Nancy Lapolla (EndPoint EMS Consulting) opened the meeting with introductions around the room and from those on the phone. Nancy reviewed the meeting norms prior to starting discussion items on the agenda.
2. Review of Notes from Last Meeting
Nancy Lapolla asked the group to review the meeting agenda and meeting notes from the previous meeting. There were no comments or changes requested by the group.
3. Community Paramedic Topic for Input
EndPoint opened the discussion with some information on the current state of Community Paramedic pilot projects in place within California. Pilot projects were implemented with the goal of improving access to timely healthcare while lowering overall health care costs. Some successes have been reported around the state, although a lack of sustainable funding sources continues to be a challenge.
EndPoint described the 7 types of pilot projects approved by the California EMS Authority:
- Post discharge follow up
- Alternate destination
- Frequent utilizer of 911 services intervention
- Public Health Collaboration for direct observation of medication compliance
- Sobering Centers
- Behavioral Health intervention
Alternate destinations need to have agreements with those agencies and have to have someone to see them all the time.
Endpoint shared a map indicating the type and location of the current California programs.
Potential benefits of different ways of addressing patient needs via a community paramedic program include reduction of ED time for patients while awaiting admission to a Behavioral Health facility, reduction of ED overcrowding and improved access to appropriate services unavailable in the ED environment. Post-discharge follow-up programs can reduce hospital readmission by catching issues early and intervening before an emergent situation develops. Collaboration with public health authorities in conducting directly observed TB therapy can free Public Health Nursing staff typically tasked to do the observation for other needed work. Hospice program integration can keep hospice patients enrolled in their program by avoiding hospital transport when patients can be cared for in their home setting.
Ambrose Stevens (American Medical Response) provided a presentation on the Ventura County Community Paramedic system and his experience working within it as a community paramedic. Ventura providers collaborated with Ventura County Public Health providing Direct Observation Therapy (DOT) for patients requiring TB medications. Patients required continuity of care over a six-month treatment regimen of daily oral medication with compliance monitored via direct observation. Four 24 hour paramedic supervisors trained as Community Paramedics filled in the gaps that Ventura County PH nursing staff couldn’t fill to provide DOT. EMS providers were able to observe a subset of homeless individuals undergoing DOT, with great results and completed treatment, without overburdening Public Health nurses.
Ventura County also participated in a project to better serve hospice patients that receive a 911 response. Patients enrolled in a hospice program are provided instructions to contact their provider rather than call 911 when they have a need for medical support, as EMS response will likely lead to a hospital transport. However, misunderstanding or miscommunication can result in a 911 call being placed by caregiver or family uncomfortable with the arrangement. Additionally, some assisted living facilities require 911 call for an unexpected change in condition or accidental fall, even for hospice enrollees. Under usual EMS protocols such situations typically result in a transport to a hospital ED. If the hospice patient is admitted, the situation could jeopardize ongoing hospice care eligibility.
Under the Pilot Program, Community Paramedics were authorized by the California EMS Authority and Ventura County EMS Agency to practice under the hospice provider’s license instead of EMS medical director. Community paramedics would respond in addition to the front line EMS response and were able to assess the situation prior to an ED transport. If situationally appropriate, Community Paramedic could coach family and/or caregivers on alternate ways to manage the hospice patient’s needs within the scope of the hospice setting and the training those caregivers had received as part of the program. Community Paramedics under expanded scope of practice were able to access and administer patient prescribed medications, or provide comfort interventions without a mandatory ED transport. Ambrose reported that significant changes in policy were required to implement the program and a culture shift for both EMS providers and their agencies was needed to make it successful. As with the DOT project, four 24- hour staffed paramedic supervisors from participating EMS provider agencies covered the entire County of Ventura. Each provider agency was an Exclusive Operating Area entity, but mutual aid agreements ensured coverage was available if there were multiple conflicting needs in one area. Response was provided by the on-duty supervisor in a Quick Response Vehicle in a non-emergent mode.
Ambrose was asked if a financial saving had been identified, and if had there been any conversations about having the entities receiving DOT or hospice support from EMS providers fund these programs to continue them? That part is more difficult to get that information. Less of an impact on system than originally thought.
David Caley, (Coast Life Support District) pointed out the ability of CLSD to utilize Redwood Coast Medical Services Gualala clinic as an alternate saves about 100 transports annually out of their service area. Transport time to an acute care hospital is roughly 2 hours out of area. Another issue identified was medication reconciliation post-discharge. Patients can be confused about new medications or changes in existing medications and this can lead to EMS calls and readmissions or poor outcomes. Could there be some language in new EOA contract that would have flexibility to grab onto these programs? Avoiding unneeded transports is not a need limited to the EOA, but still an EMS issue.
Another consideration is if the Community Paramedic program would be utilizing on-duty staff or added hours specific to the program. Community paramedics in Ventura are operating under a special arrangement for medical control; can that be duplicated in Sonoma? Is that even a requirement given the current EMS Authority position, or is there a legislative or regulatory change needed? All models need to be considered as well as the billing reimbursement.
