ventura county ems agency - health care agency … · 11/12/2019 · ventura county ems agency 5...
TRANSCRIPT
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
VenturaCountyEMSAgency 3 EMSSystemAssessmentReportVERSION2.0
Staffing……………………………………………………………………………………………………….60
InfluencingFactors……………………………………………………………………………………..62
CommunityParamedicine/MobileIntegratedHealthcare……………………………..65
TechnologyinEMS………………………………………………………………………………………67
SWOTAnalysis–EMSSystemDeployment…………………………………………………..73
EMSSystemCommunications…………………………………………………………………………………74
BackgroundandDiscussion…………………………………………………………………………74
SWOTAnalysis–EMSSystemCommunications……………………………………………77
ResponseTimes…………………………………………………………………………………………………….78
BackgroundandDiscussion…………………………………………………………………………78
SWOTAnalysis–ResponseTimes………………………………………………………………..90
CriticalCareTransport…………………………………………………………………………………………..91
BackgroundandDiscussion…………………………………………………………………………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
VenturaCountyEMSAgency 4 EMSSystemAssessmentReportVERSION2.0
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
VenturaCountyEMSAgency 5 EMSSystemAssessmentReportVERSION2.0
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
VenturaCountyEMSAgency 6 EMSSystemAssessmentReportVERSION2.0
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
VenturaCountyEMSAgency 7 EMSSystemAssessmentReportVERSION2.0
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
VenturaCountyEMSAgency 8 EMSSystemAssessmentReportVERSION2.0
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.
VenturaCountyEMSAgency 9 EMSSystemAssessmentReportVERSION2.0
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.
VenturaCountyEMSAgency 10 EMSSystemAssessmentReportVERSION2.0
LimitationsandDisclaimers
Ourfirmwasengagedinaconsultingcapacity,notinalegalcapacity.Accordingly,itisbeyondthescopeofthisengagementforustoprovidealegalanalysisofissuespresented.
Methodologiesemployedtoconductthisreview(i.e.,stakeholdermeetingsandreviewofcertainavailabledata)haveinherentlimitations.Stakeholderinput,whileimportanttoanyEMSsystemassessment,naturallytendstoreflectbuilt‐inbiasesandpoliticalconsiderationsofthestakeholders.Inaddition,anyassumptionsoroptionspresentedbasedonavailabledatawillinevitablydependupontheaccuracy,completenessandsuitabilityofthedataprovided.
Thisreportisprovidedwiththeexpectationthatitwillbecomeapublicrecord.
VenturaCountyEMSAgency 11 EMSSystemAssessmentReportVERSION2.0
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
VenturaCountyEMSAgency 12 EMSSystemAssessmentReportVERSION2.0
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.
VenturaCountyEMSAgency 13 EMSSystemAssessmentReportVERSION2.0
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.
VenturaCountyEMSAgency 14 EMSSystemAssessmentReportVERSION2.0
Strengths•MedianincomeaboveCAaverage•PercentageofpersonsinpovertyisbelowCAaverage•VCEMSAstaffrunaresponsiveandthoroughprogramwhichreceiveshighmarksfromstakeholdersdespiteastaffinglevellowerthanmostotherLEMSAsonaperpopulationbasis
Weaknesses•PopulationgrowthratebelowCAaverage
Opportunities•Higher%of65+populationthanstatewideaverage•Slightlyhigher%ofpopulationincivilianlaborforcethanCAaverage
Threats•Higher%ofpopulationwithouthealthinsurancethanCAaverage
SWOTAnalysis–CountyDemographics
VenturaCountyEMSAgency 15 EMSSystemAssessmentReportVERSION2.0
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
VenturaCountyEMSAgency 16 EMSSystemAssessmentReportVERSION2.0
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
VenturaCountyEMSAgency 17 EMSSystemAssessmentReportVERSION2.0
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.
VenturaCountyEMSAgency 18 EMSSystemAssessmentReportVERSION2.0
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.
VenturaCountyEMSAgency 19 EMSSystemAssessmentReportVERSION2.0
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).
VenturaCountyEMSAgency 20 EMSSystemAssessmentReportVERSION2.0
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
VenturaCountyEMSAgency 21 EMSSystemAssessmentReportVERSION2.0
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.
VenturaCountyEMSAgency 22 EMSSystemAssessmentReportVERSION2.0
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.
