Existing law, the Emergency Medical Services System and the Prehospital Emergency Medical Care Personnel Act, establishes the Emergency Medical Services Authority, which is responsible for the coordination and integration of all state agencies concerning emergency medical services. Among other duties, the authority is required to develop planning and implementation guidelines for emergency medical services systems, provide technical assistance to existing agencies, counties, and cities for the purpose of developing the components of emergency medical services systems, and receive plans for the implementation of emergency medical services and trauma care systems from local EMS agencies.

The act also authorizes each county to develop an emergency medical services program and requires local EMS agencies to plan, implement, and evaluate an emergency medical services system. Existing law requires local EMS agencies to be responsible for the implementation of advanced life support systems, limited advanced life support systems, and for the monitoring of specified training programs for emergency personnel. Existing law defines advanced life support as special services designed to provide definitive prehospital emergency medical care, as specified, at the scene of an emergency, during transport to an acute care hospital, during interfacility transfer, and while in the emergency department of an acute care hospital until responsibility is assumed by that hospital. Existing law makes it a crime to violate the act, or the rules or regulations adopted under the act.

This bill would authorize a local emergency medical services agency to submit, as part of its emergency medical services plan, a plan to transport specified patients who meet triage criteria to a behavioral health facility or a sobering center, as defined. The bill would make conforming changes to the definition of advanced life support to include prehospital emergency care provided before and during, during transport to a behavioral health facility or a sobering center. The bill would authorize a city, county, or city and county to designate, and contract with, a sobering center to receive patients, and would establish sobering center standards. standards that apply to sobering centers, as specified.

This bill would also require the authority to adopt guidelines for the triage criteria and assessment procedures by July 1, 2020, and would require the authority to annually analyze the administration of the local plans and to report, issue certain reports, as specified.

By expanding an existing crime, this bill would impose a state-mandated local program.

The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement.

This bill would provide that no reimbursement is required by this act for a specified reason.

Existing law, the Emergency Medical Services System and the Prehospital Emergency Medical Care Personnel Act, establishes the Emergency Medical Services Authority, which is responsible for the coordination and integration of all state agencies concerning emergency medical services. Among other duties, the authority is required to develop planning and implementation guidelines for emergency medical services systems, provide technical assistance to existing agencies, counties, and cities for the purpose of developing the components of emergency medical services systems, and receive plans for the implementation of emergency medical services and trauma care systems from local EMS agencies.

The act also authorizes each county to develop an emergency medical services program and requires local EMS agencies to plan, implement, and evaluate an emergency medical services system. Existing law requires local EMS agencies to be responsible for the implementation of advanced life support systems, limited advanced life support systems, and for the monitoring of specified training programs for emergency personnel. Existing law defines advanced life support as special services designed to provide definitive prehospital emergency medical care, as specified, at the scene of an emergency, during transport to an acute care hospital, during interfacility transfer, and while in the emergency department of an acute care hospital until responsibility is assumed by that hospital. Existing law makes it a crime to violate the act, or the rules or regulations adopted under the act.

This bill would authorize a local emergency medical services agency to submit, as part of its emergency medical services plan, a plan to transport specified patients who meet triage criteria to a community care facility, behavioral health facility or a sobering center, as defined, in lieu of transportation to a general acute care hospital. defined. The bill would make conforming changes to the definition of advanced life support to include prehospital emergency care provided before and during, transport to a community care facility, as specified. The bill would also direct the Emergency Medical Services Authority to authorize a local EMS agency to add to its scope of practice for specified emergency personnel those activities necessary for the assessment, treatment, and transport of a patient to a community care facility. behavioral health facility or a sobering center. The bill would authorize a city, county, or city and county to designate, and contract with, a sobering center to receive patients, and would establish sobering center standards.

Existing law, the Emergency Medical Services System and the Prehospital Emergency Medical Care Personnel Act, establishes the Emergency Medical Services Authority, which is responsible for the coordination and integration of all state agencies concerning emergency medical services. Among other duties, the authority is required to develop planning and implementation guidelines for emergency medical services systems, provide technical assistance to existing agencies, counties, and cities for the purpose of developing the components of emergency medical services systems, and receive plans for the implementation of emergency medical services and trauma care systems from local EMS agencies.

