEOA7.Here,too,thereareexceptionstothistimerequirementthatinclude,butarenotlimitedto,16listedreasons.

Also,aswiththeVCFPDcontractwithAMR,thesamemonetarypenaltiesmaybe

imposeduponCOVonatrip‐bytripbasisforthesameviolations.TheincentivesgiventoVCFPDintheformofpercentagedecreasesintotalpenaltiesthatwouldbeassessedagainstitarealsograntedtoCOVifCOVexceedsresponsetimestandardsinacalendarmonthbeginningwith92.5%(20%ofthetotalpenaltyamount)upto98‐100%(100%ofthetotalpenaltyamount).

AMRisdirectlyresponsibleforpaymentofthemonetarypenaltiestotheCounty.

AMRandCOVwillmeettodeterminetheapplicabilityofthefinesimposedonCOV.Ultimately,ifVCEMSAdeterminesthatafineisapplicabletoCOV,COVwillremittheamountofthefinetoAMR.

Likewise,aswithVCFPD,ifCOVfailstomaintaina90%responsetimeperformance

levelinEOA7forthreeconsecutivemonthsoratotaloffourmonthsduringa12‐monthperiod,AMRmaydeterminethatthereisamaterialbreachofthecontractandpursueitsremediesforthebreach,whichincludeterminationofthecontractandpossibleimmediatecontrolbyAMRofCOV’sfirstresponseALSserviceinalloraportionofCOV’sfirstresponseALSservicearea.

Non‐EmergencyandInterfacilityResponseTimes Becausenon‐emergencytransports(NETs)andinterfacilitytransports(IFTs)arenotpartoftheEOAcontracts,therearenobindingresponsetimestandardsfortheseservices.Inaddition,nodatawereprovidedtousthroughtheFirstWatchsystempertainingtoNETsandIFTs. Nevertheless,webelieveitisappropriatethatalocalEMSagencynotimposeresponsetimestandardsonprovidersofNETandIFTserviceswherethemarketisnon‐exclusivewithrespecttothoseservices,asitisinVenturaCounty.Becausehospitals,SNFsandotherfacilitieswithintheCountyarefreetocontractwithandutilizetheservicesofanyprovidersofNETandIFTservices,marketforcessufficetoensurethatperformanceofthoseprovidersiswithinparametersacceptabletothosefacilitieswhichoriginateNETsandIFTs.

157TheinformationprovidedunderthisheadingistakenfromCOV’scontractwithAMR.

VCEMSAdoeshaveseveralpolicieswhichclassifycertainIFTsasemergencyresponses,thereforemakingresponsetimerequirementsapplicabletothosespecifictypesoftransports.Forinstance,Policy440,“CodeSTEMI,”indicatesthattransportsofSTEMIpatientstoaSTEMIReceivingCenter(SRC)shallbedirectedtotheambulancedispatchcenter,andthattheclosestavailableALSambulancewillbedispatched,requiringanimmediateresponsebythatprovider.Thepolicyspecificallystatesthatthesetypesoftransportsarenottobeconsideredinterfacilitytransportsasitpertainstocontractcompliance. Similarly,Policy460,dealingwithacutestrokepatients,requiresdispatchoftheclosestavailableALSambulanceandspecifiesthatthosecallsarenottobeconsideredinterfacilitytransportsforpurposesofcontractcompliance.Theflowchartonpage4ofthisPolicyfurtherspecifiesthatthe“ambulancewillarrivewithin8minutes,”makingitapparentthatthemetropolitanarea/PriorityIresponsetimesareapplicabletothesecalls.

Likewise,Policy1404,“GuidelinesforInterfacilityTransferofPatientstoaTraumaCenter,”imposesanobligationonambulanceservicestorespondtocommunityhospitaltraumatransferrequests,andperformre‐triagetransportsofcommunityhospitaltraumapatientsiftheALSambulancewastheonethatinitiallytransportedthepatienttotheemergencydepartment,provideditisstillonpremises.AlthoughthePolicydoesnotspecifytheresponsetimerequirementforemergenttraumaIFTs,itdoesindicatethatforemergentIFTstheambulancecompanywill“notberequiredtoconsideremergencytransportsasan‘interfacilitytransport’asitpertainstoambulancecontractcompliance.”Thoughthislanguageissomewhatunclearanddiffersfromthelanguageusedinthetwopoliciesreferencedabove,webelievetheintentisthesame–i.e.,thattraumaIFTsaretobetreatedasemergencycallsforpurposesofresponsetimeperformancestandards(i.e.,8minutes)andcountedtowardcontractualcompliance.

Also,withrespecttotraumaIFTs,Policy1404stipulatesthaturgenttransfers

requirearesponsetimeof30minutes,thoughitdoesnotappearthatthesecallsarecountedeitherforresponsetimeorcontractualcompliancepurposes(i.e.,theyaretreatedasIFTsperthePolicy).ItisalsoworthnotingthatthePolicyimposesEDon‐scenetimestandardsoftenminutes158foremergenttraumaIFTsand20minutesforurgenttransfers.VCEMSAmaywishtoconsiderimplementingan“urgent”categoryfortheothermandatedIFTs,i.e.,STEMIandstroke.Thiscanprovideanoptionforensuringtimelyresponseinthosecaseswherethehospitalmayrequiresomeadditionaltimetopreparethepatientfortransport.

158WenotethatthePolicyinoneplace(subsectionconp.4)makesthisanexpressrequirementonthesendinghospitalED:“maintainanambulancearrivaltoEDdeparturetimeofnolongerthantenminutes”–butinanotherplace,thePolicyappearstobacktrackonthisdirectnesssomewhat:“everyeffortwillbemadetolimitambulanceon‐scenetimeinthetransferringhospitalEDtotenminutes.”(P.5,item#5.)

WhatisnotclearinthepolicyistheamountoftimethatincomingALSambulancescanbeheldforre‐triagetransports(i.e.,“TraumaCallContinuation”transportsunderPolicy1404).ItappearsthatthePolicyallowstheEDto“direct”theincomingambulancetoremainintheEDforthetraumare‐triageIFTifitisstillonthepremises,butdoesnotexpresslyindicatewhethertheambulancemustremainindefinitely,regardlessofwhetherthehospitalhasthepatientreadyfortransferwithin10minutes.Aswritten,thisPolicycouldincentivizeanincomingambulancetoleavetheEDandthehospitalpremisesasquicklyaspossibleafterhandingoffcareofapatient.Whilethedataavailabletousdonotshowanacuteproblemorasignificantimpactonambulanceunithourutilization,VCEMSAmaywishtoconsiderclarifyingthisinfutureversionsofthisPolicy.Anecdotally,however,stakeholdersindicatethatthesere‐triagetransportsandholdingofincomingambulancesarenotoccurringwithenoughfrequencytohaveanappreciableimpactondeploymentor911resourceavailability.

Whiletheclinicaljustificationforincludingcertaincondition‐basedIFTsis

apparent,insomesystemswe’veevaluated,thiscanleadtosomeinappropriateutilization,whichcanleadtodeploymentandavailabilityissuesfor911callsfromthecommunity.Insomecases,hospitalsmay“downgrade”theconditionofthepatientandclassifyitasanemergencysimplybecausetheycannotobtainacontractedtransportproviderwithinanacceptableamountoftime,ortoimprovethehospital’sthroughputandimprovebedturnoverandavailability.ItisworthnotingthatVCEMSAreviews100%oftheseurgentandemergentIFTsandpaysattentiontotheseconsiderations.

Thepotentialimpactonstakeholdersfromhospitalsutilizingemergency

ambulancesforIFTslikelywilldifferdependingupontheprovider.Forinstance,incumbentcontractorAMR’sbusinessinVenturaCountyisprimarilyemergency/911withrelativelylowIFTvolume.Forthatreason,thedeploymentof911ambulancesforIFTsbecomesmorelikely,sincemoreoftheirresourcesarededicated911resources.Ontheotherhand,LMT’sbusinessinVenturaCountyisoverwhelminglyIFT‐focused,somoreofitsresourcesaredevotedtothatlineofbusiness,andtheneedforre‐deploymentofits911assetstoemergencyIFTsbecomeslesslikely.Overall,however,stakeholdersindicatethattheemergencyIFTpolicyhasnotproventobeasignificantissueforemergency/911deploymentinVenturaCounty,thoughwerecommendthatcontinuedvigilancebemaintainedonthisissue.

Asfornon‐emergencyIFTs,asidefromtheemergencyconditionsmentionedabovewhicharetreatedasemergenciesforresponsetimeandcontractcompliancepurposes,therearenopublishedoraccepteddatawhichofferanyclinicalsupportforimprovedpatientoutcomesbywhichtojustifywhatwouldsurelybecostlyNET/IFTresponsetimestandards.Finally,totheextentsuchstandardswereimposed,theywouldessentiallyconstituteasubsidytofacilitiesintermsofimprovingtheirthroughputbyimposingcostlyperformancestandardsonIFT/NETtransportproviderswherethereisnoevidenceofuniformlyapplicableclinicalbenefit.

