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FinalReport

ASSESSMENTOF

EMERGENCYMEDICALSERVICESIN

SUBLETTECOUNTY,WYOMING

June2016

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TableofContents

ExecutiveSummary 3I. Introduction&AssessmentMethodology 6II. OverviewofSubletteCounty 7III. OverviewoftheEMSSysteminSubletteCounty 12IV. DescriptionofSubletteCountyEMS 16 V. KeyObservations 21 VI. Recommendations 32

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ExecutiveSummarySafeTechSolutionsspentthreemonthsinthespringandsummerof2016studyingtheEMSsysteminSubletteCounty,Wyoming.Thisstudyfocusedonthelong-termsustainabilityandreliabilityofSubletteCountyEMS.Thestudyincludedasitevisit;approximately20interviewswithkeystakeholders;extensiveresearchaboutSubletteCounty,theSubletteCountyRuralHealthCareDistrictanditsEMSsystem;thoroughanalysisofWyomingAmbulanceTripReportingSystemdata;andscrutinyofthefinancialandoperationaldataforSubletteCountyEMS.Basedonitsstudyandobservations,SafeTechSolutionsoffersthefollowingrecommendationstoSubletteCounty,SubletteCountyRuralHealthCareDistrict,andSubletteCountyEMS:1.CreateavisionandplanforEMSsuccessandsustainabilitythatincludesthefollowingelements:

• Adescriptionofthelevel,quantityandqualityofEMSneeded,wantedandfundable.• PrioritizationofEMSaboveotherlocalmedicalofferings.• ApowerfulandreassuringstorytotellaboutEMS.• Maximizationoftheuseofground-basedEMS.

2.StrengthentheEMSorganizationalstructureandleadershipteamtosupportsustainabilityby:

• ClarifyingtheEMSreportingstructureforEMSwithinthehealthcaredistrict.• InvestingintheEMSleadershipteam’sknowledgeofEMSoperationsandfinance

andexposuretobestpractices.• Ensuringtheleadershipteamiscommittedtotheorganizationanditsfuture.

3.Strengthenoperationalandfinancialefficiencybynarrowingthegapbetweenexpensesandrevenuesby:

• Reducingthenumberofdeployedresourcestomatchanticipatedcallvolume.• Developingandimplementinganewcallschedulethatreducesovertimeandissafe

andhumane.• Raisingrevenuebyincreasingbillingrates,capturinglostrevenueandensuringall

patientsaretransportedtoahospital.• Developingacapitalvehiclereplacementplan.• Usingairmedicalresourcesefficiently.

4.Usedatatodrivedecisionsby:

• Ensuringthatessentialdataisreliable,complete,andconsistentwithotherdatasources,suchasWATRS,billing,andthelocalcommunicationcenter.

• Developingadashboardthatincludeskeyperformanceindicatorscriticalforsuccess.

• Regularlymeasuringemployeeengagement.

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5.Continuetodevelophealthcareintegrationby:

• ExploringwaystoexpandtheuseofEMSintonon-911serviceswiththegoalofcreatingatrulyintegratedcaremodel.

Recommendationsarebasedonthefollowingkeyobservations.1.EMSisavitalandessentialelementofhealthcareandqualityoflifeinSubletteCounty.2.Asoperatingtoday,SubletteCountyEMSisnotsustainable.3.SubletteCountyEMSpossessesmanyelementsofaprogressiveandsustainableruralEMSsystem.

• 3A.BoththehealthcaredistrictandEMSdepartmenthavecapableleaders.• 3B.TheEMSDirectorhasgoodbusinessandpeople-managementskills.• 3C.TheEMSsystemisimplementingdynamicdeploymentstrategies.• 3D.TheEMSsystemprovidesahighlevelofqualityclinicalcare.• 3E.EMSisadequatelyintegratedintothelocalhealthcaresystem.• 3F.SubletteCountyEMShasaknowledgeableandcompetentbillingdepartment.

4.SubletteCountyEMSfacesmajorchallengesassociatedwiththelocaleconomyanditspositionwithinthehealthcaredistrict.

• 4A.SubletteCountyanticipatessharpreductionsintaxrevenues.• 4B.EMSwillbeaffectedbychangeswithinthehealthcaredistrict.• 4C.PerceptionsaboutthehealthcaredistrictmayhurtEMS.• 4D.SubletteCountyEMSlacksaclearvisionandstrategicplan.

5.SubletteCountyEMSlacksclaritywithregardtoitsstructure,leadership,workforceanddatagathering.

• 5A.Thehealthcaredistrictreportingstructureneedsclarification.• 5B.Departmentaljobdefinitionsandreportingstructureareweak.• 5C.ThecurrentEMSleaderdoesnothavedeepoperationalandfinancialexperience

inEMS.• 5D.EMSemployeeengagementisprecarious.

6.SubletteCountyEMSisnotoperatingefficientlynormaximizingitsrevenuefrompatientbilling,anditmayhavelittleornoincentivetodoso.

• 6A.Thecurrentschedulingsystemisnotefficient.• 6B.TheEMSsystemhastoomanyresourcesforitscallvolume.• 6C.Billingratesforpatienttransportsaretoolow.• 6D.EMSislosingpotentialrevenuebytransportingpatientstodistrictclinics.• 6E.EMSdoesnothaveacapitalreplacementplan.• 6F.Thefrequentuseofairmedicalresourcesmaynotbeclinicallynecessaryor

operationallyefficient.

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• 6G.TheongoinghealthcaredistrictsubsidyoftheEMSservicemightserveasadisincentiveforimprovedorganizationalefficiencyandrevenuemaximization.

7.SubletteCountyEMSisfailingtodoanadequatejobofcollectingdataandanalyzinginformationaboutitsEMSsystem.

• 7A.SubletteCountyEMSdoesnothavebasiccalldata,andthedatathatitdoeshaveisatoddswithstate-reporteddata.

• 7B.SubletteCountyEMSdoesnothavedefinedkeyperformanceindicators(KPIs).• 7C.SubletteCountyhasnoformalorinformalprocessformeasuringEMSemployee

engagement.• 7D.SubletteCountyhasnoformalmeasurementofEMScustomersatisfaction.

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I.Introduction&AssessmentMethodologyLikemanyruralcountiesinAmerica,SubletteCounty,Wyoming,facesgrowingchallengesinmeetingitsout-of-hospitalemergencymedicalcareneeds.TheawarenessofthesechallengesandthedesiretoovercomethemledSubletteCountyRuralHealthCareDistricttofileanapplicationwiththeWyomingOfficeofEMSandTraumaforgrantmoneytofundanassessmentofEMSinSubletteCounty.SafeTechSolutions,LLP,wascontractedtoconducttheassessment.SafeTechSolutionsisanEMSconsultingfirmwithextensiveexpertiseevaluatingEMSorganizationsandassistinginthedevelopmentofruralambulanceservicesandsystems.SafeTechSolutionshasworkedwithruralWyomingEMSagenciesthroughitsEMSLeadershipAcademyandinassessmentsinSweetwater,Fremont,CampbellandCarbonCounties.ThegoalsoftheSubletteCountyassessmentprojectareto:

• Evaluatethesustainability,reliabilityandlong-termsurvivabilityofEMSinthecounty,includingthecurrentstructureandoperationsofSubletteCountyEMS;

• Validatesystemcomponentsthatareworkingwell;and• Makerecommendationsforchangeandimprovement,asneeded.

Theassessmentfocusesonlocalneeds,currentoperations,systemdesignandavailablesupportingresourceswithaneyeonsustainability.Thescopeoftheassessmentislimitedandwasnotanauditofoperations,financesorclinicalperformance.Airmedicalserviceisnotpartoftheassessment.MethodologySafeTechSolutions’assessmentteamusedaprocessofinquiryandinvestigationthatcapitalizesonthefirm’sextensiveunderstandingofruralEMSsystems.Itsprincipalsgatheredquantitativeandqualitativedatathroughresearch,sitevisits,andinterviews.SafeTechSolutionsconsultantsvisitedSubletteCountytoreviewdocumentsanddata,conductinterviewsandassessoperations.Inadditiontoevaluatingtheambulanceorganization(organizationalstructure,leadershipandoperations),SafeTechSolutionspaidspecialattentiontothesocial,economic,demographic,culturalandpoliticalissuesinSubletteCounty,carefullyanalyzingdataandmakingrecommendationsbasedonindustrybestpractices,aswellaswhatispracticalanddoableinSubletteCounty.Thisreportsummarizesthefindings,keyobservationsandrecommendationsforEMSinSubletteCounty.