The act also authorizes each county to develop an emergency medical services program and requires local EMS agencies to plan, implement, and evaluate an emergency medical services system. Existing law requires local EMS agencies to be responsible for the implementation of advanced life support systems, limited advanced life support systems, and for the monitoring of specified training programs for emergency personnel. Existing law defines advanced life support as special services designed to provide definitive prehospital emergency medical care, as specified, at the scene of an emergency, during transport to an acute care hospital, during interfacility transfer, and while in the emergency department of an acute care hospital until responsibility is assumed by that hospital.

This bill would authorize a local emergency medical services agency to submit, as part of its emergency services plan, a plan to transport specified patients to a community care facility, as defined, in lieu of transportation to a general acute care hospital. The bill would make conforming changes to the definition of advanced life support to include prehospital emergency care provided before and during, transport to a community care facility, as specified. The bill would also direct the Emergency Medical Services Authority to authorize a local EMS agency to add to its scope of practice for specified emergency personnel those activities necessary for the assessment, treatment, and transport of a patient to a community care facility.

Date of Hearing: May 16, 2018

ASSEMBLY COMMITTEE ON APPROPRIATIONS

Lorena Gonzalez Fletcher, Chair

ABPCA Bill Id:AB 1795

Author:(Gipson) – As Amended Ver:April 19, 2018

Urgency: No State Mandated Local Program: Yes Reimbursable: No

SUMMARY:

This bill allows specially trained paramedics to transport an individual to a designated behavioral health facility or sobering center instead of a hospital emergency department (ED). Specifically, this bill:

1. Authorizes a local emergency medical services agency (LEMSA) to submit, as part of its emergency medical services (EMS) plan, a plan to transport specified patients who meet triage criteria to a behavioral health facility or a sobering center, as defined.
2. Defines required components of such a plan, including standardized triage criteria and assessment procedures, data collection and submission, policies for transfer of care to an emergency department, quality improvement, minimum paramedic training, the recommendation of a local agency director, and provisions for notifying next of kin and for protecting patient information.
3. Authorizes a city, county, or city and county to designate, and contract with, a sobering center to receive patients, and establishes standards for sobering centers.
4. Requires the EMS Authority (EMSA), by July 1, 2020, to develop and, after approval by the Commission on Emergency Medical Services, adopt guidelines for triage criteria and assessment procedures and for collection and reporting of data.
5. Requires EMSA to annually review and publicly report on data submitted by LEMSAs pursuant to the activities authorized in this bill and to make recommendations.

FISCAL EFFECT:

1. One-time contract costs of $100,000 GF to EMSA for a project manager to assist with the transition from current pilot sites to full implementation.
2. Ongoing staff costs of $150,000 GF to EMSA to develop guidelines, collect data, create reports, review local EMS agency data, and make policy recommendations.

COMMENTS:

1. Purpose. According to the author, this bill will offer a more appropriate alternative to the emergency room for individuals who have mental health care needs or who are inebriated.
2. Background. California's 33 LEMSAs provide or coordinate the provision of EMS services in their regions. EMSA oversees LEMSAs by reviewing and approving local EMS plans and provides guidance and leadership to ensure consistency and quality of EMS care statewide. Since 2015, EMSA has sponsored community paramedicine pilot projects in a dozen California communities. Community paramedicine is a fairly new and evolving health care field that allows paramedics to function outside their traditional emergency response and transport roles to facilitate appropriate use of emergency care while enhancing access to primary care for medically underserved populations. The Office of Statewide Health Planning and Development’s (OSHPD) Health Workforce Pilot Project Program, through which the community paramedicine projects were administered, allows for laws governing health care providers' scope of practice to be relaxed in order to test new health care concepts.

This bill codifies the "alternative destination" pilot concept, which allows specially trained paramedics to route qualifying patients to a sobering center or mental health facility instead of a hospital ED, pursuant to specially tailored triage protocols. The goals of the alternate destination project concept are to relieve emergency room overcrowding, reduce costs, transport patients to care sites appropriate to meet their needs, and increase emergency services availability and options for the community.