ResponseTimesasaMeasurementofEMSSystemQualityandAccountability

EMSoversightrequiresthatLEMSAsensurethattheircontractedambulanceserviceprovidersareheldaccountableforprovidingresponsivequalityserviceforthepeopletheyarecontractedtoserve.Historically,theprimarytoolEMSsystemsusefordeterminingandmeasuringperformancehasbeenestablishingresponsetimerequirementsandimposingfinesforfailingtomeetthoserequirements.ThisistheprimarytoolthatVCEMSAusestomeasureandensureEOAproviderperformancepursuanttotheexistingcontracts.However,researchhasshown,thatexceptforafewpatientconditions,quickerresponsetimesdonotequatetobetterpatientoutcomes.

ThegoalofanEMSsystemshouldbetoimprovetheoutcomesofthepatientsit

serves.Yet,theliteraturesuggeststhatthereisnocorrelationbetweenquickerresponsetimesandimprovedpatientoutcomesformostpatientconditions.Someofthestudiesoverthelastquarterofacenturythatsupporttheconclusionthatquickerresponsetimesformostpatientconditionsarenotindicativeofimprovedpatientoutcomesaresummarizedhere:

A2002study,conductedinametropolitancountywithapopulationof

620,000,examinedthecorrelationbetweenspecifiedresponsetimesandsurvivalinanurbanEMSsystem.TheEMSsystememployedasingletierresponseattheALSlevelanda90%fractileresponsetimespecificationof10:59minutesforPriority1(emergencylife‐threatening)callsand12.59minutesforPriority2(emergencynon‐life‐threatening)calls.AllstudiedcallsresultedinpatienttransportstoaLevel1traumacenter.Thereviewcovered5,424transports.Seventy‐onepatientsdied,butthestudyfoundnosignificantdifferenceinmedianresponsetimesbetweensurvivorsandnon‐survivors.Responsetimesequaltoorlessthan5minuteswereassociatedwithimprovedsurvivalwhencomparedtoresponsetimesexceeding5minutes.Thestudy’sconclusionwasthat“changingthesystem’sresponsetimespecificationstotimeslessthan[10:59minutesforPriority1callsand12.59minutesforPriority2calls],butgreaterthan5minutes,would[not]haveanybeneficialeffectonsurvival.”159

Aretrospectivecohortstudypublishedin2005evaluatedtheeffectofparamedicresponsetimeonpatientsurvivaltohospitaldischarge.Thepatientsweretransportedtoasingleurbancountyteachinghospital.Thestudyrevealedthat“aparamedicresponsetimeof≤8minuteswasnotassociatedwithsurvivaltohospitaldischargeaftercontrollingforseveralimportantcofounders,includinglevelofillnessseverity.However,asurvival

159Blackwelletal.,Responsetimeeffectiveness;comparisonofresponsetimeandsurvivalinanurbanemergencymedicalservicessystem,9AcademyofEmergencyMed.,(2002).

benefitwasidentifiedwhentheresponsetimewas≤4minutes.”Further,whenonlymedicalnoncardiacarrestpatientswereconsideredtheeffectofeventhe≤4minuteresponsetimewasnotsignificantlyassociatedwithsurvivaltohospitaldischarge.Responsetimeconsideredwastheintervalfromtheinitiationofthe911calltothearrivaloftheambulanceatthescene.160

In2006,theresultsofastudywerepublishedexamining20paramedic

accountsoftheeffectsonpatientcareandontheirownhealthandsafetyinanefforttorespondwithin8minutesofdispatchincasesinvolvingprehospitalthrombolysis.Theconclusionreachedwas“[t]he8‐minuteresponsetimeisnotevidence‐basedandisputtingpatientsandambulancecrewsatrisk.”161

Astudypublishedin2009conductedareviewofmortalityofandthe

frequencyofcriticalproceduralinterventionsperformedon373Priority1patients.Thestudywasconductedinacountyinwhichasingle‐tieredALSresponsetimelimitof10:59minuteswasimposedforPriority1calls.Responsetimeconsideredwastheintervalbetweenwhentheaddressandchiefcomplaintwereverifiedorat30secondsaftercallreceipt,whicheverwaslessandthearrivaloftheambulanceatthescene.Thestudyfoundthatforthose373Priority1patients,patientswhowaitedlongerthan10:59minutesforanambulance,whencomparedtopatientswhodidnotwaitlongerthan10:59minutes,experiencedbetweena6%increaseanda4%decreaseinmortality.Thestudyconcludedthat“[n]eitherthemortalitynorthefrequencyofcriticalproceduralinterventionsvariessubstantiallybasedon[a]prespecified[advancedlifesupportresponsetime].”162

Aone‐yearretrospectivestudypublishedin2012evaluatedresponsetimes

in7,760casestodeterminewhetheran8‐minuteEMSresponsetimewasassociatedwithmortalityattimeofhospitaldischarge.Responsetimewasdefinedas911callreceipttoALSunitarrivalonscene.Thestudyfocusedonadultswithalife‐threateningeventasassessedatthetimeofthe911call.Forpatientswhohadaresponsetimeof8minutesormore,7.1%died,whileforpatientswhohadaresponsetimeof7:59minutesorless,6.4%died.

160PeterPonsetal.,ParamedicResponseTimes:DoesitAffectPatientSurvival?,12AcademicEmergencyMedicine,(2005).161LPrice,Treatingtheclockandnotthepatient;ambulanceresponsetimesandrisk,15QualitySafetyinHealthCare,(2006).162Blackwelletal.,Lackofassociationbetweenprehospitalresponsetimesandpatientoutcomes,13JournalPrehospitalEmergencyCare,(2009).

Thosewhoconductedtheresearchconcludedtherewas“[questionable]clinicaleffectivenessofadichotomous8‐minuteALSresponsetimeondecreasingmortalityforthemajority...[n]otsuggest[ing]thatrapidEMSresponseisundesirableorunimportantforcertainpatients.”163

Theresultsofanotherstudydesignedtodeterminetheinfluenceofshorter

ambulanceresponsetimesonpatientoutcomeswerepublishedin2013.ThestudywasconductedinanEMSsystemcoveringbothurbanandruralareas.ItreviewedresponsestoPriority1dispatchesforpatients13yearsofageorolderinvolvingmotorvehiclecrashinjuries,penetratingtrauma,difficultybreathing,andchestpaincomplaints.Thereviewcovered2,164transports,569ofwhichweretransportstoatraumacenter.Thestudyfoundthat“[i]ncasesseenatamajortraumacenter,longerresponsetimeswerenotassociatedwithworseoutcomesforthediagnosticgroupstested.”164

A2016studyof503ambulanceresponsetimesforpeople65yearsofageor

olderwhohadfallentothefloorfoundthat8%ofthemdiedwithin90days,butthatthosewhodiedwithinthatperioddidnotwaitsignificantlylongerforanambulancethanthosewhosurvivedwithinthatperiod.165

Modernhealthcareismovingtowardsthe“tripleaim”ofimprovingpopulation

health,improvingtheexperienceofcare,andreducingthepercapitacostofhealthcare.166Oneofthedrivingforcesbehindthismovementistheadoptionofevidence‐basedrequirements.VCEMSAshouldconsiderworkingtowardtheimplementationofafullyevidence‐basedEMSsystem.WearenotsuggestingthatVCEMSAabandonresponsetimerequirementsandpenaltiesforfailingtosatisfythoserequirementsasatooltoensureprovideraccountabilityandresponsivenesstocustomerneeds.Yetbecausetheclinicalevidencedoesnotsupporthigh‐costfeaturessuchasstringentresponsetimestandards,wedorecommendthatthosefeaturesbede‐emphasizedandthatVCEMSAmovetowardensuringbetterEMSsystemperformancebyholdingcontractedEOAprovidersaccountablebaseduponmetricsthathaveaprovenpositiveimpactonclinicaloutcomes.

UnlikeseveralEMSsystems,theVenturaCountyEMSsystemnotonlypenalizesthesystem’scontractedambulanceserviceprovidersforfailingtomeetresponsetimestandards,butalsorewardsthemforexceedingresponsetimerequirements.Itdoesthe

163IanBlanchardetal.,EmergencyMedicalServicesResponseTimeandMortalityinanUrbanSetting,16JournalPrehospitalEmergencyCare,(2012).164StevenWeissetal.,DoesAmbulanceResponseTimeInfluencePatientConditionamongPatientswithSpecificMedicalandTraumaEmergencies?,106SouthernMedicalJournal,(2013).165EmilyCannonetal.,AmbulanceResponseTimesandMortalityinElderlyFallers,33EmergencyMedicineJournal,(2016).166InstituteforHealthcareImprovement,http://www.ihi.org/engage/initiatives/tripleaim/pages/default.aspx

latterbyreducingorpossiblyeliminatingmonthlypenaltiesforindividualviolationsbaseduponoverallexcellentperformanceduringthemonth.Webelievethisisastepintherightdirectiontode‐emphasizingresponsetimerequirementsforwhichcompliancedoesnotimprovepatientoutcomes.