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II.OverviewofSubletteCountySubletteCountycovers3.2millionacresinwesternWyoming.Of23countiesinthestate,SubletteCountyrankssixthingeographicalsize.TheWindRiverRangerunsnorthtosouthalongtheeasternportionoftheCounty,theGrosVentreWildernessliestothenorth,andtheWyomingRangerunsalongthewesternside.Thecentralportionofthecountyisavalleycomprisedofasagebrushsteppeeco-region.Elevationrangesfrom6,280feetinthevalleyto13,400feetintheWindRiverRange.Thecountyhasmorethan1,300lakes.1Geographicallyisolatedfromrailroadsandpopulationcenters,SubletteCountyretaineditsfrontiercultureforfarlongerthanmanyareasofWyomingandtheWest.Itwasnotincorporateduntil1921,makingitthenewestcountyinthestate,andithasremainedoneoftheleastdenselypopulatedareasinthestatewellintothe20thcentury.Eventoday,80percentofSubletteCountylandispubliclyowned.SubletteCountyhasexperienceddramaticgrowthsince2000duetoenergydevelopment.Thecounty’spopulationincreasedfromfewerthanthan6,000residentsin2000tomorethan10,000residentsin2013.Populationgrowthsince2000(68percent)wasfourtimesthegrowthrateforWyoming(18percent)andsixtimesthegrowthratefortheU.S.(12percent).Mostoftheincreaseinpopulationoccurredfrom2002through2009whenpopulationincreasedatanaverageannualrateof7percentperyear.Since2009,thepopulationhasplateauedataround10,000residents,reflectingaslowdowninenergydevelopmentinthecounty.2SubletteCountyhasthreeincorporatedtowns:BigPiney,MarbletonandPinedale.SmallerunincorporatedcommunitiesincludeBondurant,Cora,BoulderandDaniel.Pinedaleisthecountyseat.3Nearly60percentofresidentsliveinruralpartsofthecounty.Theotherhalf1Sublettewyo.com2ASubletteCountyProfile:SocioeconomicsbytheSubletteCountyBoardofCountyCommissioners,2015.3ibid

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liveinPinedale(25percent),Marbleton(12percent)andBigPiney(6percent).4Inadditiontoitspermanentresidents,SubletteCountyhoststransientworkerswhocometotheareaforemployment,primarilyintheoilandgasindustry.Asmanyas2,000non-residentworkers(primarilymen)areinthecountyatanygiventime,dependingonthelevelofgasfieldactivity.5SeveralhighwayspassthroughSubletteCounty,includingUS191,whichrunsnorth-souththroughPinedaleenroutetoGrandTetonsNationalPark,andUS189,whichtakestrafficthroughBigPiney,MarbletonandDaniel.Accordingtothecounty,trafficincreasedby60percentormorebetween1995and2005everywhereinSubletteCounty,exceptfortheRimonHighway189/191,whichwasupabout20percent.Bigtrucktrafficalsoshowedsignificantincreasesinandaroundallthetowns,aswellasonHighway351,andUS191betweenSandDrawandFarson.Notsurprisingly,trafficaccidentsalsoincreasedinSubletteCountyduringthistime.6

EconomySubletteCountyhasaboom-busteconomydueinlargeparttoitsmineralresources,mostnotablytheJonahandPinedaleAnticlinenaturalgasfields.Themostrecentboombeganabout1999-2000andfueledjobs,growthandinflationforabouteightyears.Itpumpedlargeamountsofmoneyintothelocaleconomythatallowedresidentstobuildnewschools

4Sublettewyo.com5ibid6ibid

Page 1 of 1

9/21/2009http://sublette-se.org/images/accidentws2.JPG

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andoutfitclassroomswithnewcomputers.7Itdrovetheconstructionofnewhomes,hotelsandrestaurants.Duringtheboom,wageswerehighandunemploymentwaslow.TheboompeakedinOctober2008withanall-timehighof67naturalgasrigsinoperation.Lessthanayearlater,however,inMay2009,thenumberofdrillingrigsinthecountyhaddroppedto30.8Thesharpdecreasewascausedbya70percentdeclineinnaturalgaspricesbroughtonbyweakeneddemandinthefaceofaglobaleconomicdownturn.Thedeclineinnaturalgasproductionhascontinuedinrecentyears.BakerHughes,whichtracksrotaryrigsbystate,reportsthatasofApril2016,onlyninerigsareoperatingintheentirestateofWyoming,comparedwith25oneyearearlier.9People

SubletteCountyishometosome10,000permanentresidents,accordingtotheUSCensusBureau.Thisnumberrepresentsanincreaseof68percentinlessthanadecade,whichismorethanfourtimesthepopulationgrowthrateforthestateandsixtimesthegrowthratefortheUS.10Thereasonfortheincreaseislargelyattributabletothenaturalgasindustry.

Accordingtothecounty,thenumberofactivedrillingrigsinSubletteCountyhashadadirectandimmediateeffectontheworkforcepopulation.Atanygiventime,eachdrillingrigrequiresadirectworkforceofabout22people,thevastmajorityofwhomarenon-residentsofthearea.Whentheweeklyrotationsoftheworkforcearetallied,about44differentindividualsarededicatedtoeachrig.Scoresofadditionalworkersarealsoneededtoprovidesupportandservicestotherigs.11Since2009,thecountypopulationplateauedataround10,000residents,reflectingaslowdowninenergydevelopmentinthecounty.12

Mostresidentsarewhite,employedandearnawageabovethestateaverage.The2015WyomingCountyProfilereportedmedianearningsforfull-timemaleworkerstobe$67,390($38,517forfemales).Mostresidentsareemployedintheprivatesector,withthegas/oilandmining/quarryingindustriesaccountingforthehighestpercentageofemployeesinrecentyears.13Alongwiththeboomalsocamecrime.Thecountyreports,“SubletteCountyenjoyedamoderatetolowcrimerate,usuallybelowtheWyomingaverage.However,withtheadventofoilandgasdevelopment,crimeratesandarrestsmadewithinSubletteCountyhavesoared.”SubletteCountyhadthehighestcrimerateinthestatein2005,eclipsingthemetropolitancountiesofNatronaandLaramie.14

7TalkoftheNation,Feb.11,20138sublettewyo.com9BakerHughesmonthlyrigreportforApril201610SubletteCountyProfile:SocioeconomicsbytheSubletteCountyBoardofCountyCommissioners,August201511sublettewyo.com12ibid13SubletteCountyProfilebytheWyomingDepartmentofInformationandAdministration,2015.14Sublettewyo.com

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HealthcareinSubletteCountyUniversityofWisconsinPopulationHealthInstituteandtheRobertWoodJohnsonFoundationeachyearpublishhealthrankingsthatshedlightonthehealthandwellnessofresidentpopulationsbycountythroughouttheUnitedStates.TheannualCountyHealthRankingsmeasurevitalhealthfactors,includinghighschoolgraduationrates,obesity,smoking,unemployment,accesstohealthyfoods,thequalityofairandwater,income,andteenbirthsinnearlyeverycountyinAmerica.Expertscompiletherankingsusingcounty-levelmeasuresfromavarietyofnationaldatasources.

The2015CountyHealthRankingsreportsuggeststhatthehealthofSubletteCountyresidentsisverygoodcomparedtotherestofthestate.Fewerthan15percentofadultresidentssmoke,comparedto20percentstatewide.Adultobesityis21percent,comparedto27percentstatewide.Preventivecaresuchasmammographyanddiabetesscreeningalsorankshigh.TheonlyfactorsinwhichSubletteCountyscoredpoorlyarealcohol-impaireddrivingdeaths,longcommutesandpoorqualityofdrinkingwater.15SubletteCountyHealthcareResourcesSubletteCountyresidentsobtainbasicmedicalcareattwoareaclinics,oneinPinedaleandtheotherinBigPiney/Marbleton.BothareoverseenandoperatedbySubletteCountyRuralHealthCareDistrict,acountywideelectedboardoffivenon-partisanmembers.ThehealthcaredistricttookoveroperationoftheMarbletonclinicinMay2005andthePinedaleclinicinJuly2006.Bothclinicshavebeenrebuiltinrecentyearsusingcountyfunds(Pinedalein2007,Marbletonin2009).Thereisnohospitalinthecounty;however,discussionsareongoingregardingconvertingthePinedaleclinictoaCriticalAccessHospital(CAH).ThisconversionwouldhaveanimpactonEMS.Out-of-CountyHealthcareResourcesPatientsthatrequiremoreacutecarethanthatwhichcanbeprovidedinSubletteCountyaretransportedbygroundorairambulancetoSt.John’sMedicalCenterinJackson(76miles);EasternIdahoRegionalMedicalCenter,aLevelIITraumaCenter(158miles);MemorialHospitalinRockSprings(103miles);SouthLincolnMedicalCenter,aCriticalAccessHospitalinKemmerer(56miles);andtothehospitalatUniversityofUtah,aLevelOneTraumaCenter,inSaltLakeCity(250miles).15CountyHealthRankings,2016

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WyomingDesignatedTraumaFacilities

source:AmericanTraumaSociety

Wyominghasaninclusivestatewidetraumasystem.Thismeanseveryfacilitythatreceivesemergencytraumapatientsreceivesadesignationreflectingitscapabilitytotreataseverelyinjuredtraumapatient.Thedesignationsutilizeascalethatrangesfrom1(thelargestfacilitywiththemostcapability)to5(thesmallestfacilitieswiththeleastcapability.)ThestandardsandcriteriafordesignationarebasedontheAmericanCollegeofSurgeons(ACS)standardsfortraumafacilityverification.Wyominghastworegionaltraumacenters(depictedinredabove)thatareverifiedbytheACSasLevelIItraumacenters.