VenturaCountyEMSAgency 23 EMSSystemAssessmentReportVERSION2.0
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
VenturaCountyEMSAgency 24 EMSSystemAssessmentReportVERSION2.0
adaptthesystemtoservethechangingneedsofitscitizens,understandthepotentialofitsEMSproviderworkforcetoservethosechangingneeds,andhavethesystemevolvetoharnessthatpotentialtomaximizethecontributionoftheEMSworkforcetothehealthandwellbeingoftheCounty’scitizens.
Strengths•StakeholdersreportgeneralsatisfactionwithLEMSA•RobustQIprograminvolvesanactivecollaborativeprocesswithallclinicalstakeholders,includinghospitals
Weaknesses•LEMSAstaffinglevelbelowCAaverage•Stakeholdersreportstringentandinflexiblestaffingrequirements•Non‐competitiveEMSwagescreateEMSpractitionerretentionissue•LevelI/IIparamedicpolicyreportedascreatinginefficiencyandexpense
Opportunities•Continuemovementtowardpatient‐focusedQImetrics•Potentialimplementationofpreceptorshipmodel
Threats•Needtokeeppaceinprovidereducationandtrainingtoprovideexpandedrangeofintegratedcareservicesinfuture
SWOTAnalysis–LocalEMSAgency/SystemIssues
VenturaCountyEMSAgency 25 EMSSystemAssessmentReportVERSION2.0
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
VenturaCountyEMSAgency 26 EMSSystemAssessmentReportVERSION2.0
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
VenturaCountyEMSAgency 27 EMSSystemAssessmentReportVERSION2.0
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
VenturaCountyEMSAgency 28 EMSSystemAssessmentReportVERSION2.0
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
VenturaCountyEMSAgency 29 EMSSystemAssessmentReportVERSION2.0
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
VenturaCountyEMSAgency 30 EMSSystemAssessmentReportVERSION2.0
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
VenturaCountyEMSAgency 31 EMSSystemAssessmentReportVERSION2.0
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.
VenturaCountyEMSAgency 32 EMSSystemAssessmentReportVERSION2.0
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
VenturaCountyEMSAgency 33 EMSSystemAssessmentReportVERSION2.0
Notethatproviderfinancialsdiscussedinthissectionarebasedonself‐reportedinformationfromthecontractedproviders.Wewerenotengagedto,nordidwe,performindependentauditsofproviderfinancialstatements.
AMR
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
VenturaCountyEMSAgency 34 EMSSystemAssessmentReportVERSION2.0
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.
VenturaCountyEMSAgency 35 EMSSystemAssessmentReportVERSION2.0
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
AMR
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.
VenturaCountyEMSAgency 36 EMSSystemAssessmentReportVERSION2.0
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.
VenturaCountyEMSAgency 37 EMSSystemAssessmentReportVERSION2.0
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.
VenturaCountyEMSAgency 38 EMSSystemAssessmentReportVERSION2.0
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.
VenturaCountyEMSAgency 39 EMSSystemAssessmentReportVERSION2.0
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.
VenturaCountyEMSAgency 40 EMSSystemAssessmentReportVERSION2.0
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
VenturaCountyEMSAgency 41 EMSSystemAssessmentReportVERSION2.0
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
VenturaCountyEMSAgency 42 EMSSystemAssessmentReportVERSION2.0
Table7:VenturaCountyProviderResponseTimeCompliance
andPenaltiesPaid2016‐2018
BasedonVCEMSAFirstWatchData
Entity
AMR
(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
VenturaCountyEMSAgency 43 EMSSystemAssessmentReportVERSION2.0
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
VenturaCountyEMSAgency 44 EMSSystemAssessmentReportVERSION2.0
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.
VenturaCountyEMSAgency 45 EMSSystemAssessmentReportVERSION2.0
Strengths•FavorablepayormixcomparedtootherCaliforniacounties• Lowerproviderchargesthaninmanycounties•LowerassessedfinesthanmanyotherCaliforniacounties
Weaknesses•Commercialplansmovingtohigherdedudctibles,creatingmorenon‐insuredpatienthealthcaredebt•Regulationofnon‐emergencyrateswhensystemexclusivityislimitedtoemergencyambulanceservices
Opportunities•Generallypositiveprofitmarginsamongthethreeproviders•NewpaymentmodelssuchasET3andcostcollection
Threats•Pressureforrateincreaseslilelytogrow•Oneproviderreportednegativeprofitmarginin2018•Impactofproviderfeesandongoingsystemsustainabilityneedstobekeptintheforefront•ProvidersusceptibilitytoMedicareoverpaymentdemands
SWOTAnalysis–SystemFinancials
VenturaCountyEMSAgency 46 EMSSystemAssessmentReportVERSION2.0
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
VenturaCountyEMSAgency 47 EMSSystemAssessmentReportVERSION2.0
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).