Ontheotherhand,webelievethecontractedambulanceserviceprovidersshouldbeheldaccountableformeetingclinicalandotherstandardsundertheircontrolthatevidencehasshowndoimprovepatientoutcomes.Forexample,VCEMSAhasrecognizedthatpatientoutcomescanbeimprovedbyparamedicsusingfieldtransmissionof12‐leadECGsandSTEMIalertstoprovideearlynotificationofaSTEMItoacardiacinterventionteam.WerecommendthatVCEMSAimposefieldtransmissionof12‐leadECGsandSTEMIalertsasacontractualrequirementwhenapatientissufferingfromaSTEMIandpenalizetheproviderfornotsatisfyingthisstandard.ThisisjustoneclinicalperformancestandardVCEMSAcouldconsiderimposingasapenalizednon‐compliancemeasuretoshiftthefocusawayfrom“speed”andinsteadfocusonincentivizingpatientoutcomes.Whilethefollowinglistisnotexhaustive,werecommendthatVCEMSAshouldconsidertransitioningitssystempenaltiesawayfromresponsetimecompliancepenaltiesandtowardestablishingdisincentivesforsuchclinicalperformancedeficienciesas:

Failuretoperform12‐leadEKGonanypatientwithachiefcomplaintofchestpainorsigns/symptomsofcardiacdistress

FailuretorecognizeanapparentSTEMIona12‐leadEKGtracing FailuretoissueaSTEMIalertpriortodepartingthescenewithapatient

withanidentifiedSTEMI FailuretotransportaSTEMIpatienttoadesignatedSTEMIcenter Failuretodocumentaprehospitalstrokescoreinaccordancewithapproved

VCEMSAprotocolsonpatientswithchiefcomplaintand/orsigns/symptomsofpossiblestroke

Failuretoissueastrokealertpriortodepartingthescenewithapatientwithapositiveprehospitalstrokescore

Failuretotransportapatientwithapositiveprehospitalstrokescoretoadesignatedstrokecenter

FailuretotransportatraumapatienttoaVCEMSA‐designatedtraumacenter

Failuretonotifythereceivinghospitalofacardiacarrestpriortodepartingscene

Failuretoalertpublicsafetydispatchcentersofamasscasualtyincident(>3patients)within5minutesofarrivalonsceneatanyMCIincident

Materialnon‐compliancewithVCEMSAclinicalprotocols

WenotethatthelistofclinicalindicatorsintheStateCoreMeasuresascontainedinAttachmentAtotheVCEMSA2017QIProgramAnnualUpdate(datedAugust2018)containsmanysimilarclinicalqualityimprovementindicatorstothoselistedhere.We

believethatperformancestandardsbasedontheseclinicalcareexpectationsmakemoresense,andhaveamoredirectrelationshiptopatientoutcomes,thanresponsetimes.

RedLightsandSiren(RLS)Usage Wenotethatredlightandsiren(RLS)usageisfairlyextensiveinbothprehospitalandsomeinterfacilityemergencyresponses.VCEMSA’s2017QIPlanUpdateincorporatesthestatecoremeasures,includingRLSusageduringresponse(85%)andduringtransport(10%).Therearenostudiesthatsupportthattheuseofredlightsandsirensarelinkedtoimprovedpatientoutcomes.Infact,studieshaveshownthattheuseofredlightsandsirensisdangeroustoEMSprofessionals,thepublic,andpatients.Onestudyfoundthatredlightsandsirenswereactivatedin80percentofallcrashesinvolvingambulances.167Thissamestudywentontoconcludethatan"essentialissueverifiedintheanalysisofthesedataisthefactthattheuseoflightsorsirensoftenplacestherespondingambulanceandthecivilianpopulationatrisk."Asecondstudyfoundthat60percentofcrashesand58percentoffatalitiesinvolvingambulancecrashesoccurredwhileredlightsandsirenswereactivated.168 NationalconsensusstandardsforEMSstatethatEMSsystemsshouldstrivetoachieveRLSusagetargetsoflessthan50%duringresponseand5%duringtransport.169WerecommendthatapplicableVCEMSApoliciesthataddressorrequiretheuseoflightsandsirens(assomeexistingVCEMSApoliciesdo)besystematicallyreviewedandrevisedasappropriatetoconsiderresponseandtransporttypesforwhichRLSusecanbeeliminated.Accordingly,werecommendthattheVCEMSAmedicaldirectorandassistantmedicaldirectorestablishnewandreviseexistingpoliciesandthatVCEMSAworkwithFCCtorevisepoliciesandresponsedeterminantsregardingtheuseofRLStolimittheirusetowheremedicalconsiderationswarrantRLSuse,thatpenaltiesbeimposedfornon‐compliancewithRLSpolicies,andthatexceptionstoresponsetimerequirementsbegrantedwhenreasonsagainsttheuseofRLSoutweighextraordinarycircumstancesthatmightpreventcompliancewithresponsetimeswithoutRLSuse.

167Sanddal,etal.,AmbulanceCrashCharacteristicsintheUSDefinedbythePopularPress:ARetrospectiveAnalysis.EmergencyMedicineInternational,Vol2010,ArticleID525979(2010).168Kahn,etal.,CharacteristicsofFatalAmbulanceCrashesintheUnitedStates:An11‐YearRetrospectiveAnalysis.PrehospitalEmergencyCare,Vol.5,No.3(July/September2001).169Kupas,D.,LightsandsirensusebyEmergencyMedicalServices:abovealldonoharm,MarynConsultingunderContractwithNationalHighwayTrafficSafetyAdministration,May2017

Strengths• Robust,data‐drivenmonitoringofcurrentperformancestandards

• Goodcontractorperformanceundercurrentstandardsexceptinless‐populatedEOA4sub‐zones

Weaknesses• Primaryrelianceonresponsetimemetricsforcontractualcompliance

• SubdivisionofEOA4intosub‐zonesleadstorepsonsetimedeficienciesin3ofthe4less‐populatedsub‐zones

Opportunities• Shiftincontractualcompliancemetricsawayfromresponsetimesandtowardimplementationofclinicalperformancestandardsandmetricswhichhaveaprovenimpactonpatientcare

Threats• Responsetimefocusforpenaltyassessmentincentivizespracticeswithoutaprovenconnectiontopatientcareoroutcomes

• Overutilizationofredlightsandsiren(RLS)

SWOTAnalysis–ResponseTimes

170CriticalCareTransport Toprovidecriticalcaretransports(CCTs)171intheCounty,exceptforoneexception,agroundALSambulanceserviceprovidermustbeapprovedbyVCEMSAtodoso.TheonlyambulanceserviceprovidersthathavebeensoapprovedandhaveanactiveCCTprogramareAMRandLifeLine.172However,anentityauthorizedtoprovideCCTsoutsideoftheCountymayconductCCTsthatoriginateintheCountyaslongasthepatient’sdestinationisnotwithintheCounty.173 TobeapprovedbyVCEMSAtoconductCCTsanALSambulanceserviceprovidermustemployorcontractwitharegisterednurse(RN)tostaffCCTs.TheRNmustsatisfyseveralrequirementsandsupplementtheBLSorALSambulancecrewparticipatingintheCCT.TheRNmusthaveatleasttwoyears‐experienceinacriticalcareareawithinthepreviousthreeyears,havecurrentBLSandACLScertification,successfullycompleteanin‐houseorientationprogramsponsoredbytheCCTproviders,andhaveoneormorecertificationsspecifiedbyVCEMSAPolicyNo.507orchallengeandpasstheCounty’sMICNcertificationexamination.Inaddition,iftheambulanceserviceprovideristoprovidePediatricCCTs,anRNmemberoftheambulancecrewwouldneedtohavePALS,PEPPorENCPcertification. TherearealsorequirementsfortheRNtomaintainauthorizationasaCCTnurse.Theyincludeworkingaminimumof384hoursincriticalcarenursingunlesstheRNisemployedfulltimeasaCCTnurse,maintainingACLScertification,andmaintainingacertificationrequiredofaPediatricCCTiftheRNistoparticipateinPediatricCCTs. ForCCTstherealsorequirementsfortheCCTnurse‐staffedALSunitstoincludeequipmentinadditiontothatrequiredforanALSambulance;tohavemedicalprotocolsapprovedandsignedbyaphysicianthattheCCTRNistofollow;tohaveaPhysicianDirectororNursingCoordinatorwhohasmedicalpersonnelongoingtraining