Independent evaluations conducted by the University of California, San Francisco, have found no evidence of patient harm associated with implementation of the alternate destination pilot projects. Highlights from a report, updated May 4, 2018, include the following:

• Stanislaus’ alternate destination – mental health crisis center project enrolled 251 persons between September 2015 and September 2017. Persons enrolled received care from a mental health professional more quickly than persons with mental health needs who were not enrolled, because they did not have to first go to an ED for a medical evaluation and then be transported to a mental health crisis center. Very few (4%) had a secondary transfer to the emergency department, with no subsequent inpatient admissions.
• San Francisco’s alternate destination – sobering center project enrolled 400 persons between February 2017 and September 2017. Very few (2%) had a secondary transfer to the emergency department, with no subsequent inpatient admissions. The intensity of case management and supportive services available to acutely intoxicated persons treated at the sobering center was said to be greater than the intensity of services provided by EDs in San Francisco.

1. Support. This bill is co-sponsored by the County of Los Angeles (LA County) and the California Hospital Association (CHA), who contend appropriate alternatives to the ED are better for vulnerable patients who qualify for such transport. They note an evaluation shows paramedic transport to alternative destinations resulted in no adverse patient outcomes, decreased ED utilization, lowered costs, and enhanced public safety. This bill is supported by a wide array of EMS system stakeholders, including associations of fire chiefs, police chiefs, district attorneys, emergency nurses, social workers, cities, counties, county behavioral health directors, EMS administrators, EMS medical directors, and hospitals. American Civil Liberties Union of California and the Medical Board of California also support this bill.
2. Opposition. The California Nurses Association (CNA) opposes this bill, questioning the rigor and representativeness of the evaluation study and arguing this bill threatens patient safety and is based on pilots that are not yet complete.
3. Related Legislation. SB 944 (Hertzberg) creates the Community Paramedicine Act of 2018, which authorizes LEMSAs to develop a community paramedicine program, as defined. It is pending in the Senate Appropriations Committee.
4. Prior Legislation. AB 820 (Gipson), of the current session, allows a LEMSA to transport specified patients to a community care facility, as defined, in lieu of transportation to a hospital. AB 820 was referred to the Assembly Health Committee and not heard.

AB 1650 (Maienschein), of the current session, creates the community paramedicine program within EMSA and allowed EMSA to authorize LEMSAs to participate, as specified. AB 1650 was referred to Suspense File of this committee and was not heard.

Analysis Prepared by: Lisa Murawski / APPR. / (916) 319-2081

Date of Hearing: April 17, 2018

ASSEMBLY COMMITTEE ON HEALTH

Jim Wood, Chair

ABPCA Bill Id:AB 1795

Author:(Gipson) – As Amended Ver:April 2, 2018

SUBJECT: Emergency medical services: behavioral health facilities and sobering centers.

SUMMARY: Authorizes a local emergency medical services agency (LEMSA) to submit, as part of its emergency medical services (EMS) plan, a plan to transport specified patients who meet triage criteria to a behavioral health facility or a sobering center, as defined. Authorizes a city, county, or city and county to designate, and contract with, a sobering center to receive patients, and would establish sobering center standards. Requires the Emergency Medical Services Authority (EMSA) to adopt guidelines for the triage criteria and assessment procedures by July 1, 2020, and requires EMSA to annually analyze administration of local plans and issue a report, as specified. Specifically, this bill:

Definitions

1. Defines "behavioral health facility" as a "designated facility" or "facility designated by the county for evaluation and treatment," which is a facility that is licensed or certified as a mental health treatment facility or a hospital, and may include, but is not limited to, a licensed psychiatric hospital (APH), a licensed psychiatric health facility (PHF), and a certified crisis stabilization unit.
2. Defines "sobering center" as a noncorrectional facility designated by a city, county, or city and county, to provide a safe, supportive environment for intoxicated individuals to become sober.
3. Expands the existing definition of "advanced life support" to authorize the transport of patients to a behavioral health facility or to a sobering center.