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III.OverviewoftheEMSSysteminSubletteCountyEmergencymedicalcareinSubletteCountyincludesa911emergencymedicalcallsystem,emergencymedicaldispatch,firstresponse,groundambulance,airmedicaltransport,medicaloversightandqualityassurance.ThesystemworksthroughthecoordinatedeffortsofavarietyofagenciesthatincludesSubletteCountyRuralHealthCareDistrict,SubletteCountyEMS,SubletteCountySheriff'sofficeand911CommunicationsCenter,SubletteCountyUnifiedFire,WyomingHighwayPatrol,TipTopSearchandRescue,SubletteCountyEmergencyManagement,andavarietyofout-of-countyairmedicalservices.Althoughthecountyhastwomodernhealthcareclinicsthatoftenoperatelikestand-aloneemergencyrooms,thereisnohospitalinSubletteCounty.ThenumberofrequestsforemergencymedicalresponseinSubletteCountyisunknown,ascountyEMSofficialsdisagreewiththewayinwhichdataisreportedtothestateEMSdataregistry(WATRS).16SafeTechSolutionsestimatestotalcallvolumeinSubletteCountytobeabout600annually,basedonareported491billablepatienttransportsin2015(transportstypicallyoccuron80percentofcalls).Requestsforserviceappeartobedownfrompreviousyears.Volumeinpastyearswasreportedlyashighas766(2011).2015EMSVolume(estimated)

§ Groundambulanceresponses:589§ Airmedicaltransports:192§ Searchandrescuerequests:18-24

Communications&DispatchCallsforout-of-hospitalemergencymedicalcarearereceivedbySubletteCountySheriff'sOffice911CommunicationsCenter.TheCommunicationsCenteranswersabout10,000callsperyear.Ofthese,fewerthan600requireEMSresponse.Thecenterismodernandup-to-date,withanewCADsystem,CRTradiosystem,andhasAVLmonitoringcapability.ThecenterisstaffedbydispatcherstrainedinEmergencyMedicalDispatchandpreparedtoprovidepre-arrivalinstructions.EMSandtheCommunicationsCenterhaverecentlyaddedActive911capabilities.

16ItisdifficulttoassessSubletteCountyEMS’scallvolumebecauseofhowdataiscollected.In2015WATRS(thestateEMSdatacollectionsystem)reports816totalcalls.SubletteCountyEMSbelievesthisnumberisunreliableduetosomeresponsesbeingenteredintoWATRSmultipletimes.Forexample,apatientwhoistransportedfromhometothehealthcareclinicandthenfromtheclinictoahospital,suchasinJackson,wouldbeenteredintoWATRStwice,butwouldonlyaccountforonebillabletransport.Themostreliabledataavailablewasthebillingdepartment’sdatafortotalbilledtransportsduringagivenperiod.SafeTechSolutionsincreasedthisnumberby20percenttoaccountforresponsesinwhichapatientwasnottransported(the20percentnon-transportnumberiscommonacrossthenation).

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CallsforemergencymedicalassistancearetonedoutsimultaneouslytofirstrespondersandSubletteCountyEMS.TherearebaseradiosintwoEMSstations,locatedinBigPiney/MarbletonandPinedale.Respondersusein-vehicleandhandheldradiosaswellascellphonestostayincontactduringcalls.Respondersreportmoderatelygoodreceptionthroughoutthecounty,butoccasionallyareinlocationswherethereisnoreception.SubletteCountyEMSisdispatchedviaradiosystemandpagers.ThesystemispartofWYOLINK,thestatewidedigitaltrunkedVHFP-25compliantpublicsafetycommunicationssystemdesignedtocoordinateandintegratecommunicationsamongstate,localandfederalpublicsafetyagencies.Communicationtechnologybetweenthedispatchcenterandambulancecrewsappearssufficient,withnoproblemsreported.ThereisnodirectcosttoSubletteCountyEMSforthedispatchservice.Thedispatchandcommunicationsystemisfundedthroughacombinationof911surchargedollarsandresourcesfromthecountygeneralfund.FirstResponse&Co-ResponseFirstresponseinSubletteCountyisprovidedbyavarietyofagencies,includingSubletteCountySheriff’sDepartment,WyomingStatePatrol,SubletteCountyUnifiedFire,andTipTopSearchandRescue.Sheriff’sdeputiesco-respondwithSubletteCountyEMStoamajorityof911emergencymedicalcalls.SubletteCountyUnifiedFireDepartmentco-respondswithEMSintheareasofBondurantandKendallValley.Somepart-time,off-dutyEMTsalsorespondasvolunteerfirstresponders.SubletteCountySheriff’sDepartmenthas55swornofficersandanadditional15employeeswhoprovidecountywidelawenforcement,operatethe911CommunicationsCenterandjail,andoverseethevolunteersearchandrescueprogram.SubletteCountyUnifiedFireisavolunteerdepartmentlocatedinsixfirestationsscatteredacrossSubletteCounty.Thedepartmentisaconsolidationofsixdepartmentsthatwerebroughttogetherin2014.Itisintheprocessofcreatingaunifieddepartmentandcultureundertheleadershipofafull-timefirechiefandfull-timeadministrativeassistant.Thedepartmenthasapproximately110volunteerfirefightersandanannualbudgetofapproximately$2.4million.Thedepartmentexpectssignificantbudgetreductionsin2017-18becauseofalowertaxbaseinashrinkingeconomy.SubletteCounty’sremotetopographyoftenmakesitnecessaryfordispatchtosendsearch-and-rescueteamsonEMScalls.SearchandrescueisprovidedbyTipTopSearchandRescue,aPinedale-basedvolunteer,non-profitorganizationofapproximately40memberswhoreportthattheyrespondtooneortwocallspermonthyear-round.TheorganizationoperatesunderSubletteCountySheriffDepartmentandreceivesfundingfromtheSubletteCountyCommission,StateofWyoming,andprivatedonations.Theorganizationrespondstohighanglerescues,waterrescues,icerescues,avalanches,missingandoverduepersons,medicalevacuationsandbodyrecoveries.

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Firstresponders,EMSrespondersandtheCommunicationCenterreporthavingrespectfulworkingrelationshipswitheachother.911Response&MedicalTransportEmergencymedicalresponseisprovidedbySubletteCountyEMS,anambulanceserviceownedandoperatedbySubletteCountyRuralHealthCareDistrict.ItwasformedinJanuary2006fromthemergeroftwocombinationEMSagencies:PinedaleEMSandBigPiney/MarbletonEMS.SubletteCountyEMSoperatesoutoftwoEMSstations,oneinBigPiney/MarbletonandtheotherinPinedale.InthePinedalestation,anALSunitisstaffed24/7,withtheavailabilityofasecondunitstaffedbytheDirectorandsupervisingparamedic.InBigPiney/Marbleton,anALSunitisstaffed24/7.Staffingismainlywithpaidemployees,withfourvolunteersoccasionallyfillinginwhenneededforbackup.Duringsummermonths,whentourisminthecountyisatitspeak,anadditionalambulanceisstaffedinPinedale.Whileambulancesarestationedabout35milesapart,SubletteCountyEMSusesadynamicdeploymentsystemtoensurethatambulancesarebestpositionedforrapidresponse.Forexample,whenbothambulancesinPinedaleareoncalls,theBigPiney/MarbletonambulancemovestoDaniel.WhenanambulancegoesoutonacallinBigPiney/Marbleton,thePinedaleambulancemovestoDaniel.Thissystemallowsforshorterresponsetimesoveralargeservicearea.SubletteCountyEMSreportsenroutetimeof2.2minutesandanaverageon-scenetimeunder15minutes.Occasionally,anon-transportingquickresponseunitstaffedbyaparamedicfromPinedaleisusedtorespondandbegintransportwhileawaitingambulanceresponse.EMSrespondersprovideanadvancedlevelofserviceandtransportpatientseithertothehealthcaredistrictclinicsinPinedaleorBigPiney/Marbletonortoout-of-countyhospitals.Out-of-countymutualaidisrarelyused,butisinplacefromsurroundingcountiesandavailableonanas-neededbasis.BecauseofthelongdistancetothetraumacenterinSaltLakeCity(upto10hoursround-trip),SubletteCountyEMSmaypassoffpatientstoGoldCrossambulancemid-route,inwhatisknownasapatientintercept.Inadditionto911responseandtransport,SubletteCountyEMSparticipatesinavarietyofcommunityoutreachactivities,including:

• FirstaidandCPRclasses;• Standbysforfootballgames,rodeos,etc.;• Servingfoodatlocalnursinghome(whileonduty);• Deliveringfoodbags;• Supportingcommunityevents,suchasbreastcancerwalk;and• EmergencyMedicalResponderandEmergencyMedicalTechnicianBasiccourses.

Inaddition,becauseSubletteCountyEMSispartofthehealthcaredistrictandbecauseambulancestationsarelocatednexttohealthcaredistrictclinics,on-dutyEMSpersonnel

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maybesummonedbytheCommunicationsCentertomeetpatientsattheclinicdoorsafterhours,opentheclinic,andbegintotriageandcareforpatientswhilewaitingforanurseandphysiciantorespond.AirMedicalServiceAvarietyofout-of-countyhelicopterflightservices(AirIdahoRescue,ClassicAirMedical,GuardianFlight,LifeFlightWyoming,LifeFlightNetwork)areavailablewhenthegroundambulancecreworclinicstaffrequeststhem.TherearenoairmedicalresourcesbasedinSubletteCounty,buthelicopterandfixedwingservicesareavailablefromIdahoFalls,LanderandotherlocationsinWyoming,ColoradoandUtah.AirambulancesarenotdispatchedthroughtheSherriff’sDepartment;rather,ambulancepersonnelcontactthemdirectlyusingcellphones.ThetotalnumberofairmedicaltransportsfromSubletteCountyeachyearisnotknown;however,ambulancepersonnelreportapproximately75airmedicaltransportsannuallyfromSubletteCountyhealthcareclinics.WyomingAmbulanceRunTransportSystem(WATRS)datashowedasmanyas16airmedicalflightsamonth,orapproximately192airmedicalflightsayearfromSubletteCounty.EMSEducationSubletteCountyEMSprovidesfirstaid,CPR,firstresponderandEMTtraining.Italsoprovidesongoingstafftrainingandcontinuingmedicaleducation.Therearenoparamedicprogramswithinthecounty.EMSSystemOversight&PlanningThereisnoformalEMSsystemoversightinSubletteCounty;however,anadvisorygroupcalledtheSubletteCountyEmergencyServicesGroupmeetsregularlytodiscussemergencyplanning,challenges,interoperability,bigeventplanning,needs,grantrequestsandagroupapproachtosolutions.Thegroupiscomprisedofthecountyemergencymanager,EMS,Sheriff’sDepartment,searchandrescue,HighwayPatrol,mayors,publichealth,industry/mining,andschools,withoccasionalrepresentationfromcitizens,theparkandforestservices,homelandsecurityandotherstakeholdersasneeded.