170Unlessotherwiseindicated,theinformationprovidedunderthisheadingistakenfromVCEMSAPolicyNo.507,CriticalCareTransports.171ACCTintheCountyisnotthesameasaspecialtycaretransport(SCT)isdefinedbyMedicareregulationsat42CFR§414.605.AnSCTisdefinedbyMedicareas:“Interfacilitytransportationofacriticallyinjuredorillbeneficiarybyagroundambulancevehicle,includingmedicallynecessarysuppliesandservices,atalevelofservicebeyondthescopeoftheEMT‐Paramedic.SCTisnecessarywhenabeneficiary’sconditionrequiresongoingcarethatmustbefurnishedbyoneormorehealthprofessionalsinanappropriatespecialtyarea,forexample,nursing,emergencymedicine,respiratorycare,cardiovascularcare,oraparamedicwithadditionaltraining.”172MemofromVCEMSAtoPWW.173Id.

responsibilitiestoensurethequalityofpatientcaretransfersbyconductingpatientcareaudits,andisfamiliarwithapplicablepatienttransferlaws.SatisfactionofCQIresponsibilitiesisalsorequired. AfterallCCTprogramapprovalrequirementsaremet,andVCEMSAapprovestheCCTprogram,VCEMSAmayperformon‐siteauditsofrecordstoensurecompliancewithCCTprogramrequirements,andmaysuspendorrevokeCCTprogramapprovalifthoserequirementsarenotsatisfied. OneconcernraisedinthisassessmentistheoverallfinancialsustainabilityofCCTprogramswithinVenturaCounty,particularlygiventherelativelylowvolumeandhighcostsforthecurrentproviders.Wherenurse‐levelstaffingisrequired,thisproblemcanbeparticularlypronounced.WhilewereceivednoindicationthatanyprovidersarecontemplatingdiscontinuingtheirCCTprograms,thereisnocontractualobligationforanyprovidertomaintainoroperateaCCTprograminVenturaCounty.ThismeansanyprovidercanterminateitsCCTprogramwithoutnoticeandwithoutconsequence.

Forthisreason,werecommendthatVCEMSAconsidergrantingCCTexclusivitytoasingleproviderinVenturaCounty.174AnexclusiveCCTcontractwouldhavetheeffectofsecuringadequatevolumeforasingleprovidertoincreasethepossibilityofongoingCCTprogramsustainability.AnexclusivecontractspecifictoCCTscouldallowVCEMSAtoimplementothercontractualprotectionsandsafeguardsaswell.

Asanalternative(orinaddition)tograntingasole,exclusiveCCTcontract,we

recommendthatVCEMSAconsiderimplementingCriticalCareParamedics(CCPs)andallowingCCPstomeettheminimumcrewconfigurationforCCTsinVenturaCounty.CCP‐levelstaffingispermittedbycurrentEMSAguidelines.175Whilethisissuecontinuestogeneratesomecontroversyamongnationalorganizations,theuseofCCPsisnotinconsistentwithmajornationalstandardsontheissue,176andthereisnodefinitivedatasuggestingworsepatientoutcomeswithCCPs.WhileatleastonenationalorganizationhastakenthepositionthatanurseshouldconstituteaminimumstaffingrequirementforCCTs,177wenotethatthisorganizationdidnotsupportitsrecommendationwithanyevidence‐based,publisheddataspecifictocriticalcaretransportcrewconfigurations(anditsbibliographyincludesananonymoussource),anditsrecommendationappearsmore

174AswithourdiscussionoftheimpactofimplementingaBLSemergencytieronthegrandfatheringofEOAproviders,itwouldlikewisebenecessaryforVCEMSAtoobtainalegalopinionontheimplementationofCCTsintoagrandfatheredEOAcontractandwhetheracompetitiveprocesswouldbenecessary,and,ifso,whetherthatprocesscouldbelimitedtoCCTsonly.Inaddition,thepotentialimpactofacompetitiveCCTprocessonexistingALSEOAcontractsandtheircontinuedeligibilityforgrandfatheringshouldalsobepartofsuchalegalopinion.175California’sEmergencyMedicalServicesPersonnelPrograms,6thRev.,CaliforniaEMSAuthority,2017.176CriticalCareTransportStandards,v.1.0,AssociationofCriticalCareTransport,2016.177AirandSurfaceTransportNursesAssociation(ASTNA),StaffingofCriticalCareTransportServices,2010.

basedoneconomicprotectionofnursesthanonanyclinicalevidenceinthecriticalcaretransportenvironment.

AnothervitalreasonformakingourrecommendationtopermitCCPstaffingofCCTs

isthattheeconomicsustainabilityofthisvitallevelofserviceisenhancedwithaCCPmodel.ManyCCTsareforpatientsondripsusingIVpumpswheretheparticularmedicationmaybebeyondthescopeofatraditionalparamedic,butcouldbehandledwithinthescopeofaCCP.Ofcourse,incaseswhereadditionalpersonnelarerequiredduringtransport,suchasanurse,respiratorytherapist,physicianorotheradvancedpractitioner,arrangementscouldbemadetosupplementtheCCTcrewwithhospitalpersonnel.178IfVCEMSAdecidesnottoimplementanexclusiveCCTcontractwithasoleprovider,itshouldgiveevenstrongerconsiderationoftheCCPstaffingoption,sinceitwouldbeimportanttomanagethecoststructureofCCTsinthefaceofcontinuedlowvolume‐per‐provider.

178WearemindfulofthefactthattherearecoststhatwouldbeincurredbyhospitalstosendadvancedpractitionersonCCTtransports.However,wenotethattheultimateresponsibility–bothclinicallyandlegally–forthetransportofcriticalpatientsdoesrestwiththesendinghospital.RequiringEMScompaniestostaffCCTsatthenurselevelisunquestionablyanEMSsubsidyforhospitals,sincethehospitalbearstheresponsibilityforthecriticalcaretransferofitspatient.ThisisasubsidythatmostEMScompaniescannotaffordoverthelongtermanditthreatenstheongoingsustainabilityofCCTprograms.Therefore,ifnurse‐or‐higher‐levelCCTsaredesired(despitethelackofclinicalevidencethatpatientoutcomesarebetterwithnurseCCTsthanwithparamedicCCTs),thisportionofthecostisrightlybornebythehospital,iftheydeemitnecessarytohaveadvancedpractitionerscaringfortheirpatientduringtransporttothereceivingfacility.Asonestakeholderinterviewedforthisprojectputitsuccinctly,“EMSexiststotransportpatientsfromthefieldtothehospital.Afterthat,ithastobeacollaborativeefforttomovethehospital’spatients.”

Strengths• CCTprovideravailability;2of3EOAprovidersincountyfurnishthislevelofservice

Weaknesses• Relativelyexpensivestaffingstandardswithnoprovenpatientbenefit;forcaseswhichrequirealevelofcarebeyondthescopeofaCCP,hospitalpersonnelcanbeutilized

Opportunities• ExclusiveOperatingAreaauthorityforasingleCCTprovidertoassuresustainablevolume

Threats• InsufficientcallvolumetoensureCCTsustainabilitywithstaffingstandardsascurrentlyconfigured

• WithoutacontractedproviderforCCT,entitiesfurnishingthislevelofservicecanexitmarketatanytime

SWOTAnalysis–CriticalCareTransport

Non‐Emergency Generally,thereappearstoberelativelyminimalimpactofnon‐emergencyandinterfacilitytransportoperationson911/EMSsystemdeploymentandoperations.BecausethemajorityofIFTsarelow‐acuity,non‐emergencytransports,mostareappropriatelyhandledattheBLSlevel.Therefore,thoseunitsarededicatedtotheselow‐acuity,non‐emergencyIFTsanddonotrepresentdisplacedcapacityfor911/emergencyresponses. Ontheotherhand,whenthereareALSIFTs,thosemaynecessitatetheutilizationofambulancesfromthe911/emergencyoperationsside.Stakeholdersinterviewedindicatethatthisdoesnotplaceanunduestrainon911/emergencydeployment,and,overall,theresponsetimecompliancedataindicatethisisthecase(withthenotableexceptionofthethreeEOA4sub‐zonesdiscussedearlierinthisreport). Ordinarilynon‐emergencyvolumeprovidesasubsidyfor911/emergencydeployment.Inotherwords,manycompaniesrelyonthenon‐emergencytransportrevenueinordertofinanciallysupportthelevelofdeploymentnecessarytomeetthefractileresponsetimerequirementsinplaceinmostso‐called“high‐performance”EMSsystems.However,becauseoftherelativelyfavorablepayormixinVenturaCounty,thisislessofaconcern.Inaddition,stakeholdersinterviewedforthisprojectreportthatpaymentontheir911/emergencyvolumehasgenerallybeenmorefavorablethanthenon‐emergencyvolume,whichisatypical.