Planning, triage, and training

1. Authorizes a LEMSA to submit, as part of its EMS plan, a plan to transport patients, who meet the triage criteria, to a behavioral health facility or to a sobering center. Requires the plan to include at least all of the following:
   1. Standardized triage criteria and assessment procedures based on peer-reviewed data to be used by Emergency Medical Technician - Paramedics (EMT-Ps) to identify patients to be transported to a behavioral health facility or to a sobering center. Requires the LEMSA to revise the triage criteria and assessment procedures to adhere to guidelines developed by EMSA;
   2. One or more policies for the treatment of patients being transported to a behavioral health facility or to a sobering center;
   3. One or more policies for the prompt transfer of patient care between prehospital care personnel and medical personnel at a behavioral health facility or at a sobering center, including, but not limited to, an assessment to determine if the patient's condition requires transport to an emergency department (ED) of a general acute care hospital;
   4. A list of behavioral health facilities and sobering centers that have agreed to participate and their hours of operation, including the hours when they are available to receive patients;
   5. A quality improvement plan that includes the submission of service data to the LEMSA and EMSA by participating behavioral health facilities and sobering centers to ensure the quality of the EMS services being provided. Requires the data to be redacted as necessary to ensure patient confidentiality and to be reported in aggregate form only, with no personally identifiable patient information;
   6. A training component for transport to a behavioral health facility as follows:
      1. A requirement that a participating EMT-P complete at least 32 hours of instruction on all of the following:
         1. Behavioral health crisis intervention, provided by a licensed physician and surgeon with experience in the ED of a general acute care hospital (GACH);
         2. Assessment and treatment of intoxicated patients; and,
         3. LEMSA policies for the triage, treatment, transport, and transfer of care, of patients to a behavioral health facility.
      2. A requirement that the LEMSA verify that the participating EMT-P has completed training in all of the following topics meeting the standards of the United States Department of Transportation National Highway Traffic Safety Administration National Emergency Medical Services Education Standards:
         1. Psychiatric disorders;
         2. Neuropharmacology;
         3. Alcohol and substance abuse:
         4. Patient consent;
         5. Patient documentation; and,
         6. Medical quality improvement.
   7. For transport to a sobering center, a training component that requires a participating EMT-P to complete at least eight hours of instruction, with a four-hour online didactic portion and a four-hour classroom portion, on all of the following:
      1. The impact of alcohol intoxication on the local public health and EMS system;
      2. Alcohol and substance use disorders;
      3. Triage and transport parameters;
      4. Health risks and intervention in stabilizing acutely intoxicated persons:
      5. Common conditions with presentations similar to intoxication; and,
      6. Disease process, behavioral emergencies, and injury patterns common to those with chronic alcohol use disorders.
   8. A policy requiring that a patient who meets the triage criteria for transport to a behavioral health facility or to a sobering center, but who requests to be transported to the ED of a GACH, must be transported to the ED of a GACH;
   9. A provision setting forth the recommendations of the appropriate county agency or director, including the county mental health director, for the transport of persons to a behavioral health facility, in support of the plan to transport patients meeting triage criteria to a behavioral health facility or to a sobering center; and,
   10. Provisions setting forth procedures for notification of next of kin and for the protection of the confidentiality of patient records consistent with applicable law, including but not limited to, the Confidentiality of Medical Information Act (CMIA) and the privacy provisions of the federal Health Insurance Portability and Accountability Act of 1996.
2. Specifies that these provisions do not authorize a LEMSA to adopt policies authorizing an EMT-P to initiate an involuntary detention or hold of a patient, also known as a "5150" hold.
   