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IV.DescriptionofSubletteCountyEMSOrganizationalOwnership&StructureSubletteCountyEMSisadepartmentofSubletteCountyRuralHealthCareDistrict,acountytaxingdistrict.SubletteCountyRuralHealthCareDistrictwasestablishedin1987followingthedissolutionoftheSubletteCountyMemorialHospitalDistrict.ThedistrictisoverseenbyaBoardofTrusteeswhoareelectedbycountyresidents.Thetrusteeshireahealthcareadministratorwhoservesaschiefexecutiveandoverseestheoperationsoftheservicesprovidedbythedistrict.Servicesincludetheoperationoftwoclinicswithmedicalstaffs,nursingservices,radiologyservices,laboratoryservicesandemergencymedicalservices.Thedistrictoperatesindependentlyofcountyandmunicipalgovernment,butusespropertyandbuildingsownedbythecounty.Theclinicisunabletomakeimprovementstothesebuildingswithoutconsentofcountycommissioners.EMSfunctionsasadepartmentofthehealthcaredistrict.Thedirectoroftheambulanceserviceishiredbythehealthcareadministratorandreportstotheadministrator.ThecurrentorganizationalchartshowstheEMSdirectorreportingdirectlytotheEMSmedicaldirector,however,inpractice,theEMSdirectorreportstotheadministratoronoperationalandfinancialissuesandtotheEMSmedicaldirectoronclinicalissues.TheEMSdirectorhasanassistantwhofunctionsintheroleofasupervisingparamedic.

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WorkforceSubletteCountyEMSemploys17full-timeand9part-timepersonnel.Allareactive.Fourofthepart-timestaffareunpaidvolunteers–remnantsofatimewhenallemployeesdonatedtheirtime.Theagespanoftheworkforceisbetween25and61,withanaverageageof38.Fivefieldpersonnelareparamedics,15areAEMTs,and6areEMTbasics.EmployeesarehiredandevaluatedbytheEMSdirector.EMSstaffwork48hoursonand96hoursoff.Thereisconsiderableschedulingflexibility,andemployeesareabletoschedulesignificantstretchesoftimeoff.Whenoff-duty,someofthestaffmakethemselvesavailabletobecalledinforback-up.Employeeshaveapayandbenefitpackagethroughthehealthcaredistrictthatincludeshealthanddentalinsurance.Currenthourlypayratesare:

§ EMT-Basic:$10.50§ Intermediate/AdvancedEMT:$12.20§ Paramedic:$15.60

Onthesurface,theseratesappearlowcomparedtonationalaveragesforEMSorganizationsofsimilarsizeservingruralcommunities.However,actualtake-homepayissignificantlyhigherduetoscheduledandunscheduledovertime.Scheduledovertimecanaddseveralmoredollarsperhour.Anaccurateevaluationofcompensationincludesanevaluationofannualcompensationdividedbyhoursworked.Facilities,Vehicles&EquipmentSubletteCountyEMSoperatesoutoftwospaciousEMSstationsthatareownedbySubletteCountyandrentedtothehealthcaredistrictforthecostofupkeep(approximately$100,000peryear).Bothfacilitiesaremodernandcomfortable,withlargevehiclebays,officespace,ampletrainingrooms,dayroomswithkitchensandlivingareas,andsleeprooms.FourvehiclesaregaragedinPinedale,threeinBigPiney/Marbleton.Ambulancesavailablefor911responseinclude:

§ Unit15,firstoutinPinedale:2012FordF-450madebyOsagewith48,789miles,StrykerPowerliftcot,ZollX-seriesMonitorwiththeabilitytotransmit12leadECG,LucasDevice,ePCR,modernequipment,ingoodorder,andwellmaintained;

§ Unit129,secondoutinPinedale:2007FordF-450madebyLifelinewith121,894miles,StrykerPowerliftcot,ZollX-seriesMonitorwiththeabilitytotransmit12leadECG,ePCR,modernequipment,ingoodorder,andwellmaintained;

§ UnitMS14,thirdoutinPinedale:2001FordF-350madebyLifelinewith139,000miles,StrykerPowerliftcot,ZollE-seriesMonitor,ePCR,equipmentingoodorder,andwellmaintained;

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§ UnitEMS1,EchoUnit(AdvancedLifeSupportRapidResponseVehicle)inPinedale:2012ChevyTahoewith39,00miles,ZollX-seriesMonitorwiththeabilitytotransmit12leadECG,LucasDevice,Autovent,Minimedpump,ALSsupplies,Kingvision,ePCR,modernequipment,ingoodorder,andwellmaintained;

§ UnitMS140,firstoutinMarbleton:2012Dodge4500madebyOsagewith49,000miles,StrykerPowerliftcot,ZollX-seriesMonitorwiththeabilitytotransmit12leadECG,LucasDevice,ePCR,modernequipment,ingoodorder,andwellmaintained;

§ UnitMS256,secondoutinMarbleton:2008FordF-450madebyLifelinewith70,000miles,StrykerPowerliftcot,ZollX-seriesMonitorwiththeabilitytotransmit12leadECG,ePCR,modernequipment,ingoodorder,andwellmaintained;and

§ UnitMS141,thirdoutinMarbleton:2005FordF-350madebyOsagewith101,000miles,StrykerPowerliftcot,ZollE-seriesMonitor,ePCR,Equipmentingoodorder,andwellmaintained.

Allmedicalequipmentisuptodateandappropriateforthelevelofcareprovidedandthedemandsoftheservicearea.MedicalOversight&QualityAssuranceSubletteCountyEMShasprogressivepatientcareprotocols,internalqualityassuranceandengagedmedicaldirection.Afull-timeparamedicactsastheQA/QIofficerandreviewsallrunreports.Patientcarereportsoncomplicatedand/orhighacuitycallsareforwardedtothemedicaldirectorforreview.Providerdocumentationiscontinuouslyevaluatedandsupportedwithproviderfeedbackandtraining.Thedepartmentparticipatesinregularcasereviewswithitsmedicaldirectorandclinictraumacoordinator.PatientcarereportdataisconsistentlysubmittedtoWATRS.TheSubletteCountyMedicalDirectorisresponsibleforensuringfieldprovidershaveappropriatepatientcareprotocols,areclinicallycompetent,andadequatelysupportedwithclinicalcasereviews,continuingeducationandskillmaintenance.HekeepsupwithclinicaldevelopmentsandseekstoensureSubletteCountyEMSisdeliveringbestpractices.Hisinvolvementintheclinic’semergencyservicesallowsfrequentinteractionwithfieldcrews.Finance&FundingSubletteCountyEMSisfundedthroughbillingforpatientcare,taxrevenuereceivedbySubletteCountyRuralHealthCareDistrict,andlabordonatedbyvolunteers.SubletteCountyRuralHealthCareDistrictisfundedthroughbillingforpatientservicesandataxof2millsthatisleviedeachyearbythecounty.HealthcarefundsalsoaresecuredbytheRuralHealthFoundation(RHF),a501(c)(3)nonprofitcorporation.ItiscloselyaffiliatedwiththeSubletteCountyRuralHealthCareDistrictbutisseparatelygoverned

19

andmanaged.FundsraisedbytheRHFareusedforprojectsthatimprovehealthcarethroughoutthecounty.DonationsmadetotheRHFaretaxdeductibleasallowableundercurrentIRStaxcodes.Aspartofhealthcaredistrict,SubletteCountyEMShasadepartmentalbudgetandtracksEMS-specificrevenuesandexpenses.In2015,itreportedtotalrevenuesof$513,654receivedfrompatientbilling.Duringthesametimeperiod,itreportedtotalexpensesof$1.9million,resultinginanetlossof$1.4million.Thebillingprocessincludesthefollowingsteps:Patientcarereports(PCR)arereadandcodedbythebillingdepartment;anyquestionsaboutthePCRsarereturnedtoEMSstaffforclarificationsandcorrections;aclaimiselectronicallysubmittedthroughaclearinghouse,whenallowed.ExplanationofBenefits(EOBs)arereturnedinthesamemanner.Statementsaresenttopatientsevery28days.Paymentplansforunpaidbillsareaccepted.Internalcollectionprocessesareenacted,andwhenapplicable,anoutsidecollectionagencyused.Billingratescomparewithnationalaveragesasfollows:

BillingLevels

SubletteCountyEMS

RatesNationalAverages

Non-emergencytransportation(WC) $25 $17Mileage $22/mile $30ALSnon-emergency $662 ALSemergency $1,048 $2,500-$3,500BLSnon-emergency $551 BLSemergency $882 $1,000-$2,000ALS2emergency $1,517 $3,000-$4,000ALStreatmentwithnotransport $200 ALStreatmentwithnotransport $100

AmbulanceStandby $50/hour $200BLS/$400ALS

A0434SpecializedCriticalTransport NoUse $3,500-$4,500

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Totalbillabletransportsbyyearareasfollows:

TotalBillableTransports,byTypeofTransportYear-to-Year17

2011 2012 2013 2014 2015

TotalAmbulanceResponses(estimated) 766 658 580 582 589

TotalBilledAmbulanceTransports 638 548 483 485 491A0426,ALS1non-emergency 2 1 1 96 173A0427,ALS1emergency 422 342 255 182 154A0428,BLSnon-emergency 20 6 10 92 67A0429,BLSemergency 151 170 195 94 66A0433,ALS2 43 29 22 21 31A0998,ResponseandTreatment,Notransport 12 30AmbulanceStandbys 27.5 48.3 32.2 39.5

Ambulanceresponsesversusbilledambulancetransportsbyyearareasfollows:

17Accuratelyassessingvolumeremainsproblematic.SeesectiononEMScallvolumeabove.