WerecognizethatALSunitsdeployedforemergencyresponsearesometimespulledtoconductIFTsthataBLSunitcouldconductifavailable.However,wehaveseennoevidencethatnon‐emergencydeploymentisaffectingcontractors’911obligations.Nevertheless,werecommendVCEMSAcontinuetomonitorresponsetimecomplianceandalsolookatpatientoutcomestoseeifthoselateresponsescausedbythepullingofALSunitsforBLS‐levelIFTsareactuallyresultinginpatientharm.

Whenaperson,asaresultofamentalhealthdisorder,isadangertoothers,orto

himselforherself,orgravelydisabled,apeaceofficer,professionalpersoninchargeofafacilitydesignatedbyacountyforevaluationandtreatment,memberoftheattendingstaffasdefinedbyregulationofafacilitydesignatedbythecountyforevaluationandtreatment,

BehavioralHealth

designatedmembersofamobilecrisisteam,orprofessionalpersondesignatedbythecountymay,uponprobablecause,take,orcausetobetaken,thepersonintocustodyforaperiodofupto72hoursforassessment,evaluation,andcrisisintervention,orplacementforevaluationandtreatmentinafacilitydesignatedbythecountyforevaluationandtreatmentandapprovedbytheStateDepartmentofHealthCareServices.179

Countypolicyprovidesthatapatientmaybetakenintocustodyif,asaresultofa

mentaldisorder,thereisadangertoselfandothersorisgravelydisabled.ACaliforniapeaceofficer,aCalifornialicensedpsychiatristinanapprovedfacility,VenturaCountyHealthOfficerorotherCounty‐designatedindividuals,cantaketheindividualintocustody,butitmustbeenforcedbythepoliceinthefield.180

Countypolicyfurtherprovidesthataminormaybetakenintocustodyif,asaresult

ofamentaldisorder,thereisadangertoselfandothersortheminorisgravelydisabled.ACaliforniapeaceofficer,aCalifornialicensedpsychiatristinanapprovedfacility,VenturaCountyHealthOfficerorotherCounty‐designatedindividuals,cantaketheindividualintocustody,butitmustbeenforcedbythepoliceinthefield.181

Ifthepatientatthecommencementoforduringambulancetransportexhibits

behaviorthatpresentsadangertothepatientormembersoftheambulancecrew,thepatientmayberestrainedverbally,physicallyorchemically.182Beforethecrewmayusephysicalorchemicalrestraints,everyattempttocalmthepatientverballyshouldbeemployed.Ifphysicalrestraintsarerequired,theyaretobesoftpaddedrestraints.Chemicalrestraintsshouldbeconsideredonlyifwhileinphysicalrestraintsthepatientengagesinbehaviorthatcouldresultinharmtothepatientorothersontheambulance.Whentransportingthepatienttotheemergencydepartmentofabasehospital,priortoarriving,thecrewshallnotifythehospitalwhenphysicalorchemicalrestraintsareusedandthecircumstancesthatrequiredthem.

TheVenturaCountyBehavioralHealthDepartment(VCBH)hasaCrisisStabilization

Unit(CSU)183,whichisafour‐beddesignatedreceivingcenterinNorthOxnardfortheassessmentofyouths6to17yearsofage,whoareonaWIC5585184applicationforacivilcommitmentholdfordangertoselforothersorhaveagravedisabilityduetoamentaldisorder,andthoseindividualsvoluntarilyreferredtotheCSUbytheMobileCrisisTeam.

179Cal.Welfare&InstitutionsCode§5150.180VCEMSAPolicyNo.705.4.BehavioralEmergencies.181Id.182VCEMSAPolicyNos.705.4and732.UseofRestraints.183TheremaininginformationprovidedundertheBehavioralHealthheadingistakenfromaDecember8,2016memofromtheVCEMSAMedicalDirectorandEMSAdministratortoambulanceproviderpersonnelreVenturaCrisisStabilizationUnit(CSU)184Cal.Welfare&InstitutionsCode§5585.

TheCSUisonlyformedicallystableclientsinurgentcrisisduetoamentaldisorder,andwhoseneedsmaybemetinlessthan24hours.

LawenforcementoraVCBHcertifiedclinicianmaycontactFCCatadesignated

phonenumbertorequestanambulancetransportoftheindividualtotheCSU.Theyaretoaskfora“JuvenileBehavioralTransport.”However,beforerequestingsuchtransporttheyaretoconductamedicalscreeningoftheindividualandcontacttheCSUtodeterminebedavailabilityandtosecureauthorizationforthetransfer.

IftheindividualasassessedbythelawenforcementofficerorVCBHcertified

clinicianisinanemergencysituationorhasapotentiallifethreateningcondition,thecallistobedispatchedtotheambulanceasanormalEMSresponseandwiththerequestthattheindividualbetransportedtothenearestappropriateemergencydepartment.However,theambulancecrewistoscreentheindividualforamedicalcondition,eveniftheambulanceisdispatchedtotransporttheindividualtotheCSUand,ifthecrewmakesfindingsestablishingamedicalconditionrequiringtransportoftheindividualtoanemergencydepartment,thecrewshalltransporttheindividualtoanemergencydepartment.

EOAproviderambulancesareoftenusedtotransportmentalhealth/behavioral

patients.Whentheseambulancesareinvolvedthepatientistobetransportedtothemostaccessibleemergencydepartmentformedicalassessmentandclearancepriortoapprovalforadmissiontoapsychiatrichospital.However,stakeholdershavereportedthistobeacriticalissueinVenturaCounty,onewhichhassignificantimpactonEMSdeploymentgiventhesubstantialresourcesbeingconsumedformentalandbehavioralhealthtransports.Onestakeholderreportedthatthisissueposes“thebiggest,mostacutethreattotheEMSsystem,”addingthatitdevotesanaverageof11unithoursperdaytomentalhealthtransports.Stakeholdersnotedthatsomeofthesetransportsinvolvelong‐distancedestinations(includingsomeinNorthernCaliforniaandNevada)duetobedunavailabilityinSouthernCalifornia,placingunitsoutofserviceforprolongedtimes.

Stakeholdersalsonotedthatasubstantialnumberofthesetransportsoccurinthe

eveninghours,addingtothepossibilityofcrewfatigue.Wewerealsotoldthatmanyofthesepatientsaremedicallycleared,andthatambulancesareoftenutilizedduetothefactthatmentalhealthvansarenolongerinserviceintheCounty.Wenotethatinsomecases,providersmaybepartytofacilitycontractswhichmayobligatethemtoperformcertaintransportsfortheirfacilitypartners.Ananalysisofsuchcontractsisbeyondthescopeofthisassessment.Therefore,itmaybeincumbentupontheEMScompaniesintheCountytoaddressthisintheircontractsandbusinessarrangementswithfacilities.185However,wewerealsotoldthatwhenthisissuehasariseninthepast,andcomplaintsaboutambulance

185Forexample,onestakeholderreportedthattheyplantoeliminatementalhealthtransportsoccurringafter8:00p.m.fromtheircontractualratescheduleandplantochargefull,County‐allowedretailratesforsuchtransports.

availabilityformentalhealthtransportshavebeenmadetothelocalEMSagency,VCEMSAhasbeenperceivedasadvocatingforthehospitalsinsteadofindicatingthatthisisnotanEMSsystemissue.Werecognizethatthishasbeenaperplexingandlargelyintractableissueforbehavioralhealth,EMS,electedofficialsandhealthcarepolicymakersthroughoutCalifornia,buttheEMSsystemcannotbethefailsafeorthe“safetynet”forinterfacilitytransfersofotherwisestablebehavioralhealthpatientsattheexpenseofmaintainingcapacityfor911emergenciesinthecommunitiesofthestate.

WerecommendthatVCESMAensurethatitspositiononthisissueaboveall

preservestheintegrityoftheEMSsystemratherthanensuringthereadyavailabilityofambulancesformentalhealthtransportsforpatientswhocanoftenbetransportedsafelybymeansotherthanambulance.