   

Sobering centers

1. Authorizes a city, county, or city and county to designate, and contract with, one or more sobering centers for the receipt of intoxicated individuals for the purpose of providing a safe environment for individuals to regain sobriety, and requires a written agreement with the center to monitor safety and programmatic implementation pursuant to the agreement.
2. Requires a sobering center, pursuant to the agreement, to develop a plan to access EMS at one or more facilities providing emergency-level care.
3. Requires a sobering center to comply with all of the following:
   1. To provide one bed or mat per individual;
   2. To be equipped with, and maintain, an automated external defibrillator;
   3. To be adequately staffed and have at least one registered nurse (RN);
   4. To be equipped to monitor and treat intoxicated persons who do not require emergency medical care at a GACH;
   5. To establish medical and nursing standardized procedures for its nursing staff; and,
   6. To have sufficient bathroom and shower facilities to serve the projected caseload, including at least one Americans with Disabilities Act accessible option.

Reporting

1. Requires EMSA, by July 1, 2020, to develop and, after approval by the Commission on Emergency Medical Services, adopt guidelines for the triage criteria and assessment procedures and for the collection and reporting of data pursuant to 4) e) above.
2. Requires EMSA to annually do all of the following:
   1. Work in partnership with the LEMSAs to review and analyze the data reported pursuant to 4) e) above;
   2. Analyze EMT-P training provided pursuant to the quality improvement plan outlined in 4) e) above including, but not limited to a statewide analysis of the data to provide feedback to LEMSAs;
   3. Issue a report that includes at least all of the following:
      1. A provision setting forth the analysis required in a) and b) above;
      2. Detailed findings on the past and current status of LEMSA plans submitted pursuant to 4) above;
      3. An assessment of patient outcomes in the aggregate resulting from services provided under approved plans; and,
      4. Policy recommendations for improvement of administration of local plans for the improvement of patient outcomes.
3. Requires the first annual report to be issued by January 1, 2021.
4. Requires the reports to be public records and to be retained by EMSA and made available to the public by posting on its Internet Web site.
   
   
   

EXISTING LAW:

1. Establishes EMSA and grants EMSA the authority, utilizing regional and local information, to assess each EMS area for the purpose of determining the need for additional EMS services, coordination of EMS, and the effectiveness of EMS. Requires EMSA to develop planning and implementation guidelines for EMS systems which address the following components:
   1. Manpower and training;
   2. Communications;
   3. Transportation;
   4. Assessment of hospitals and critical care centers;
   5. System organization and management;
   6. Data collection and evaluation;
   7. Public information and education; and,
   8. Disaster response.
2. Requires EMSA to provide technical assistance to existing agencies, counties, and cities for the purpose of developing the components of EMS systems, and requires EMSA to adopt rules and regulations as may be reasonable and proper, and to enable EMSA to perform its duties.
3. Defines "advanced life support" as special services designed to provide definitive prehospital emergency medical care, including, but not limited to, cardiopulmonary resuscitation, cardiac monitoring, cardiac defibrillation, advanced airway management, intravenous therapy, administration of specified drugs, and other specified techniques and procedures administered by authorized personnel under the direct supervision of a base hospital as part of a local EMS system at the scene of an emergency, during transport to an acute care hospital, during inter-facility transfer, and while in the ED of an acute care hospital until responsibility is assumed by the emergency or other medical staff of that hospital.
4. Establishes the Health Workforce Pilot Projects (HWPP) Program within the Office of Statewide Health Planning and Development (OSHPD) which allows organizations to test, demonstrate, and evaluate new or expanded roles for healthcare professionals, or new healthcare delivery alternatives before changes in licensing laws are made by the Legislature.
5. Establishes, through regulation, minimum standards required for HWPPs that:
   
   1. Provide for patient safety;
   2. Provide qualified instructors to prepare trainees;
   3. Assure that trainees have achieved a minimal level of competence before they enter the employment/utilizations phase;
   4. Inform trainees that there is no assurance of a future change in law or regulation to legalize their role;
   5. Demonstrate that the project has sufficient staff to monitor trainee performance and to monitor trainee supervision during the employment/utilizations phase;
   6. Possess the potential for developing new or alternative roles for health care personnel or for developing a reallocation of health care task, which would improve the effectiveness of health care delivery systems; and,
   7. Demonstrate the feasibility of achieving project objectives.
6. Defines an EMT-P, paramedic, or mobile intensive care paramedic as an individual whose scope of practice is to provide advanced life support according to specified standards.
7. Licenses and regulates hospitals, including GACHs and APHs, by DPH. Permits GACHs, in addition to the basic services all hospitals are required to offer, to be approved by DPH to offer special services, including an ED, and psychiatric services.
   