VenturaCountyEMSAgency 48 EMSSystemAssessmentReportVERSION2.0
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).
VenturaCountyEMSAgency 49 EMSSystemAssessmentReportVERSION2.0
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)
X X
St. John’s Regional
Medical Center (SJO)
X X X X X
Ventura County Medical Center
(VMC) X X
* Pending X
85Unlessotherwisenoted,theinformationprovidedunderthisheadingistakenfromtheVenturaCounty2017EMSPlanUpdate.
VenturaCountyEMSAgency 50 EMSSystemAssessmentReportVERSION2.0
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
VenturaCountyEMSAgency 51 EMSSystemAssessmentReportVERSION2.0
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
EOA2
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
EOA3
SimiValleyEast 4322EileenSt,SimiValley,CA93063
MED431,24‐hr,7days,0700‐0700
SimiValleyWest 665‐CLosAngelesAve,SimiValley,CA93065
MED432,24‐hr,7days,0700‐0700
EOA4
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
EOA5
VenturaCountyEMSAgency 52 EMSSystemAssessmentReportVERSION2.0
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
EOA6
Oxnard 200BernoulliCircle,Oxnard,CA93030
MED691,12‐hr,7days,1000‐2200MED692,24‐hr,7days,0700‐0700
Oxnard 401NorthAStreet,Oxnard,CA93030
MED662,24‐hr,7days,0700‐0700MED663,24‐hr,7days,0700‐0700
PortHueneme 2675SouthVenturaRdPortHueneme,CA93033
MED664,24‐hr,7days,0700‐0700
Oxnard 4225SaviersRd#7,Oxnard,CA93033
MED665,24‐hr,7days,0700‐0700
EOA7
Ventura,Central 3418LomaVistaRd#2a,Ventura,CA93003
MED481,24‐hr,7days,0700‐0700MED482,24‐hr,7days,0700‐0700
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
VenturaCountyEMSAgency 53 EMSSystemAssessmentReportVERSION2.0
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.
VenturaCountyEMSAgency 54 EMSSystemAssessmentReportVERSION2.0
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.
VenturaCountyEMSAgency 55 EMSSystemAssessmentReportVERSION2.0
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
VenturaCountyEMSAgency 56 EMSSystemAssessmentReportVERSION2.0
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/
VenturaCountyEMSAgency 57 EMSSystemAssessmentReportVERSION2.0
‐ 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.
VenturaCountyEMSAgency 58 EMSSystemAssessmentReportVERSION2.0
torespondtocallswhereonlyBLSskillsarerequired,ambulanceservicesareincurringgreatercoststhanwarrantedfromaclinicalperspective.And,asmentionedabove,reimbursementisnotbaseduponthelevelofvehicle(BLSvs.ALS)thatisdeployed;itisbasedupontheinformationcommunicatedtothedispatcherandtheservicesrequiredbythepatient.Therefore,thereisalargesubsetofresponsesforwhichcomparativelyexpensiveALSunitsaredeployedwhenonlyBLS‐levelreimbursementcanproperlybereceived.
IthaslongbeenrecognizedasanindustrystandardofcarethatmedicallyvalidateddispatchprotocolswithdifferentialALS‐BLSresponsedeterminantscansafelyandeffectivelysupporttieredEMSsystemdeployment.Accordingly,werecommendthatVCEMSAshouldconsiderimplementationofaBLSresponseandtransporttierforthosecallsinwhichtheFCC’sdispatchprotocolspermitaBLS‐levelresponse.104Althoughtiereddeploymentisalong‐recognizedstandardofcareinEMS,VCEMSAmaywishtorequiresomeadditionaltrainingforEMTsandtoincorporatefocusedreviewofBLS‐onlyemergencyresponsesintoitssystemwideQIplanforaprescribedtimeperiodtoensurethatthedispatchresponsedeterminantsareresultinginappropriateBLSresponses.105
STEMI
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
VenturaCountyEMSAgency 59 EMSSystemAssessmentReportVERSION2.0
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.
VenturaCountyEMSAgency 60 EMSSystemAssessmentReportVERSION2.0
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
VenturaCountyEMSAgency 61 EMSSystemAssessmentReportVERSION2.0
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.
VenturaCountyEMSAgency 62 EMSSystemAssessmentReportVERSION2.0
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
VenturaCountyEMSAgency 63 EMSSystemAssessmentReportVERSION2.0
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
VenturaCountyEMSAgency 64 EMSSystemAssessmentReportVERSION2.0
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
VenturaCountyEMSAgency 65 EMSSystemAssessmentReportVERSION2.0
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
VenturaCountyEMSAgency 66 EMSSystemAssessmentReportVERSION2.0
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.