ThereareseveralparatransitservicesintheCounty.Theyinclude,butarenotlimitedto,AgouraHillsDial‐A‐Ride,CamarilloAreaTransitDial‐A‐Ride,GoAccess,HelpofOjai,MoorparkCityTransitDial‐A‐Ride,SimiValleyTransitADA/ParatransitDial‐A‐Ride,ThousandOaksTransitDial‐A‐RideandValleyExpress.Amongotherparatransitservices,theyoperateaparatransitserviceforpeoplewithdisabilities.Alloftheseprogramsoperatetransportationvehiclesthatareequippedwithwheelchairliftsorramps.Thevehiclesarenotdesignedtoprovidehighlypersonalizedservicesuchasescortingpassengerswhocannotbeleftunattended,oroperatingacustomer'selectricmobilitydevice.Personalcareattendantsareallowedtoridewithpassengerswhorequirepersonalcare,toprovideassistancetothem.Reservationsaretakenthedaypriortotransport.Weidentifiednoentitiescurrentlyprovidingambulette(stretchervan)servicesbasedintheCounty.

Paratransit/Ambulette

Strengths•Competitivenon‐emergencytransportmarketapeparstobemeetingdemandoffacilitiesandpatients•Contractorsreportthatnon‐emergencyutilizationnotplacingunduestrainonemergencydeployment,whichisgenerallysupportedbythedata

Weaknesses•Stakeholdersreportthatbehavioralhealthtransportsareconsumingexcessiveunithoursandthatambulanceresourcesarebeingutilizedmerelyduetounavailabilityofmoreappropriateresources

Opportunities•Deregulatenon‐emergencyratestoallowopenmarkettofunctionasintended

Threats•Inappropriaterelianceonambulanceresourcesforbehavioralhealthtransportcanresultinicnreasedsystemcostandmayrequiresubsidy

SWOTAnalysis–Non‐Emergency

FindingsandRecommendations TheVenturaCountyEMSsystemis,overall,anoutstandingsystemwithagreatmanystrengths.ItcomparesfavorablytoothersystemswehaveevaluatedinCaliforniaandnationally.AmongthemajorstructuraladvantagesenjoyedbytheVenturaCountyEMSsystemare:

‐ Relativelyaffluentandwell‐insuredpopulationbase‐ CentralizeddispatchwithEMD‐ Experiencedandstablecontractedproviderswithlongstanding

communityties‐ Excellentcooperationbetweenprovidersandpublicsafetyagencies‐ Outstandingintegrationofprehospitalandhospitalentities‐ Arobustqualityimprovementprogramwithstrongclinicalfocus‐ Relativelyshortpatientoffloadtimes‐ ExperiencedandaccessibleLocalEMSAgencystaffwhichmaintainsopen

communicationswithstakeholders‐ TwoofCalifornia’scommunityparamedicinepilotprogramsaretaking

placeinVenturaCounty

BecausethefundamentalcomponentsofarobustEMSsystemarealreadyinplaceinVenturaCounty,ourrecommendationsshouldnotbeseenascriticismsofthisoutstandingsystem,butmoreas“nextlevel”recommendationsdesignedtobenefitthesystem,itsstakeholdersanditspatientsinthecomingdecade.

Majorrecommendationsmadeinthisreportaresummarizedatthebeginningofthisreport.Thefollowingisasummaryofalltherecommendationscontainedinthisreport,intheordertheyarepresentedinthereport:

‐ EliminateLevelI/LevelIIparamedicpolicy(p.21)‐ AdoptCMSambulancecostdatacollectionmethodologyforcontractor

costaccountingandreporting(p.27)‐ Eliminatenon‐emergencyratesfromrateregulationpolicytoallownon‐

emergencymarkettofunctioninatruecompetitivemanner(p.30‐31)

Discussion

SummaryofAllRecommendations

‐ Requireannualoutsidebilling/codingauditsofcontractedproviders(p.32)

‐ RequireeachcontractortoimplementacomplianceprograminaccordancewithOIGguidance(p.32)

‐ Continued,specificengagementoffireservicestakeholdersregardingappropriatelevelsofcontractorinvestmentinEMSsystem(p.40‐41)

‐ Addpenaltiesandeconomicincentivesthatpromoteclinicalperformanceandsafety(p.44,88)

‐ ExcludefromlocalEMSagencyoperatingbudgetanyrelianceonproviderpenaltiesandbudgetonlypredictablecost‐basedfeesforcostsdirectlyrelatedtosystemoversight,contractadministrationandcoststhatdirectlybenefitcontractedproviders(p.44)

‐ EliminateincentivestructureforseparateEOA4sub‐zonesandallowforincentivestobeearnedinEOA4onlyifresponsetimecomplianceismetintheEOAasawhole(p.54)

‐ ImplementBLStransporttierforlowacuity911calls(p.56‐58)‐ LimitEMSpractitionershiftlengthstonomorethan24hours(p.59)‐ ImposeothershiftrequirementsreasonablydesignedtoeliminateEMS

practitionerfatigueasasignificantworkimpediment(p.61)‐ ContinueassessmentofCountyneedsthatcanbeservedbycommunity

paramedicineprogramsandalsointegratelessonslearnedinparamedicpracticewherefeasible(p.67)

‐ Establishatargetdateforrequiringcontractorparticipationinhealthinformationexchange(p.72)

‐ ConsiderIAEDACEaccreditationforFCCsecondaryPSAP(p.75)‐ ConsiderOmegaprotocolandECNSimplementationaspartofdispatch

system(p.75)‐ Implementclinicalmetricsaspenaltydisincentives(p.88)‐ SystematicallyreviewandupdateVCEMSApoliciesregardingRLSuse(p.

89)‐ Reviseexistingpoliciesanddispatchresponsedeterminantstolowerthe

rateofRLSusebydisallowinguseofRLSexceptwhenbaseduponmedicalconsiderationsthatwarrantRLSuseandimposepenaltiesfornon‐compliance.MakepolicyanddispatchrevisionsthatworktowardachievementofnationalbenchmarksofRLSuseof<50%duringresponseand<5%duringtransport(p.89)

‐ GrantCCTexclusivitytoasingleprovider(p.92)‐ ImplementCriticalCareParamedics(p.92)‐ Continuetomonitorresponsetimecomplianceandalsolookatpatient

outcomestoseeifthoselateresponsescausedbythepullingofALSunitsforBLS‐levelIFTsareactuallyresultinginpatientharm(p.95)

‐ IncludeaprovisioninnewcontractsexpresslypermittingVCEMSAtoenterintoacompetitiveprocurementprocessintheeventVCEMSAconcludesthatexistingcontractorsarenotmeetingtheneedsoftheEMSsystem(p.104)

OneofthethresholdissuesfacingVCEMSAishowitshouldapproachthenextcontractingcycle.InCalifornia,alocalEMSagencyessentiallyhasthefollowingoptions:

1) MaintainEOAsbycontractingwithexistingproviderswhoareeligiblefor

grandfatheringunderHealthandSafetyCode§1797.224

2) ConductacompetitiveprocurementprocessinsomeorallexistingEOAs–orcreateasinglenewEOAornewEOAs–andenterintoexclusivecontractswithnewprovidersselectedasaresultofthecompetitiveprocess(notethatVCEMSAcanalsoincludenon‐emergency,interfacilityandCCTservicesinitscompetitiveprocess(es)ifitsochooses)

3) OpenthemarketinsomeorallEOAssothatanyqualifiedproviders

whichenterintocontractswithVCEMSAcanprovideservices

OptionsforFutureContractingCycle

Alloftheseoptionshavebenefitsanddrawbacks.Wesummarizesomeoftheminthistable:

Table13:BenefitsandDrawbacksofContractingOptions

Option

Benefits

Drawbacks

Contractwithexistinggrandfatheredproviders

‐Maintainscontinuity‐Avoidsdisruptionandpossibilityof“lameduck”providers‐Avoidsnecessityofcostlyprocurementprocess‐Assuressufficientcallvolumeforproviders

‐Deprivespotentiallyqualifiednewcontractorsfromparticipatinginthesystem‐CannotredrawEOAboundariesandmaintaingrandfatheringeligibility

Conductnewcompetitiveprocurementprocess

‐Allowspotentiallyqualifiednewproviderstoparticipateinsystem‐Mayimprovepricesensitivityamongcontractedproviders‐Ensuressufficientcallvolumeforproviders‐CanredrawEOAboundariesorformsingleEOAifdesired‐CanexploreotherEMSdeliverymodelsbasedondesignofanRFP

‐Costly‐Countyforeverforfeitsitsgrandfatheringoption‐Potentiallycontroversial‐Maynotresultinselectionofnewprovidersatconclusionoftheprocess

Becomeanopen,competitivemarket

‐Allowsanyqualifiedprovidertoparticipate‐MayincreaseavailableresourceswithinCounty‐Mayfostergreaterpricesensitivity

‐Maynotprovidesufficientvolumeforprovider(s)‐Providersundernoobligationtoprovideservices,canexitmarketatanytime