Nathan DuVardo (United EMS Workers-AMR) mentioned Alameda County has a sobering center project that allows paramedics to bypass Hospital EDs with direct transport to alcohol rehab centers. Another system in place in the San Mateo County SMART program that sends a paramedic trained in Behavioral Health interventions to facilitate direct transport of patients appropriate for BH care to an alternate destination facility. Additionally, a majority of law enforcement are trained a MH assessments in that system and will transport them to an ED associated with BH services instead of a basic ED facility.
Dr. Omar Ferrari (Santa Rosa Memorial Hospital) talked about the challenges his ED faces with BH transports. Regulatory requirements for BH patients in the ED setting are significant and difficult to meet. Patients must have ED staff present at all times on an individual basis which depletes available ED staff and delays care to other patients, and can lead of ambulance offload delays downstream. Regulatory requirements for physical security are steep, with special locking doors and security barriers required in rooms that can board a BH client in the ED for a medical clearance. The process of clearing the patient and finding an available bed can place 2-5 patients in ED for 24-hour period. Dr. Ferrari strongly encouraged the system to create mechanisms to better serve such patients rather than transporting all of them to an ED the only option.
EndPoint EMS Consulting asked the group if they were supportive of a specific program or if the group preferred a general statement in the RFP that allows flexibility for a proposer to initiate at Community Paramedic Program (CPP) join the County as a partner. The consensus was to provide flexibility and innovation in the RFP and any subsequent agreement.
4. Training Program Student Placement Topic for Input
Art Hsieh (Santa Rosa Junior College- Public Safety Training Center) brought forward the issue of access to ambulance service provider agencies for student internship opportunities. EMT & paramedic students are required to have clinical time in hospitals and ambulance clinical sites each semester. Per state regulations, the school has 90 days to place students into clinical internship after conclusion of their classroom training.
Art said that historically 50% of SRJC students go on to be employees of local EMS partners including fire service and ambulance provider agencies. Art felt in most cases relationships with local providers have been strong, but there is increasing pressure from outside schools to find local placement within Sonoma County. Many other county Local EMS Agencies are reserving space within their jurisdictions for local programs. This reduces overall number of available internship sites and increases demand on the remaining unrestricted providers.
Additionally, within Sonoma County, provider agencies dealing with new hires due to retirements must ensure their own needs are met by internal preceptors ahead of offering spots to students. Art felt although smaller departments may each only precept a few interns every year, considered as a group, the smaller agencies fill a gap in needed internship spots. If 2-3 departments normally precepting 2-3 students are no longer available, those students must be placed out of county, and it becomes easier for them to leave county and ultimately leave the local workforce. Students have an easier time working as new providers in a system they are familiar with and they may establish a relationship with the interning organization that can benefit both. Art asked if it would be possible to exert some influence to reserve space locally for internships. Art asked if the requirement to reserve space for local programs could be a requirement for any EOA bidder. Currently a challenge to have students graduate with well-rounded education and experience.
Bryan Cleaver (CVEMSA) talked about some strategies to ensure Local students have priority. Students or the schools placing them are required to notify LEMSAs that they are entering the system. It would be possible to create a Paramedic intern application, signed off by local agencies including the local school to ensure sites are available locally first. SRJC could have priority, but not an exclusive right to student spots. It was pointed out that such solutions and the issue itself are broader topics with impact beyond the RFP process and stakeholder input meeting forum, but requirement for local access to the EOA provider was a valid point for consideration. Steve Suter (Santa Rosa Fire Department) mentioned his agency could consider taking on paramedic interns for 1st responder agencies or a portion of a larger internship that included some transport agency time as well.
Steve Herzberg (Bodega Bay FPD-Sonoma County Fire District) talked about the rural providers with lower call volume but longer transport times as willing to participate but feeling the current contact-based criteria limited their ability to finish students. His point was the length of time per call should count for several shorter contacts. The point was acknowledged with SRJC mentioning the possibility of exposure to longer patient contacts a potential enhancement to current internships, but also mentioned number of contacts is a regulatory requirement set by the State of California. That said, sharing load may include more than just urban areas, there is value in rural calls.
Upcoming Discussion Topics
Adam Radtke (Sonoma County Deputy Counsel) discussed the request from a previous meeting to move the EOA boundary discussion topic up in timeframe. Sonoma County Fire District Chief Mark Heine had expressed concern regarding the County position on his agency LAFCo process. Adam stated the position of the County including Department of Health Services and CVEMSA is defined within the county code as revised in the most recent ordinance and clarifies provider agency rights. Sonoma County Counsel’s Office has no plan to write a memo with any contrary position. Steve Herzberg affirmed that the County position is in keeping with the intent expressed in the ordinance. Adam had no legal objection with moving the EOA boundary discussion to February 18th.
Upcoming topics include the Inter-facility Transport (IFT) discussion on February 3rd, EOA Boundaries on February 18th and Clinical Performance on March 2ndMaterials submitted by Tuesday may be sent out to the group email list for consideration prior to the meeting.
Meeting adjourned. Next meeting will be held at County of Sonoma Department of Health Services Administration 1450 Neotomas Blvd, Santa Rosa in the Santa Rosa Conference Room on February 3rd 2020 from 10:00-11:30 AM.