VenturaCountyEMSAgency 67 EMSSystemAssessmentReportVERSION2.0
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
VenturaCountyEMSAgency 68 EMSSystemAssessmentReportVERSION2.0
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.
VenturaCountyEMSAgency 69 EMSSystemAssessmentReportVERSION2.0
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.
VenturaCountyEMSAgency 70 EMSSystemAssessmentReportVERSION2.0
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.
VenturaCountyEMSAgency 71 EMSSystemAssessmentReportVERSION2.0
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.
VenturaCountyEMSAgency 72 EMSSystemAssessmentReportVERSION2.0
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/
VenturaCountyEMSAgency 73 EMSSystemAssessmentReportVERSION2.0
Strengths• VenturaCountyhasgrandfatheringeligibilityforallprovidersinallEOAs,givingittheoptiontomaintainsystemcontinutyandavoidtheexpenseofacompetitiveprocurement
• Effectivevoluntarypublic‐privatepartnershipswithfiredepartmentsforEMSfirstresponse
• Goodspecializedfacilitycapabilities• EfficientEMS‐hospitalinterfaceandrelativelylowAPOT
• Leadershipincommunityparamedicineneedsassessment
Weaknesses• Zone4deploymentinthreeoftheless‐populatedsub‐zonesinadequatetocoverdemand
• Inefficientdeploymentofall‐ALSresourcesregardlessofseverityofEMDresponsedeterminant
• NocurrentEMSHIEparticipation
Opportunities• AbilitytoaddaBLSresponseandtransporttiertomoreeffectivelymatchresourceswithdispatchcondition
• Buildoncommunityparamedicinemodelprogramsuccesstofulfillotheridentifiedcommunityneeds
• ImplementHIEparticipationbyEMS
Threats• Populationgrowthexceedinghospitalbedcapacity
SWOTAnalysis–EMSSystemDeployment
VenturaCountyEMSAgency 74 EMSSystemAssessmentReportVERSION2.0
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
BackgroundandDiscussion
VenturaCountyEMSAgency 75 EMSSystemAssessmentReportVERSION2.0
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.
VenturaCountyEMSAgency 76 EMSSystemAssessmentReportVERSION2.0
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.
VenturaCountyEMSAgency 77 EMSSystemAssessmentReportVERSION2.0
alsoHAMradiosintheCountyEmergencyOperationsCenter,intheHealthDepartment’sOperationsCenterandinDisasterResponseVehicles.AllCountyhospitalshavetheabilitytocommunicatewitheachotherthroughtheReddiNetsystemandsatellitebackupserviceisavailableforthatsystemintheeventofafailureofregularInternetconnections.149
149Id.;VCEMSAPolicyNo.920.ReddiNetCommunicationsPolicy.
Strengths• CentralizedsecondaryPSAPforallEMSdispatch
• EMDonallEMSemergencycalls• StrongpartnershipforEMSdispatchoperations
Weaknesses• EMDresponsedeterminantsnoteffectivelyutilizedsinceallresponseisatALSlevel
Opportunities• ObtainACEaccreditationforsecondaryPSAPthroughIAED
Threats• Interoperabilityinamulti‐jurisdicationalevent
SWOTAnalysis–EMSSystemCommunications
VenturaCountyEMSAgency 78 EMSSystemAssessmentReportVERSION2.0
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.
BackgroundandDiscussion
VenturaCountyEMSAgency 79 EMSSystemAssessmentReportVERSION2.0
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.
VenturaCountyEMSAgency 80 EMSSystemAssessmentReportVERSION2.0
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)
o PriorityCode2—Metro(10),Urban(15),Suburban(25),Rural(50),Wilderness(75)
o PriorityCode3—Metro(20),Urban(25),Suburban(30),Rural(50),Wilderness(75)
SanMateoCounty.Thiscountyuses2prioritycodesandappliesthemto3zones—Urban/Suburban,RuralandRemote.Theresponsetimerequirements
155Exceptfor2018,theseamountsarebasedonthenumbersofemergencyresponsesandemergencytransportslistedinthe2013VenturaCountyEMSSystemPlanandthe2014‐2017EMSSystemPlanUpdates.
VenturaCountyEMSAgency 81 EMSSystemAssessmentReportVERSION2.0
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.
VenturaCountyEMSAgency 82 EMSSystemAssessmentReportVERSION2.0
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.