Basedonallconsiderations,itisourconclusionthatVCEMSAshouldnegotiaterenewedcontractswiththeexistingproviderswhoareeligiblefor“grandfathering.”Thisrecommendationisbasedonseveralconclusions.Firstandforemost,theincumbentprovidersaresubstantiallymeetingexistingperformanceexpectationsandtherewasnosignificantstakeholdersupportforabandoningthegrandfatheredprovidersinfavorofacompetitiveprocurementprocess. AnothersignificantfactoristhattheCaliforniaEMSsystemonastatewidebasisispresentlyinastateofsignificantupheavalanduncertainty,andrecentcompetitive

procurementsundertakenbyotherlocalEMSagencieshaveincurredsignificantoppositionandunexpectedaddedexpenseduetothisunsettledenvironment.Inaddition,inanEMSsystemthatisfunctioningwell,asVentura’sis,thetimeandcostofacompetitiveprocessislikelynottoresultinabettersystemthanwhatVCEMSAcanachievebynegotiatingnewcontractswiththeexistingproviders. Finally,onceanEOAinCaliforniaiscompetitivelybid,itislikelythatgrandfatheredeligibilityisthereafterlostandcannoteverberestoredinthefuture.ThisassessmentrevealednocompellingreasonstoforeverabandonthegrandfatheredstatusthattheVenturaCountyEMSsystemenjoys.Wedo,however,recommendtheinclusionofprovisionsinthenextcycleofprovidercontractswhichexpresslypermitsVCEMSAtoenterintoacompetitiveprocessfortheselectionofnewcontractorsanytimeVCEMSAconcludesthatexistingcontractorsarenoteffectivelymeetingtheneedsoftheEMSsystem,thoughwebelievethethresholdforexercisingsuchanoptionshouldbequitehighandshouldnotbeutilizedunlessabsolutelynecessary.

Appendices

AppendixA

ProjectDocumentRequestList

EMS System Review

County of Ventura

Initial Document and Data Request

January 30, 2019 *Note – all requests should be for three (3) year period unless otherwise specified

Category Requested Documents N/A Fulfilled Comments

A. Plans/Annual Reports

1 2018 Annual Report (or draft) 2 2018 EMS Plan (or draft)

B. EMS Agency Organization and Staffing

1 VCEMS organization chart 2 VCEMS staff list with areas of responsibility

C. EMS Agency QA/QI Program

1 Individual provider QA/QI plans 2 VCEMS system‐wide QA/QI plan

D. Prehospital Education and Training

1 List and descriptions of current VCEMS‐sponsored EMS education programs 2 List of VCEMS‐approved approved agency‐level training programs 3 VCEMS policies and procedures regarding EMS education and training

E. County Budget & Revenue

1 Annual VCEMS budget 2 Ventura County EMS and/or dispatch‐related budget expenditures 3 VCEMS schedule of approved charges 4 VCEMS revenues derived from providers, by the following categories: ‐Franchise fees/annual contract fees ‐Fines/penalties ‐QA/QI or other similar program fees ‐Other fees

F. Ground EMS Documents

1 VCEMS contract with each ground EOA provider (including any amendments) 2 VCEMS contracts with each first response agency (ALS and/or BLS) 3 All contracts between ground EOA providers and first response agencies 4 Any current mutual aid agreements to which any ground EOA providers are a party

G. Ground EOA Contractor Performance Documents

1 Ground ambulance response data by category: ‐ Emergency/911 calls (by dispatch level) ‐Interfacility transports ‐Non‐emergency transports

(all data should be monthly)

‐Specialty/critical care transports (SCT/CCT) 2 Transport data by above categories 3 Call declination data (all calls for which contractor was unable to respond and utilized mutual aid, by above categories) 4 Contractor self‐dispatch data (all emergency response requests received directly by EOA contractors) 5 Service mix (level‐of‐service transport data by HCPCS code for each EOA provider) 6 Emergency response time compliance data (including response time performance by month, deviations from required standards and financial penalties assessed by month) 7 Response time data for: ‐Interfacility transports ‐CCTs/SCTs ‐Non‐emergency transports 8 Average transport distance (contractor data of average loaded mileage per transport for HCPCS code A0425. If possible, include overall average loaded mileage‐per‐transport, and average loaded mileage‐per‐transport for each level of service – A0428, A0429, A0427, etc.) 9 Average total call time (contractor and/or dispatch center data measuring average interval of time responded through time available, both overall and for each level of service, if available 10 Ambulance Patient Offload Times (APOT) data 11 Transports originating at healthcare facilities (total number and percentage of total transport volume) 12 VCEMS policies and procedures regarding fines and penalties 13 Identification of fines and penalties imposed 14 Any current listing of paratransit providers serving the County and services provided 15 Policies and procedures regarding transport of 5150 patients (VCEMS and provider‐level policies) 16 Any county ordinances, laws or resolutions regarding EMS permits, operations, or other regulatory issues

H. Dispatch Documents and Data

1 List of all primary PSAPs answering 911 calls for areas within Ventura County (even if PSAP is outside of County) 2 List of all secondary EMS PSAPs (ambuolance and/or first response dispatch, including function(s) performed and agencies dispatched by each) 3 Description of EMD protocols utilized by each PSAP (including copies if non‐commercial, or any local modifications to commercial EMD protocols) 4 Identification and description of individual EOA contractor dispatch centers 5 Any contracts regarding dispatch between municipal entities and/or County/Fire for dispatch or PSAP operations within Ventura County 6 Emergency dispatch data – contractor (all 911 dispatches of EOA provider by response determinant) 7 VCEMS and provider policies on red lights and siren responses

I. Clinical Documents

1 Current ground EMS clinical protocols 2 Applicable transport destination protocols (trauma, STEMI, stroke, peds, etc.)

J. EMS Resource Inventory Documentation and Data

1 By contractor, total number of contractor transport‐capable ambulances dedicated to in‐county utilization 2 By contractor, total number of contractor transport‐capable ambulances dedicated exclusively to 911 response 3 Identification of all contractor station and substation locations (including # of ambulances garaged at each location and staffing at each) 4 Total number of contractor transport‐capable ambulances stationed out‐of‐county that are utilized for in‐county 911 response 5 Each EOA contractor’s staffing plan and/or staffing schedules 6 VCEMS ambulance staffing policies

K. Hospital Resource Inventory Documentation and Data

1 Total number of hospital‐based EDs in county (including number of facilities and estimated ED bed capacity)

2 Total number of out‐of‐county based hospital EDs that regularly serve in‐county patients (including number of facilities and estimated ED bed capacity) 3 Designated specialty hospitals serving the county (trauma, PEDS, STEMI, stroke, etc.; include LEMSA‐designated facilities as well as “verified” facilities) 4 Non‐designated specialty care facilities serving the county (behavioral health, etc.)

L. Contractor Revenue Cycle Data (Provide for each EOA provider), for previous five (5) years

1 Total billable transports by level of service (i.e., by HCPCS code) 2 Chargemaster or contractor list of retail charges, by level of service 3 Identification of payor contracts to which contractor is a party (including payor and rates, by level of service) 4 Contractor financial hardship policy and forms 5 Contractor write‐offs (including hardship, bad debt, etc.) 6 A/R aging report by payor 7 Payor mix (contractor revenues by payor, by the following categories: ‐Medicare (including fee‐for‐service and Medicare Advantage) ‐MediCal (FFS and managed care) ‐Commercial (including all non‐government FFS and managed care payors) ‐Self‐Pay 8 Net collection percentage (total and by payer, after refunds and contractual allowances) 9 Average revenue per transport (total and by level of service)

M. Contractor Financial Data

1 Provider financial reports (audited, reviewed, or compiled, as applicable) for previous 5 years

N. Special Programs (health care and HIE programs)

1 Identification and available documentation of special health care programs (i.e. community paramedicine, Nalaxone administration, stop the bleed, PulsePoint, community CPR and public access defibrillation, etc.) 2 Any health information exchange (HIE) programs operating in Ventura County 3 Special Procedures implemented to enhance efficiency i.e., Emergent Large Vessel Occlusion

(ELVO) alerts, critical incident stress management, tec.) 4 Identification of existing community paramedicine programs (pilot or ongoing) 5 Curriculum/training models for community paramedics

O. First Responders 1 List of fire departments providing first response by level(s) of service provided 2 Available first response‐specific cost data 3 Identification of funding sources for first response services (i.e., city budget, first response fees from transport providers, patient charges) 4 Total number of responses by first response agency, by level of service 5 First response time data 6 First response staffing policies

P. System Status/Move‐up Plan

1 Most current system status/move‐up plan 2 Individual provider deployment plans

Q. Communications 1 Identification of all communication systems in use (radio, redundant communications, etc.) 2 Inventory of communication assets 3 Non‐emergency and IFT communications structure

S. Critical Care Transports

1 List of providers approved to provide CCTs 2 Applicable CCT regulations, policies and procedures

T. Stakeholders

1 List of stakeholders recommended for interviews/focused stakeholder meetings (include names, titles, agency affiliation and contact information)