0100200300400500600700800

2011 2012 2013 2014 2015

TotalAmbulanceResponses(es<mated)

TotalBilledAmbulanceTransports

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IV.KeyObservations1.EMSisavitalandessentialelementofhealthcareandqualityoflifeinSubletteCounty.Geography,climate,distancestomedicalresources,highlevelsoftrauma,andlimitedresourcescombinetomakeEMSavitalserviceinSubletteCounty.Informantsviewtheavailabilityofambulancetransporttodefinitivemedicalcareasveryimportanttotheirsenseofsecurityandwell-being.Intheabsenceofalocalhospitalandreadilyaccessibleadvancedmedicalspecialties,informantsdeemlocalEMSresourcesasessentialtolifeandsafetyissues.SomeinformantsreportviewingEMSasthemostessentialpartofthelocalhealthcaresystem.2.Asoperatingtoday,SubletteCountyEMSisnotsustainable.ThecurrentoperatingbudgetandoperationalstrategiesforSubletteCountyEMSappeartobebasedonfinancialandoperationalassumptionsmadeduringalocaleconomicboom.AnticipateddeclinesintaxrevenuesandotherfinancialdemandsonthehealthcaredistrictsuggestthatSubletteCountyEMSisnotsustainableasoperatingtoday.Thecurrentgapbetweenoperatingexpensesandtransportrevenuesforcesthedepartmenttorelyona$1.4millionsubsidythatislikelytonotbeavailableinthenearfuture.Withoutreducingexpensesorincreasingrevenues,thecurrentEMSoperationsarenotsustainable.

3.SubletteCountyEMSpossessesmanyelementsofaprogressiveandsustainableruralEMSsystem.Creatingasustainable,highquality,ruralEMSsystemintoday’smarketdemandsleadership,vision,operationalandfinancialefficiency,communitysupportandprogressivemedicaldirection.SubletteCountyEMShasmanyoftheseelementsinplace.3A.BoththehealthcaredistrictandEMSdepartmenthavecapableleaders.Theexecutive

$0.00

$500,000.00

$1,000,000.00

$1,500,000.00

$2,000,000.00

$2,500,000.00

$3,000,000.00

$3,500,000.00

2013 2014 2015

ExpensesVs.Pa^entBillingRevenue

TotalExpenses

TotalRevenues

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leadershipoftheSubletteCountyRuralHealthCareDistricthasdemonstratedclearleadershipinseekingoutthisassessment,endeavoringtounderstandruralout-of-hospitalemergencymedicalservices,developinganappropriateplaceforEMSindistrictplanning,andchoosingaqualifiedEMSdirectorwhoinspirespeopletofollowhim.3B.TheEMSDirectorhasgoodbusinessandpeople-managementskills.TheEMSDirectorhasasubstantivebackgroundinbusinessdevelopmentandpeople-managementandiscreatingaculturethatemployeesvalue.Heiscurrentlymanagingasignificantbudgetcontractionbyfindingefficiencies,isopen-minded,andconstantlyseekingwaystoimprovethesystem.Employeesdescribehimas“oneofthebestthingsthathashappenedtoSubletteCountyEMS.”3C.TheEMSsystemisimplementingdynamicdeploymentstrategies.SubletteCountyEMSmovesitsambulancestostrategicstaginglocationswhenresourcesaredepleted.Thissystemofdynamicdeploymentrequiresmonitoringthesystem’sstatusandproactivelymovingresources(sometimestothediscomfortofemployees).Dynamicdeploymentisabestpracticestrategythatmovesambulanceassetswithinageographicareatoprovidethebestpossibleresponsetimeswhileminimizingfixedcosts.Suchforward-thinkingandpracticeisrareinruralEMSsystems.3D.TheEMSsystemprovidesahighlevelofqualityclinicalcare.TheclinicalcareprovidedbySubletteCountyEMSmatchesbestpracticesinruralareasaroundthenationandisclearlyanorganizationalpriority.Theserviceprovidesadvancedlevelcareandisappropriatelystaffed.TheMedicalDirectorisappropriatelyqualified,preparedandengagedandisalwaysseekingwaystoensurethatSubletteCountyEMSisontheleadingedgeindeliveringhigh-quality,ruralemergencymedicalcare.Informantswiththecommunity,clinicandreceivinghospitalsreportnoconcernsaboutclinicalcareprovidedbySubletteCountyEMS.

3E.EMSisadequatelyintegratedintothelocalhealthcaresystem.TensionbetweenEMSandclinical/hospitalstaffoftenoccurswhenEMSispartofahospitalorhealthcaredistrict.ThistensionoftenisduetodifferencesbetweenhowEMSoperatescomparedtoclinicsandhospitals.IssuesthatcreatetensionareEMScrews’downtimebetweencalls,theprovisionofuniforms,andanexpectationthatEMScrewsbeusedtosupplementclinicorhospitalstaff.ThereisasurprisingabsenceofthesetensionsinSubletteCounty.TheclinicstaffclearlyembracestheEMSdepartmentandtheuniquenessofhowEMSoperates.ThedistricthassucceededinintegratingEMSinwaysthatstrengthenbothEMSandthedistrict.EMSiscalledupontoassistwithpatientcareinamannerthatstrengthensEMSclinicalskillsanddeepenstherelationshipbetweenEMSandclinicpersonnel.EMScrewsprovideavitalandcost-savingafter-hourfunctionofopeningtheclinicforpatients,beginningpatientcareandsummoningnursing/medicalstaff.TheintegrationdescribedabovepavesthewayforfurtherintegrationusingCommunityParamedicineandMobileIntegratedHealthcare.

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3F.SubletteCountyEMShasaknowledgeableandcompetentbillingdepartment.WhenevaluatinganEMSagency’sbillingcapacity,SafeTechSolutionsconsidersthebillingstaff’stechnicalknowledgeofEMS-specificbilling,theuseandunderstandingofkeyreimbursementperformancemeasures,thetimeavailabletomanageEMSclaims,andwhetherEMSreimbursementisseenasaprioritycomparedtootherclaimswithintheorganizations.SubletteCountyEMSbillingstaffisknowledgeableaboutEMSbilling,includingareassuchasHCPCcodes,originanddestinationmodifiers,andtheneedtobillMedicareforadenialpriortobillingabeneficiaryforanon-coveredservice.Thebillingstaffisabletoquicklyandeasilyprovidedataonkeybillingperformancemeasures,suchasA/Rdays,A/R,payermix,andbillablecallsbyoriginanddestination.Itisunlikelythatoutsourcingbillingwouldbringadditionalrevenuesintothesystem.Outsourcingcouldcomplicatefinancialmanagement;impedethewayinwhichbillingpracticesworkwithintheorganizationalmission,vision,andvalues;andhindercustomerservice.4.SubletteCountyEMSfacesmajorchallengesassociatedwiththelocaleconomy,aswellaswithitspositionwithinthehealthcaredistrictanditslackofaclearvisionandstrategicplan.MajorchallengesfacingSubletteCountyEMSarethelocaleconomy,howEMSispositionedwithinSubletteCountyRuralHealthCareDistrict,andtheabsenceofaclearvisionandstrategicplanforEMS.Specifically,thesechallengesare:4A.SubletteCountyanticipatessharpreductionsintaxrevenues.Duringthepastdecade,SubletteCountyEMShasoperatedwithoutmuchconcernaboutoperationalcosts.Thelocaleconomyprovidedampleresourcesthroughtherevenuescollectedbythehealthcaredistrictthat,inturn,subsidizedtheEMSsystemtothetuneofmorethan$1millionannually.18Asignificantdownturninthelocalmineralextraction-basedeconomyisthreateningtheresourcesavailabletosubsidizeEMSoperations.

InformantsfromSubletteCountyandthehealthcaredistrictreportedanexpectationofsignificantdeclinesinrevenuesin2016andbeyond.EffectiveMay21,2016,thehealthcaredistrictbeganinitiativesto“rightsize”healthcareservicesprovidedinSubletteCounty.Theseinitiativescomeontheheelsofananticipated$3.5millionreductionoftaxrevenuethiscomingbudgetyear.Itisalsoanticipatedthatthedistrictwillfaceanadditional$1.75millionreductionforthe2017budget.

Reductionsinexpendituresincludeadjustmentstoemployeebenefits,positioneliminationperattrition,paywageadjustmentsperattritionandchangesofpurchasinggroupfor18Asubsidyistherevenuesneededtomakeupthedifferencebetweenoperationalcostsandwhatiscollectedfrombillingforservices.