VenturaCountyEMSAgency 83 EMSSystemAssessmentReportVERSION2.0
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.)
VenturaCountyEMSAgency 84 EMSSystemAssessmentReportVERSION2.0
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.
VenturaCountyEMSAgency 85 EMSSystemAssessmentReportVERSION2.0
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).
VenturaCountyEMSAgency 86 EMSSystemAssessmentReportVERSION2.0
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).
VenturaCountyEMSAgency 87 EMSSystemAssessmentReportVERSION2.0
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
VenturaCountyEMSAgency 88 EMSSystemAssessmentReportVERSION2.0
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
VenturaCountyEMSAgency 89 EMSSystemAssessmentReportVERSION2.0
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
VenturaCountyEMSAgency 90 EMSSystemAssessmentReportVERSION2.0
Strengths• Robust,data‐drivenmonitoringofcurrentperformancestandards
• Goodcontractorperformanceundercurrentstandardsexceptinless‐populatedEOA4sub‐zones
Weaknesses• Primaryrelianceonresponsetimemetricsforcontractualcompliance
• SubdivisionofEOA4intosub‐zonesleadstorepsonsetimedeficienciesin3ofthe4less‐populatedsub‐zones
Opportunities• Shiftincontractualcompliancemetricsawayfromresponsetimesandtowardimplementationofclinicalperformancestandardsandmetricswhichhaveaprovenimpactonpatientcare
Threats• Responsetimefocusforpenaltyassessmentincentivizespracticeswithoutaprovenconnectiontopatientcareoroutcomes
• Overutilizationofredlightsandsiren(RLS)
SWOTAnalysis–ResponseTimes
VenturaCountyEMSAgency 91 EMSSystemAssessmentReportVERSION2.0
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.
BackgroundandDiscussion
VenturaCountyEMSAgency 92 EMSSystemAssessmentReportVERSION2.0
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.
VenturaCountyEMSAgency 93 EMSSystemAssessmentReportVERSION2.0
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.”
VenturaCountyEMSAgency 94 EMSSystemAssessmentReportVERSION2.0
Strengths• CCTprovideravailability;2of3EOAprovidersincountyfurnishthislevelofservice
Weaknesses• Relativelyexpensivestaffingstandardswithnoprovenpatientbenefit;forcaseswhichrequirealevelofcarebeyondthescopeofaCCP,hospitalpersonnelcanbeutilized
Opportunities• ExclusiveOperatingAreaauthorityforasingleCCTprovidertoassuresustainablevolume
Threats• InsufficientcallvolumetoensureCCTsustainabilitywithstaffingstandardsascurrentlyconfigured
• WithoutacontractedproviderforCCT,entitiesfurnishingthislevelofservicecanexitmarketatanytime
SWOTAnalysis–CriticalCareTransport
VenturaCountyEMSAgency 95 EMSSystemAssessmentReportVERSION2.0
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,
BackgroundandDiscussion
BehavioralHealth
VenturaCountyEMSAgency 96 EMSSystemAssessmentReportVERSION2.0
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.
VenturaCountyEMSAgency 97 EMSSystemAssessmentReportVERSION2.0
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.
VenturaCountyEMSAgency 98 EMSSystemAssessmentReportVERSION2.0
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
VenturaCountyEMSAgency 99 EMSSystemAssessmentReportVERSION2.0
Strengths•Competitivenon‐emergencytransportmarketapeparstobemeetingdemandoffacilitiesandpatients•Contractorsreportthatnon‐emergencyutilizationnotplacingunduestrainonemergencydeployment,whichisgenerallysupportedbythedata
Weaknesses•Stakeholdersreportthatbehavioralhealthtransportsareconsumingexcessiveunithoursandthatambulanceresourcesarebeingutilizedmerelyduetounavailabilityofmoreappropriateresources
Opportunities•Deregulatenon‐emergencyratestoallowopenmarkettofunctionasintended
Threats•Inappropriaterelianceonambulanceresourcesforbehavioralhealthtransportcanresultinicnreasedsystemcostandmayrequiresubsidy
SWOTAnalysis–Non‐Emergency
VenturaCountyEMSAgency 100 EMSSystemAssessmentReportVERSION2.0
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
VenturaCountyEMSAgency 101 EMSSystemAssessmentReportVERSION2.0
‐ 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)