AppendixB

SummaryofSelectedStakeholderComments

SELECTEDSTAKEHOLDERCOMMENTS(IndividualCommenterIdentitiesWithheld)

GeneralEMSSystem

Thefieldcriteriafortheissuanceoftrauma,STEMIandstrokealertsisprettygood

VCEMSpoliciesandproceduresareexcellent Therearenomajorconcernsregardingresponsivenessandqualityof

interfacilitytransports(IFTs),criticalcaretransports(CCTs)andnonemergencytransports(NETs)

TheEMSsystemisdoinggreatwithevidencebasedpracticesforconditionssuchasSTEMIs

TheEMSsystemisrunningwell—notsureanewEMSsystemreviewisneeded MoreresourcesshouldbedevotedtoQA/QI TheStateEMSauthorityhashinderedourLEMSAandweneedmoreauthority

todothingsliketreatnotransport TheMedicalDirectorshouldhavemoreleewayindevelopingprogramsfor

treatingpatientsathome TheLEMSAruleswithan“ironfist.”“Recently,wetriedtobringsomethingto

theirattention,andtheywouldn’tevenhearusout.” PuttingtheEOAproviderserviceoutforbidwouldjeopardizewhatwe’ve

establishedandthatcouldharmpatients Responsetomasscasualtyincidentshasbeenphenomenal

MentalHealth

Mentalhealthcallsforambulancetransportstakeambulancesoutofservicetorespondtoemergenciestoomuch

Tyingupambulancesforlongdistanttransportsofmentalhealthpatientsisaparticularproblem

Thereneedstobeabettersystemtodealwithmentalhealthpatients.Thecurrentprocessplacestoomuchstrainonhospitalsandthesystem.

MoretrainingofSheriffandEMSpersonnelisneededtobetteridentify5150situations

50%ofourcallstosheriff’sofficeinvolvesomementalhealthaspect.EMS’sroleinthesecallsneedstobebetterdefined.

FireDepartments

FirefightersshareastrongEMSculture Firefightersaresatisfiedwithcentraldispatch Taxpayerswanttoseetheirtaxesatwork

Firefightersareemployedtoservethepublicandneedtobedispatchedonallemergencycallsforthepublic’sbenefit

TheEMSAgencyshouldnotbedictatingthecallstowhichfiredepartmentsrespond

Theworkingrelationshipbetweenthefiredepartmentsandtheprivateambulancecompanieswasbadatonetime,butisnowmuchbetter

Firedepartmentscanprovidefirstresponseservicesbutshouldnotbetransportproviders

ThefiredepartmentsandtheresidentsareopentoasystemrevampwheretheCityfiredepartmentsaregettingthereimbursementforambulanceservices

Thereisnoneedforfiveparamedicstobeonsceneforapatientwithabrokenankle

Skilldegradationisaconcerniffiredoesnotgettorespondandtreat Interfacilitytransfersdonotneedafire/ambulancejointresponse

EOAProviders

TheturnoverrateforambulancecompanyEMSpersonnelistoohigh Ambulancecompanyprovidersareleavingforhigherpayingfiredepartment

jobs Issuesincludepersonnelburnout,workingconditions,callloadsandnot

enoughambulancesdeployed Ifwedon’taddressworkload–24hourshifts–folkscouldleave TheCountyisdiverse.TheEMSsystemneedstomeettheneedsofallresidents Notallneedsarebeingcurrentlymet.Somepatientsneedtowaittoolongfor

anambulance ThemorefieldprovidersintheEMSsystemcauseslowerskillproficiencydue

toprovidersrespondingtofewercalls DifficultforLevel2paramedicsinruralareastomaintainLevel2statusand

theyhavetocontinuouslyrotateinandoutoftheruralareatomaintainLevel2statusandgetmorecalls

Responsetimepenaltiesshouldnotbeimposedonapercallbasis Patientsreceivenorealbenefitfromresponsetimepenalties “Ilikethatwehaveaparamediconboardourambulances,youneverknowif

thepatient’sconditionisgoingtochange.” Wehavetoomanyparamedics—mostALSresponsesaren’tnecessary.More

BLSunitsshouldberun Ambulanceresponsesthatdonotresultinatransport,andthereforepayment,

isabigissue RecommendremovaloftheLevel1andLevel2paramediccategoriesandjust

haveparamedics

Dispatch

About20%ofdispatchesgetdowngraded Ambulancesaresentoncallsthatarenotlikelytoresultinanambulance

transport Thereisagreatneedtoaddressdryruns ThetimefromcallreceiptbyaprimaryPSAPtoitstransfertoasecondaryPSAP

cannotcurrentlybetracked ECNSorOMEGAprotocolstopermitreferraltoresourcesotherthan

ambulancescouldbebeneficialwhencallintakedoesnotwarrantanambulanceresponse

Tieredresponse—wehavetodoit.It’sthewaiveofthefuture.Idon’tknowhowwecan’tdoit.

Don’tbelieveatieredresponsemodelworksfortheCounty’sEMSsystem Forcriticalcalls,Countycanensurethattheclosestunitisalwaysdispatched

eveniftheunitisnotusuallyfirstdueinthearea Measuresneedtobetakentoaddresspatientswhoabusethe911system HavinganurseintheCommunicationCenterisamustforthefuture

Hospitals

HospitaloftenhastoprovideitsownRNsforCCTs HospitalsfrequentlyrequestALSIFTswhenALSisnotneeded,andthiscreates

911responseproblems Diversionisalargeproblem EOAprovidersshouldreceivemoreinformationfromhospitalsonpatient

outcomes ItiseasierforsomeofthelargerhospitalstocomplywiththeLEMSA’spolicies

CommunityParamedicine

Thecommunityparamedicinepilotprogramshavebeeneffective Communityparamedicine–weknowtheyaresavingtheCountymoney,butwe

needtodemonstratethat.Weneedtoturnthisfrompilotintopermanentprogram

ThehomelessareadrainontheEMSsystem.Thesituationcanbesolvedbycommunityparamedicine

AppendixC

ProjectBibliography

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Binstein,A.(2007,July1).ReplaceorReconditionEmergencyVehicles?RetrievedfromGovernmentFleet:https://www.government‐fleet.com/145667/replace‐or‐recondition‐emergency‐vehicles

Blackwell,T.H.Etal(2008).ResponseTimeEffectiveness:ComparisonofResponseTimeandSurvivalinanUrbanEmergencyMedicalServicesSystem.AcademicEmergencyMedicine,288‐295.

Blackwell,T.H.Etal(2009).LackOfAssociationBetweenPrehospitalResponseTimesAndPatientOutcomes.Prehospitalemergencycare,444‐450.

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Breen,N.Etal(2000).ANationalCensusOfAmbulanceResponseTimesToEmergencyCallsInIreland.JAccidEmergMed,392‐395.

Brollini,J.(2018,August22).Prop.11WillSkirtPayforAmbulanceWorkersandPutThematRisk.TheSanDiegoUnion‐Tribune.

Brown,L.Etal(2000).DoWarningLightsAndSirensReduceAmbulanceResponseTimes?PrehospitalEmergencyCare,70‐74.

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ContraCostaHealthServices.(2018).AmbulanceRatesEMS.RetrievedfromContraCosta:http://cchealth.org/ems/ambulance‐rates.php

Craig,A.M.Etal(2010).Evidence‐BasedOptimizationOfUrbanFirefighterFirstResponseToEmergencyMedicalServices9‐1‐1Incidents.PrehospitalEmergencyCare,109‐117.

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HealthCareComplianceAssociationOIG.(2017,January17).MeasuringComplianceProgramEffectiveness:AResourceGuide.Washington,DC,UnitedStatesofAmerica.

Hinchey,P.Etal(2007).LowAcuityEMSDispatchCriteriaCanReliablyIdentifyPatientsWithoutHigh‐AcuityIllnessorInjury.PrehospitalEmergencyCare,42‐48.

Hutchison,A.W.Etal(2009).Prehospital12‐LeadECGtoTriageST‐ElevationMyocardialInfarctionandEmergencyDepartmentActivationoftheInfarctTeamSignificantlyImprovesDoor‐to‐BalloonTimes.Circulation:CardiovascularInterventions,528‐534.

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MateoCounty,(2018,July18).NoticeOfRequestForProposalsOpportunityEmergencyAmbulanceServicesWithAdvanceLifeSupport(Als)AmbulanceTransports.

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Myers,J.B.Etal(2008).Evidence‐BasedPerformanceMeasuresForEmergencyMedicalServicesSystems:AModelForExpandedEmsBenchmarkingAStatementDevelopedByThe2007ConsortiumU.S.MetropolitanMunicipalities’EmsMedicalDirectors.PrehospEmergCare,141‐151.

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