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suppliesandequipment.SaturdayclinichoursattheBigPiney/MarbletonandPinedaleClinicsweresuspendedindefinitely.

4B.EMSwillbeaffectedbychangeswithinthehealthcaredistrict.Aspartofitsefforttoincreaseservicesandrevenue,SubletteCountyhealthcaredistricthasbeenaggressivelyseekingCriticalAccessHospital(CAH)designationforitsPinedaleclinic.CAHdesignationhasthepotentialtogreatlyenhancebillingrevenuethroughcost-basedreimbursementforcurrentservices,aswellaspermitadditionalservicessuchasin-patientcare,swingbedcareandobservationcare.ThischangeofdesignationcouldhavebothpositiveandnegativeimplicationsforEMS.Currently,about30percentofpatienttransferstoout-of-countyemergencydepartmentswouldbeeligibleforcareataCAH,meaningpatientswouldnotbetransferred,andasaresult,transferrevenuewoulddiminish.However,CAHstatusalsohasthepotentialtoincreaseEMSrevenuebecauseambulancetransportstotheCAHwouldbecomeeligibleforreimbursement(whereastransportstotheclinicarenot).AmbulanceservicesthatarepartofaCAHthatmeetthe35-milerulealsoareeligibleforcost-basedreimbursement,unlikethemajorityofambulanceserviceswhicharereimbursedunderaMedicareFeeschedule.Thehealthcaredistrictiscurrentlyawaitinga“greenlight”fromcountycommissionerstomakerequiredphysicalchangestotheclinicstructurestomeethospitallifesafetycodesandregulations.WhetherCAHdesignationwillbesuccessfulisunknown.Acrossthenation,manyCAHsfacesignificantsustainabilityissues.Informantsareconcernedthatdistricttime,attention,focusandresourceswillbeneededtomakeaSubletteCountyCAHsuccessfulandmaydivertimportantresourcesfromEMS.Asoneinformantsaid,“Ifthathospitalfails,we’llstillneedEMS.”4C.PerceptionsaboutthehealthcaredistrictmayhurtEMS.SomeinformantsreportedhavinglittleconfidenceinthehealthcaredistrictBoardofTrusteesbeingabletoadapttodeclinesintaxrevenues.Someinformantsbelievethatthedistricthasoverbuilt,growntoolarge,andisunwillingtoreduceservicestomatchdecliningrevenues.Theseperceptionsmayhaveanimpactonthelong-termviewofEMSinSubletteCountyandtheresourcesthatitneedstocontinuetoprovideahighlevelofqualityservice.4D.SubletteCountyEMSlacksaclearvisionandstrategicplan.Localresidents,ambulancepersonnelanddistrictleadersareeasilyabletoarticulatetheday-to-daybenefitsofhavingahighlevelofqualityEMSinSubletteCounty.CommunityinformantsspokepassionatelyabouttheimportanceofEMSasameanstoaccessthehealthcaresystem.However,bothinformantsandEMSstaffalsoexpressedconcernaboutthefuturebecauseEMSlacksaclearvisionandstrategicplan.Asresourcesbecomescarce,findingandkeepingtherightpersonnelbecomesmoredifficult,leadersareforcedtomakedifficultdecisions,andthereisuncertaintyaboutwhatwillguideplanninganddecision-making.Havingaclearlydefinedandeasilyunderstoodvisionandplanforthefutureprovidesleaderswithapowerfulstorywhenfightingforresources.

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5.SubletteCountyEMSlacksclaritywithregarditsstructure,leadership,workforce,anddatagathering.5A.Thehealthcaredistrictreportingstructureneedsclarification.ThecurrentorganizationalchartshowstheEMSdirectorreportingdirectlytotheEMSmedicaldirector.Inpractice,informantsdescribetheEMSdirectorasreportingtothehealthcaredistrictadministratorforoperationalandfinancialissuesandtotheEMSmedicaldirectorforclinicalissues.Organizationalchartsprovideclearlinesofauthorityandresponsibilities.Theycreatestructurestosupportefficiencies,synergiesandcollaborations.Operations(theambulancedepartmentleader)andclinicalcare(themedicaldirector)mustworkcloselyandhavesharedresponsibilitieswithintheambulancedepartment.However,attimes,theyhaveconflictingresponsibilities,suchasmeetingbudgetresponsibilitiesversusnewclinicalinitiatives.5B.Departmentaljobdefinitionsandreportingstructureareweak.SubletteCountyEMShasaninformalstructurethatidentifiesanambulancedirector,assistantdirector,supervisors,employeeswithassignedareasorresponsibilities(suchasQAorvehiclemaintenance),andclinicalstaff.Jobdescriptionsandkeyperformanceindicatorsforeachjobarenotup-to-date,nordotheyaccuratelyreflectcurrentperformance.Formalizingtitles,positions,jobdescriptionsandreportingstructureprovidesclarityandensuresallemployeeshavetheappropriateresponsibilityandempowermenttobesuccessfulwithintheirpositions.5C.ThecurrentEMSleaderdoesnothavedeepoperationalandfinancialexperienceinEMS.Whilewellliked,thecurrentEMSleaderlacksexperienceintheEMSindustry.InformantswithinandoutsideoftheorganizationreportthatthecurrentEMSdirectorisanexcellentchoicetoleadtheorganization.Heisrespectedandcreditedwithbringingafun,friendly,team-likeculturetotheorganization.SafeTechSolutionsagrees;however,whilehehasgreatbusinessandpeople-managementskills,heandthedepartmentcouldbenefitfromadeepeningofhisexposuretoandknowledgeofEMSleadershipandmanagementconceptsspecifictoEMSorganizations.ThisincludesEMSleadership,matchingcallvolumewithresources,schedulinginalow-volumeagency,longtransports,matchingorganizationalresourcestoadecreasingcallvolume,andEMSemployeeengagement.5D.EMSemployeeengagementisprecarious.Whileemployeesgenerallyreportbeingcommittedtotheorganizationandpleasedwithitscurrentleadership,employeeengagementatSubletteCountyEMSnonethelessseemstenuous.Thisconclusionisrelatedtothemannerinwhichcut-backswerehandledpriortotheleadershipofthecurrentEMSdirector,concernsaboutannualearnings,concernsaboutthelocaleconomyandthefinancialhealthofthehealthcaredistrict,perceptionsthatEMSisnotapriorityforthedistrict,concernsthatannualincomewillbereducedastheEMSdepartmentlimitsovertime,andconcernsthatthecurrentleaderwillnotstay.Employeeengagementisawayoftalkingaboutemployees’enthusiasm,commitment,

26

loyaltyandwillingnesstodomorethanrequiredtoadvancetheorganizationalmission.Employeeengagementiskeytoorganizationalsuccess.Engagementisconnectedtoefficiency,safety,customerservice,patientcareandlong-termsuccess.Currently,SubletteCountyEMShasnoformalmeansofmeasuringemployeeengagement.6.SubletteCountyEMSisnotoperatingefficientlynormaximizingitsrevenuefrompatientbilling,anditmayhavelittleornoincentivetodoso.6A.Thecurrentschedulingsystemisnotefficient.Thecurrentcallscheduleof48hourson/96hoursoffisdemandingonfieldpersonnelandresultsin2,496hoursofovertimeperfull-timeemployeeperyear.Thismodelisfinanciallyunsustainableandexposestheorganizationtolargelegalrisks,suchaswageandhourcomplaintsandlitigation,andtheriskofmedicalerrors,vehiclecrashes,andlowemployeemoraleandengagement.ThecallscheduleusedbySubletteCountyEMSjeopardizestheorganization’slong-termsurvivabilitybycreating96hoursofovertimeperweek.Inatwo-weekpayperiod,thetypicalfull-timeemployeeworks48hoursofstraighttimeand96hoursoftime-and-a-half.Thissystemisusingthe8and80rule,inwhichovertimeispaidforanyhoursovereightinagivenday.With96hoursofovertimeperpayperiod,anemployeereceives2,496hoursofovertimeeveryyear.Thissystemresultsinemployeesreceivingmoreinovertimepaythantheydoinstraighttime(1,248hoursofstraighttime,2,496hoursofovertimepay)andanannualwageof$77,875peryearforastartingparamedic.Payrollcostswillgrowexponentiallyduetothescheduledovertime.Thelogicalresultisunsustainablegrowthinsalarydollars.

AnticipatedWageIncreasesOvertheNextFiveYears

UndertheCurrentOvertimeSystem19

19Thecalculationusesstartingparamedicpayandassumesatotalyearlyincreaseincompensationof3percent.