VenturaCountyEMSAgency 102 EMSSystemAssessmentReportVERSION2.0
‐ IncludeaprovisioninnewcontractsexpresslypermittingVCEMSAtoenterintoacompetitiveprocurementprocessintheeventVCEMSAconcludesthatexistingcontractorsarenotmeetingtheneedsoftheEMSsystem(p.104)
OneofthethresholdissuesfacingVCEMSAishowitshouldapproachthenextcontractingcycle.InCalifornia,alocalEMSagencyessentiallyhasthefollowingoptions:
1) MaintainEOAsbycontractingwithexistingproviderswhoareeligiblefor
grandfatheringunderHealthandSafetyCode§1797.224
2) ConductacompetitiveprocurementprocessinsomeorallexistingEOAs–orcreateasinglenewEOAornewEOAs–andenterintoexclusivecontractswithnewprovidersselectedasaresultofthecompetitiveprocess(notethatVCEMSAcanalsoincludenon‐emergency,interfacilityandCCTservicesinitscompetitiveprocess(es)ifitsochooses)
3) OpenthemarketinsomeorallEOAssothatanyqualifiedproviders
whichenterintocontractswithVCEMSAcanprovideservices
OptionsforFutureContractingCycle
VenturaCountyEMSAgency 103 EMSSystemAssessmentReportVERSION2.0
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
VenturaCountyEMSAgency 104 EMSSystemAssessmentReportVERSION2.0
procurementsundertakenbyotherlocalEMSagencieshaveincurredsignificantoppositionandunexpectedaddedexpenseduetothisunsettledenvironment.Inaddition,inanEMSsystemthatisfunctioningwell,asVentura’sis,thetimeandcostofacompetitiveprocessislikelynottoresultinabettersystemthanwhatVCEMSAcanachievebynegotiatingnewcontractswiththeexistingproviders. Finally,onceanEOAinCaliforniaiscompetitivelybid,itislikelythatgrandfatheredeligibilityisthereafterlostandcannoteverberestoredinthefuture.ThisassessmentrevealednocompellingreasonstoforeverabandonthegrandfatheredstatusthattheVenturaCountyEMSsystemenjoys.Wedo,however,recommendtheinclusionofprovisionsinthenextcycleofprovidercontractswhichexpresslypermitsVCEMSAtoenterintoacompetitiveprocessfortheselectionofnewcontractorsanytimeVCEMSAconcludesthatexistingcontractorsarenoteffectivelymeetingtheneedsoftheEMSsystem,thoughwebelievethethresholdforexercisingsuchanoptionshouldbequitehighandshouldnotbeutilizedunlessabsolutelynecessary.
VenturaCountyEMSAgency 105 EMSSystemAssessmentReportVERSION2.0
Appendices
VenturaCountyEMSAgency 106 EMSSystemAssessmentReportVERSION2.0
AppendixA
ProjectDocumentRequestList
VenturaCountyEMSAgency 107 EMSSystemAssessmentReportVERSION2.0
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
VenturaCountyEMSAgency 108 EMSSystemAssessmentReportVERSION2.0
(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
VenturaCountyEMSAgency 109 EMSSystemAssessmentReportVERSION2.0
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)
VenturaCountyEMSAgency 110 EMSSystemAssessmentReportVERSION2.0
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
VenturaCountyEMSAgency 111 EMSSystemAssessmentReportVERSION2.0
(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)
VenturaCountyEMSAgency 112 EMSSystemAssessmentReportVERSION2.0
AppendixB
SummaryofSelectedStakeholderComments
VenturaCountyEMSAgency 113 EMSSystemAssessmentReportVERSION2.0
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
VenturaCountyEMSAgency 114 EMSSystemAssessmentReportVERSION2.0
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
VenturaCountyEMSAgency 115 EMSSystemAssessmentReportVERSION2.0
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
VenturaCountyEMSAgency 116 EMSSystemAssessmentReportVERSION2.0
AppendixC
ProjectBibliography
VenturaCountyEMSAgency 117 EMSSystemAssessmentReportVERSION2.0
ProjectBibliography
Accessto911PublicSafetyCenters,EmergencyMedicalDispatch,andPublicEmergencyAidTraining.(2018).AnnalsofEmergencyMedicine,29.
Ali,K.(2018,August22).Prop.11isAboutPublicSafetyandEnsuringQuickEmergencyMedicalResponse.TheSanDiegoUnion‐Tribune.
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.
Blanchard,I.E.Etal(2011,April).EmergencyMedicalServicesResponseTimeandMortalityinanUrbanSetting.PrehospitalEmergencyCare.
Breen,N.Etal(2000).ANationalCensusOfAmbulanceResponseTimesToEmergencyCallsInIreland.JAccidEmergMed,392‐395.