1248

2496

StraightTimevs.OverTime

StraightTime

OverTime

27

2016 2017 2018 2019 2020

StraightTime $19,468.80 $20,052.86 $20,654.45 $21,274.08 $21,912.31OverTime $58,406.40 $60,158.59 $61,963.35 $63,822.25 $65,736.92AnnualComp $77,875.20 $80,211.46 $82,617.80 $85,096.33 $87,649.22

Anothersignificantconcernisthepossibleeffectthat48hoursofon-dutytimecouldhaveonemployees,suchastheriskoffatigueresultinginmedicalerrors,motorvehicleaccidents,lowengagement,poormorale,andpoorphysicalhealth.Nationally,mostorganizationsareeliminating24-hourshiftsduetooverwhelmingresearchlinkingshiftlengthwithmedicalerrors,vehicleaccidentsandpooremployeehealth.6B.TheEMSsystemhastoomanyresourcesforitscallvolume.Thecurrentunitdeploymentmodelofthree24-hourambulancecrewsondutyperday(fourduringsummerhours)plusasupervisorwithaccesstoanEchounitdoesnotmatchthecallvolumeoffewerthantwocallsaday.Themostreliabledataforunderstandingthecurrentcallvolumecomesfromthebillingdepartment,whichsuggeststhatSubletteCountyEMSrespondstoanestimated589callsperyear.20Thisaveragesto1.7callsaday.Becauseofalackofdata,someassumptionsneedtobemadetocalculateneededresources.Forexample,let’ssayonecallperdayresultsinapatientbeingtransportedtoalocalclinic,andthattransporttakesonehourfromstarttofinish.Asecondcallresultsinanout-of-countytransportthattakesatotalofsixhours.Theresultwouldsuggestthatambulancesareengagedanaverageofsevenhoursperday.Basedonthisassumption,aswellasavailabledata,itisreasonabletoassumethattwo24-hourambulancecrewscouldeasilyprovidecoveragetoSubletteCounty,withaminimaldelayinresponsetimesoroccurrenceswhentheunitsareunavailable.21Incontrast,SubletteCountyEMScurrentlystaffsthreeambulances24hoursaday,andfourinthesummermonths.Thisstaffingmodel,coupledwiththeamountofovertimethatresultsfromit,ispartlyresponsiblefor$1.9millioninexpenses(muchofwhichgoestolabor),anda$1.4millionannualshortfall.6C.Billingratesforpatienttransportsaretoolow.SubletteCountyEMSmaybelosingrevenuebybillingatratesthatarelessthanthecostofprovidingservice.Acrudewaytocalculatetargetbillingratesistodividetotalexpensesbytotalbillabletransports.Withexpensesof$1.9millionand491billabletransports,eachcallwouldneedtoreturn$3,853tothesystemtocovertheexpenseofprovidingtheservice.20Thisiscalculatedbyadding20percentor99responsestothereported491billablecallsin2015.A20percentno-transportrateiscommonforU.S.EMSservices.21AtypicalEMSgoalistostaffforcoverageof80percentofthecallvolume.Itwouldbefinanciallyunsustainabletostafffor100percentofcallvolume(i.e.alwayshavinganambulancewaitingforthepotentialofacall).

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Incontrast,SubletteCountyEMSreceives,onaverage,$913percall,resultinginalossof$2,940.95percall,basedoncurrentexpenses.Raisingratesclosertonationalaverages(seechartonPage17)couldoffsetasmuchas50percentofthecurrentexpenses.Forexample,let’ssayrateswereraisedtoananaveragechargeof$3,335pertransport.Atthecurrentrateofreturn(45percent),eachtransportwouldresultin$1,500.75,foratotalofroughly$740,000annually.TheEMSsystemmightfindadditionalrevenuebytakingall192patientscurrentlybeingtransportedbyairmedicalservicesandshiftingthemtogroundambulance,whichcouldaddanadditional$288,144totherevenue,foratotalof$1,028,000annuallyorapproximatelyone-halfofthecurrentexpenses.ItisunlikelythatSubletteCountyEMScouldraiseitsrateshighenoughtobreakeven;however,withcostcontainmentandincreasedrevenues,itcoulddramaticallyreducetheamountofneededsubsidy.6D.EMSislosingpotentialrevenuebytransportingpatientstodistrictclinics.WhenSubletteCountyEMStransportspatientstodistrictclinicsratherthantohospitals,andthepatientsaretreatedattheclinicsandnottransferredtohospitals,SubletteCountyEMScannotcollectforitsservices.TheCentersforMedicareandMedicaidServices(CMS)doesnotallowambulanceservicestobillMedicareforambulancetransportstoalternatedestinations,suchasclinicsandphysicians’offices.Theexactnumberofpatientstransportedtoclinicseachyearisnotknown;however,SafeTechSolutionsbelievesthatitrepresentssomepotentiallostrevenue.AnambulanceservicemaybillMedicarepatients(usingtheuniqueclaimcodeA0888non-coveredservice)fortransportstoaclinicorphysician’sofficeonceanofficialdenialofpaymentisreceivedfromMedicare;however,thereisnoindicationthatthispracticebeingdone.UseofA0888,oftenreferredtoas“billingforadenial,”wouldprovideanindicationofhowoftenthissituationoccurs.6E.EMSdoesnothaveacapitalreplacementplan.Havingadetailedcapitalreplacementplanguidesadepartmentinplanningfortheuseoflimitedcapitalfunds.Withoutalong-termplan,resourcesoftenareallocatedtothecrisisoftheday,ordepartmentsarepittedagainsteachother,whichresultsintensionandturmoilwithintheorganization.6F.Thefrequentuseofairmedicalresourcesmaynotbeclinicallynecessaryoroperationallyefficient.SubletteCountyEMScurrentlydoesnottracktheuseofairmedicalresourcesinthecounty,nordoesithaveanairmedical-specificprotocoltoguidefieldandclinicpersonnelintheuseofairmedicaltransport.Theuseofairmedicalresourcescanbedifficultandcomplex.Whendistancesaregreatandapatientappearsacute,airmedicaltransportappearstobeareasonablechoice.However,costs,risksandlossofgroundtransportrevenueareimportantfactorsintheairmedicalequation.AnairmedicalhelicopterbillinWyomingtodayisroughly$65,000andcouldhavea20percentco-paytothepatientofroughly$13,000.Airmedicalresourcesareoftenoverused.22Bydeveloping

22http://www.theatlantic.com/health/archive/2016/01/air-ambulance-helicopter-cost/425061/

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guidelinesforappropriateuseandarigorouspost-usereviewprocess,SubletteCountycanensurethatairmedicaltransportiswarranted,andthecostandrisksjustified.6G.TheongoinghealthcaredistrictsubsidyoftheEMSservicemightserveasadisincentiveforimprovedorganizationalefficiencyandrevenuemaximization.TheexpensestooperateSubletteCountyEMStodayfarexceeditsrevenues.ThepolicybythehealthcaredistricttooffsetEMSlossesusingdistrictfundsmaybeadisincentivetotheEMSsystemtoraiseitsbillingrates,takeonmorepatienttransfers,andmakeotherchangesnecessarytoachieveabalancedbudget.Withoutasignificantsubsidyfromthedistrict,SubletteCountyEMSwouldberequiredtomakesignificantadjustmentstoitsexpensesandrevenuestoremainfinanciallyviable.Whileitisnotuncommonforruralambulanceserviceswithalargegeographiccoverageareaandalowcallvolumetobesubsidized,asubsidythatconsistentlymakesupforashortfallwithoutdemandingconcomitantresponsibilitymaycreateanenvironmentinwhichattentiontofiscalresponsibilityisoverlooked.7.SubletteCountyisfailingtodoanadequatejobofcollectingdataandanalyzinginformationaboutitsEMSsystem.SubletteCountyEMSlacksreliabledataandinformationneededforanalysisandimprovement.BasicdataandespeciallyhistoricaldataaresomeofthemostimportanttoolsanEMSleadercanhave.Databecomesevenmoreimportantwhenmanagingaruralorganizationwithalargeanddiverseserviceareaandlowcallvolume.7A.SubletteCountyEMSdoesnothavebasiccalldata,andthedatathatitdoeshaveisatoddswithstate-reporteddata.SubletteCountyEMSneedsreliableanddependabledatasourcesthatitcanminetoconductanalysesofkeyperformanceindicators,suchascalldata,peakvolumeperiods,financialperformance,medicationandequipmentutilization,etc.BasedonSafeTechSolutions’multipleattemptstoobtainreliablecalldata,theonlysourceofreliableinformationappearstobethebillingsystem.TherealsoisadiscrepancybetweendatareportedtothestateEMSdatabase(WATRS)andtheorganization’srunvolumedata(Seegraphiconpage30),resultinginaninabilitytoproperlyuseretrospectivedatatodrivestrategicdecision-making.Calldata,suchascallsbytimeofdayanddayofweek,helpmanagerstoknowwhentodeployresources.Ascallvolumegrowsordeclines,datainformsdecisionsaboutwhentoaddresourcesorwhentotakeresourcesoutofthesystem.

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DataDiscrepancies

2011 2012 2013 2014 2015

WATRSDataforTotalResponses 1117 976 994 859 799

AmbulanceResponses(estimatedfrombillingdata) 766 658 580 582 589

TotalBilledAmbulanceTransports 638 548 483 485 4917B.SubletteCountyEMSdoesnothavedefinedkeyperformanceindicators(KPIs).KPIsaremeasurablevaluesthatdemonstrateshoweffectivelyanEMSsystemisperforminginkeyobjectives.EMSorganizationsuseKPIstoevaluatetheirsuccessatreachingtargetsandmakingneededchange.7C.SubletteCountyhasnoformalorinformalprocessformeasuringEMSemployeeengagement.Employeeengagementisakeyindicatoroforganizationalperformance.Engagedemployeesdriveorganizationalsuccess.Disengagedemployeesmaydragdownothersandimpactoperationalperformance,patientcarequality,customerserviceandrecruitmentandretention(especiallyinatimeofworkforceshortages).A2013HarvardBusinessReviewAnalyticServicesreportofmorethan550executivesfoundthat71percentofexecutivesrankemployeeengagementasveryimportantinachievingsuccess.23Acrossthenation,someofthebestEMSorganizationsarefindingthatprioritizingandmeasuringemployeeengagementisaperformancemeasurethathasabigimpactonall

23TheImpactofEmployeeEngagementonPerformance,2013,HarvardBusinessSchoolPublishing.

0

200

400

600

800

1000

1200

2011 2012 2013 2014 2015

WATRSDataforTotalResponses

TotalAmbulanceResponses(es<matedfrombillingdata)

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others.Engagementisformallymeasuredusingengagementsurveysandinformallymeasuredbypreparingleadersandsupervisorstoprioritizeengagementandrecognizeitspresenceorabsence.7D.SubletteCountyhasnoformalmeasurementofEMScustomersatisfaction.WhileSubletteCountyHealthCareDistrictdoestrackcustomersatisfactionthroughsurveys,itscustomersatisfactiondataisnotspecifictoindividualdepartments.ThegeneralityofthedatamakesitdifficulttounderstandthesuccessesandareasforgrowthintheEMSdepartment.EMSmaybeapatient’sfirstexperienceorthelastexperiencewithahealthcaresystem.Theseimpressionsoftencolortheentirepatientexperience.UnderstandingmorespecificallyhowEMSismodelingtheactionsandbehaviorsoftheorganizationwouldprovideactionablegoalsandobjectivesforthedepartment.

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V.Recommendations1.CreateavisionandplanforEMSsuccessandsustainability.Avisionisavisualizationanddescriptionofthefuturethatguidesplanninganddecision-making.Theprocessofcreatingavisionassistsanorganizationinthinkingthroughwhereitisgoingandwhatspecificallyisneededtogetthere.AsthehealthcaredistrictpursuesCAHdesignationforitsclinic,itshouldalsocreateavisionforsustaininghighqualityEMSinthecounty.WhileaCAHwillexpandlocalmedicalcareandprovideadvantagesforpatientstabilizationandlocalmitigationofminormedicalemergencies,SubletteCountywillalwaysbereliantuponemergencymedicaltransportationtohigherlevelsofcare.AvisionforthefutureofEMSinSubletteCountyshouldincludethefollowingelements:

§ Adescriptionofthelevel,quantityandqualityofservicesneeded,wantedandfundable.Thevisionshouldreflectalevel,quantityandqualityofEMSserviceappropriateforalargeruralregionwithlimitedmedicalresources,longresponseandtransporttimes,andlimitationsofclimate,weatheranddistancetovariousmedicalspecialties.ThelevelofcareenvisionedwilllikelybeAdvancedLifeSupportwithsomecriticalcareandcommunityparamediccomponents.ThequantityofEMSresourcesshouldappropriatelyfitanticipatedcallvolume,andqualityshouldbeassessedandguidedbybestpractices.

§ PrioritizationofEMSaboveotherlocalmedicalofferings.BecauseofEMS’svitaltransportationroletoadvancedlevelsofcare,itisessentialthatEMShavepriorityinhealthcarespendinginSubletteCounty.ThevisionshouldtakeintoconsiderationtheopportunitiesandrisksofCAHdesignation,whichcouldprovideadditionalresourcestoEMS,suchastheabilitytobillwhenpatientsarebroughttotheCAH,aswellascost-basedreimbursementforEMS.ButCAHdesignationalsocouldbecomealiabilityforEMSbybecomingthetoppriorityincommandingdistrictresources,suchastime,attentionandmoney,inboththeshort-termandlong-term.EMSmustremainapriorityregardlessofCAHdesignation.

§ ApowerfulandreassuringstorytotellaboutEMS.AvisionthatensuresEMSwillbeprioritizedindistrictplanningmayassistleadershipintellingareassuringstoryabouttheuseoflocalfinancialresources.

§ Maximizationoftheuseofground-basedEMS.Inenvisioningthefuture,itisimperativethatEMSisappropriatelyusednotonlyfor911responseandtransportbutalsoforinterfacilitytransfersaswellintheemergingroleofintegratingwithandextendingaccesstohealthcarethroughcommunityparamedicine.

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2.StrengthentheEMSorganizationalstructureandleadershipteamtosupportsustainability.HavingastrongorganizationalstructureintheEMSdepartmentwillcontributetolong-termsustainabilityandisvitaltoorganizationalperformance.SubletteCountyEMSshouldtakethefollowingactions:

§ ClarifytheEMSreportingstructureforEMSwithinthehealthcaredistrict.BoththeEMSdirectorandtheEMSmedicaldirectorshouldreportdirectlytothehealthcareadministrator,withdottedlinereportingbetweentheEMSdirectorandtheEMSmedicaldirector.Thisstructurecreatesanadvantageousseparationbetweenclinicalcarereportingandoperationalandfinancialreporting.

§ Clearlydefinetheroles,responsibilitiesandperformanceindicatorsoftheEMSleadership/managementteam.Identifytheneededteamstructureandroles(suchasdirector,assistantdirector/manager,qualitycoordinator,supervisors,trainingcoordinator,etc.).Rolesandtitlesshouldhaveclearjobdescriptionsandperformanceindicatorsthatareunderstoodbyallandusedtoguideperformance.

§ InvestintheEMSleadershipteam’sknowledgeofEMSoperationsandfinanceandexposuretobestpractices.SubletteCountyEMSwillbenefitfromEMSleadershiptrainingandeducation,exposuretoothersystems,andcontinuouslearningaboutbestpracticesandinnovation.LeadershipshouldbeencouragedtoattendEMSleadershipeducation,conferencesandseminars.

§ Ensuretheleadershipteamiscommittedtotheorganizationanditsfuture.

3.Strengthenoperationalandfinancialefficiencybynarrowingthegapbetweenexpensesandrevenues.Efficientuseofhuman,financialandmaterialresourcesiskeytolong-termsustainability.SubletteCountyEMScouldcutitscurrentlossesinhalf,andpossiblymovethedepartmenttobreak-evenstatusbytakingthefollowingactions:

§ Reducethenumberofdeployedresourcestomatchanticipatedcallvolume.Basedonbestavailabledata,SubletteCountyEMShastoomanystaffedambulancesondutyperdayandshouldreduceresourcestotwo24-hourtransportingambulancesperday.UnitutilizationshouldbestudiedtoconsidertheadditionofanEchounittoaugmentresponsecapability.

§ Developandimplementanewcallschedulethatreducesovertimeandissafeandhumane.Thecurrent48on/96offscheduleshouldbemodifiedtoonethatislesstaxingonfieldpersonnelandresultsinlessovertime.SafeTechSolutionsrecommendsa36-hourworkweekforfieldstaff.Theschedulewouldconsistofthree12-hourshifts.Twoofthe12-hourshiftscouldbeputtogetherforamaximumof24hoursonduty,withatleast12hoursoffbetweenshifts.Thischangemay

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requirethehiringofadditionalfieldpersonnelandwillresultinadditionalshort-termexpenses(hiring,uniforms),butissaferinthelong-term.Inaddition,itwillresultinlessovertime,whichwillreduceexpenses.Eliminatingscheduledovertimeshouldbeagoal,andunscheduledovertimeshouldbenomorethan10percentoftotalwages.

§ Raiserevenuebyincreasingbillingrates,capturinglostrevenueandensuringallpatientsaretransportedtoahospital.

§ Developacapitalvehiclereplacementplan.Developaschedulewithcostsforallcapitalpurchasesoverthenext10years.Usethisscheduleasamaptoplanfinanciallyandoperationallytoensurethattheorganizationhasthemostup-to-datephysicalassetsandfinancestopayforthoseassets.

§ Useairmedicalresourcesefficiently.Airmedicaluseshouldbeguidedbyclinicalandoperationalneedsanddeterminedbyastandardprotocol.Createanairmedicalprotocolbystudyingcurrentairmedicaluseanddeterminingwhetheruseismedicallynecessaryandappropriate.DeterminewhetherSubletteCountyEMSislosingrevenuebyover-useofairmedicalresourcesversuslong-distancegroundtransports.

4.Usedatatodrivedecisions.Thecollectionandappropriateuseofdataisessentialtoefficientsystemoperations.Decision-makingshouldbeguidedbyreliabledataandinformation.Specifically,SubletteCountyEMSshould:

§ Ensurethatessentialdataisreliable,complete,andconsistentwithotherdatasources,suchasWATRSandthelocalcommunicationcenter.TheWATRSsystemprovidesmanypre-definedandcustomreportstoanalyzesystemperformance.EnsuringthedatasubmittedtoWATRSis100percentreliableshouldbeapriority.

§ Developadashboardthatincludeskeyperformanceindicatorscriticalforsuccess.A

dashboardisaquickwayofmonitoringsystemperformance.ForSubletteCountyEMS,adashboardmayinclude:

o Systemstatus(howoftendeployedresourcesarebeingusedandhowoften,whenthesystemislowonresourcesandresponsetime);

o Schedulingandovertime(consistencyofscheduletolimitovertimetopredeterminedlevel);

o Clinicalquality(protocolcompliance);o Financialperformance(expenses,revenues,collectionrates)’o Airmedicaluse;ando Customersatisfaction.

§ Regularlymeasureemployeeengagement.Employeeengagementiskeytoensuring

thattheorganizationhasaculturethatemployeesloveandtowhichtheyare

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attracted.Engagementshouldbemeasuredthroughannualsurveysandregularconversationswithemployeesconcerningkeyengagementissues.

5.Continuetodevelophealthcareintegration

• ThedistrictshouldcontinuetointegrateEMSintoitshealthcareofferings,andexploreexpandingitsuseofEMSintonon-911serviceswiththegoalofcreatingatrulyintegratedcaremodel.