Brollini,J.(2018,August22).Prop.11WillSkirtPayforAmbulanceWorkersandPutThematRisk.TheSanDiegoUnion‐Tribune.
Brown,L.Etal(2000).DoWarningLightsAndSirensReduceAmbulanceResponseTimes?PrehospitalEmergencyCare,70‐74.
CaliforniaHealthCareFoundation.(2018).CaliforniaHealthCareAlmanac.CaliforniaHealthCareFoundation.
Cannon,E.Etal(2016).AmbulanceResponseTimesAndMortalityInElderlyFallers.EmergencyMedicineJournal.
Clawson,J.Etal(1983).MedicalPriorityDispatch:ItWorks!!JournalofEmergencyMedicalServices.
FederalCommunicationCommission,(2018).FCCMasterPSAPRegistryasof03‐01‐2018.
VenturaCountyEMSAgency 118 EMSSystemAssessmentReportVERSION2.0
ContraCostaHealthServices.(2018).AmbulanceRatesEMS.RetrievedfromContraCosta:http://cchealth.org/ems/ambulance‐rates.php
Craig,A.M.Etal(2010).Evidence‐BasedOptimizationOfUrbanFirefighterFirstResponseToEmergencyMedicalServices9‐1‐1Incidents.PrehospitalEmergencyCare,109‐117.
Dami,F.(2015).PrehospitalTriageAccuracyinaCriteriaBasedDispatchCentre.BMCEmergencyMedicine,15‐32.
EMSSystemStandardsAndGuidelines.(1993,June).StateofCaliforniaEmergencyMedicalServicesAuthority.
EMSWorld.(2004,April01).EMSResponseTimeStandards.EMSWorld.
Harvey,A.L.Etal(1998).ActualvsperceivedEMSresponsetime.PrehospitalEmergencyCare,11‐14.
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.
InyoCountyExclusiveOperatingArea(EOA)1GroundEmergencyMedical(Ambulance)Transportation.(2016,February12).SanBernardino,CA.
Isenberg,D.Etal(2005).Doesadvancedlifesupportprovidebenefitstopatients?:Aliterature.PrehospDisasterMed.,265‐270.
JeffJ.Clawson,K.B.(2001).ThePrinciplesofEmergencyMedicalDispatch.SaltLakeCity:PriorityPress.
JeffJ.Clawson,R.L.(1990).ModernPriorityDispatch.Emergency.
Kahn,C.A.Etal(2001).CharacteristicsOfFatalAmbulanceCrashesInTheUnitedStates:An11‐YearRetrospectiveAnalysis.PrehospitalEmergencyCare,261‐269.
Kupas,D.F.(2017).LightsandSirenUsebyEmergencyMedicalServices(EMS):AboveAllDoNoHarm.MarynConsulting,Inc.
Kurz,M.C.Etal(2018).Advancedvs.BasicLifeSupportintheTreatmentofOut‐of‐Hospital.Resuscitation,132‐137.
VenturaCountyEMSAgency 119 EMSSystemAssessmentReportVERSION2.0
Lin,C.B.Etal(2012).EmergencyMedicalServiceHospitalPrenotificationIsAssociatedWithImprovedEvaluationandTreatmentofAcuteIschemicStroke.Circulation:CardiovascularQualityandOutcomes,514‐522.
MacKenzie,E.J.Etal(2006).ANationalEvaluationsoftheEffectofTrauma‐CenterCareonMortality.TheNewEnglandJournalofMedicine,366‐378.
MateoCounty,(2018,July18).NoticeOfRequestForProposalsOpportunityEmergencyAmbulanceServicesWithAdvanceLifeSupport(Als)AmbulanceTransports.
MAXWELL,R.J.Etal(1984).Qualityassessmentinhealth.BritishMedicalJournal,1470‐1472.
Morrison,L.J.Etal(2006).Prehospital12‐leadElectrocardiographyImpactonAcuteMyocardialInfarctionTreatmentTimesandMortality:aSystematicReview.AcademicEmergencyMedicine,84‐89.
Myers,J.B.Etal(2008).Evidence‐BasedPerformanceMeasuresForEmergencyMedicalServicesSystems:AModelForExpandedEmsBenchmarkingAStatementDevelopedByThe2007ConsortiumU.S.MetropolitanMunicipalities’EmsMedicalDirectors.PrehospEmergCare,141‐151.
Narad,R.A.Etal(1999).Regulationofambulanceresponse.PrehospitalEmergencyCare.
Nicholl,J.Etal(2007).Therelationshipbetweendistancetohospitalandpatientmortalityinemergencies:anobservationalstudy.EmergencyMedicineJournal,665‐668.
O’Keeffe,C.Etal(2010).RoleofAmbulanceResponseTimesintheSurvivalofPatientswithOut‐of‐HospitalCardiacArrest.EmergencyMedicineJournal,703‐706.
Okubo,M.Etal(2018).VariationinSurvivalAfterOut‐of‐HospitalCardiacArrestBetweenEmergencyMedicalServicesAgencies.JAMACardiology,E1‐E11.
Ong,M.E.Etal(2010).ReducingAmbulanceResponseTimesUsingGeospatial–TimeAnalysisofAmbulanceDeployment.ACADEMICEMERGENCYMEDICINE,951‐957.
Patterson,P.D.Etal(2001).ThelongitudinalstudyofturnoverandthecostofturnoverinEMS.PrehospEmergCare,209‐221.
Pell,J.P.Etal(2001).EffectofReducingAmbulanceResponseTimesonDeathsfromOutofHospitalCardiacArrest:CohortStudy.BMJ,1385‐1388.
Pit,S.R.Etal(2010).UsingPrehospitalElectrocardiogramstoImproveDoor‐to‐BalloonTimeforTransferredPatientsWithST‐ElevationMyocardialInfarction.CircCardiovascQualOutcomes,93‐97.
VenturaCountyEMSAgency 120 EMSSystemAssessmentReportVERSION2.0
Pons,P.T.Etal(2002).Eightminutesorless:doestheambulanceresponsetimeguidelineimpacttraumapatientoutcome?JEmergMed.,43‐48.
Pons,P.T.Etal(2005).ParamedicResponseTime:DoesItAffectPatientSurvival?AcademicEmergencyMedicine,594‐600.
Price,L.Etal(2016).Treatingtheclockandnotthepatient:ambulanceresponsetimesandrisk.BMJ,127‐130.
RequestForProposalNo.EMS‐901017ForEmergencyAmbulanceService,911Response,ALSTransport,andStandbyServicewithTransportationAuthorization.(2017,October27).SanLeandro,CA:AlamedaCountyHealthCareServicesAgency.
Ro,Y.S.Etal(2018).Associationbetweenthecentralizationofdispatchcentersanddispatcher‐assistedcardiopulmonaryresuscitationprograms:Anaturalexperimentalstudy.Resuscitation,29‐35.
Sampalis,J.S.Etal(1997).DirectTransporttoTertiaryTraumaCentersVersusTransferfromLowerLevelFacilities:ImpactonMortalityandMorbidityAmongPatientsWithMajorTrauma.JournalorTrauma,288‐295.
Sanddal,T.L.Etal(2010).AmbulanceCrashCharacteristicsintheUSDefinedbythePopularPress:ARetrospectiveAnalysis.EmergencyMedicineInternational.
Scott,G.Etal(2007).WithoutMinutesToSpare.Callprocessingtimeshouldreflectnatureofthecrisis.TheJournal,13.
Smith,D.Etal(2018,August20).AmbulanceCos.andClientsInk$21MDealinKickbacksSuit.Law360.
Studnek,J.R.Etal(2010).AssociationBetweenPrehospitalTimeIntervalsandST‐ElevationMyocardialInfractionSystemPerformance.Circulation,1464‐1469.
Thakore,S.Etal(2002).Emergencyambulancedispatch:isthereacasefortriage?JRSocMed.,126‐129.
TheTowardZeroDeathsSteeringCommittee.(2014).TowardZeroDeaths:ANationalStrategyonHighwaySafety.
U.S.CensusBureau.(2018,August31).QuickFactsventuraCounty,California.RetrievedfromU.S.CensusBureau
Weiss,S.Etal(2013).DoesAmbulanceResponseTimeInfluencePatientConditionamongPatientswithSpecificMedicalandTraumaEmergencies?SouthernMedicalJournal,230‐235.
VenturaCountyEMSAgency 121 EMSSystemAssessmentReportVERSION2.0
White,L.Etal(2010).Dispatcher‐assistedcardiopulmonaryresuscitation:risksforpatientsnotincardiacarrest.Sendto,91‐7.
Wilde,E.T.Etal(2009,July10).DoEmergencyMedicalSystemResponseTimesMatterforHealthOutcomes?NewYork.
Wolfberg,D.M.(2016,June6).EMSuseofredlightsandsirensisadangeroussacredcow.EMS1.
YS,R.Etal(2018).Associationbetweenthecentralizationofdispatchcentersanddispatcher‐assistedcardiopulmonaryresuscitationprograms:Anaturalexperimentalstudy.Resuscitation.,29‐35.