8. Requires hospital EDs, under the federal Emergency Medical Treatment and Active Labor Act (EMTALA), to provide emergency screening and stabilization services without regard to the patient’s insurance status or ability to pay. Federal EMTALA imposes this requirement on any hospital that participates in Medicare. State law imposes this requirement on any hospital that operates an ED.
9. Requires, in state law, emergency services and care to be provided to any person requesting the services or care, or for whom services or care is requested, for any condition in which the person is in danger of loss of life, or serious injury or illness, at any health facility that maintains and operates and ED, when the health facility has appropriate facilities and qualified personnel available to provide the services and care. Prohibits the provision of emergency services and care from being based upon the person's ethnicity, citizenship, age, preexisting medical condition, insurance status, economic status, ability to pay, age, sex, or physical or mental disability, except to the extent that a circumstance is medically significant to the provision of appropriate medical care to the patient.
10. Establishes the federal Health Insurance Portability and Accountability Act of 1996 (HIPAA) and the state CMIA. HIPAA, among other things, provides standards for privacy of individually identifiable health information and security standards for the protection of electronic protected health information. CMIA defines medical information to mean, among other things, any individually identifiable information, in electronic or physical form, in possession of or derived from a provider of healthcare regarding a patient’s medical history, mental or physical condition, or treatment.
11. Establishes the Lanterman-Petris-Short (LPS) Act and declares the intent of the Legislature to end the inappropriate, indefinite, and involuntary commitment of persons with mental health disorders, developmental disabilities, and chronic alcoholism, as well as to safeguard a person’s rights, provide prompt evaluation and treatment, and provide services in the least restrictive setting appropriate to the needs of each person.
12. Authorizes, under Section 5150 of the Welfare and Institutions Code, a peace officer, member of the attending staff of a designated facility, member of the attending staff of a designated facility, or other professional person designated by the county, upon probable cause, to take a person with a mental disorder who is a danger to self or others, or is gravely disabled, into custody (a “5150” hold) and place him or her in a designated facility.
13. Defines “designated facility” or “facility designated by the county for evaluation and treatment” as a facility that is licensed or certified as a mental health treatment facility or a hospital, as defined, and includes, but is not limited to, APHs, PHFs, and a certified crisis stabilization unit.

FISCAL EFFECT: This bill has not yet been analyzed by a fiscal committee.

COMMENTS:

1. PURPOSE OF THIS BILL. The author states that many of us have personally experienced waiting in an ED for hours at a time. EDs have a primary responsibility, which is to serve as a rapid response to emergencies whether they are individual medical crises or mass disasters. The author contends they are not well-equipped to serve patients who have mental health care needs or those who are inebriated, as these individuals often require specialized care and access to supportive services. California’s health care needs have evolved over time and the current emergency response system must be updated to reflect this. The author concludes this bill will ensure that well-trained paramedics will have the option to direct a person to a mental health urgent care center or sobering center to receive timely and appropriate care, if the county authorizes alternate destination care into their emergency response plan.
2. BACKGROUND.
   1. Hospital ED usage. According to a 2010 study by the RAND Corporation, between 14% and 27% of all ED visits are for non-urgent care and could take place in a different setting, such as a doctor’s office, after-hours clinic or retail clinic, resulting in a potential cost savings of $4.4 billion annually. A 2010 study published in the Annals of Emergency Medicine found that frequent users comprised 4.5% to 8% of all ED patients, yet account for 21% to 28% of all visits. Patients with co-occurring chronic disease, mental illness and/or substance use disorders may use the ED periodically as their only source of care. According to the Agency for Healthcare Research and Quality, homelessness is also associated with frequent use of EDs, and that ED encounters were nine times higher among homeless single men, 12 times higher for homeless single women and 3.4 times higher for homeless adults in families.
   2. Existing shortage of psychiatric beds. According to a California Hospital Association (CHA) report, California's Acute Psychiatric Bed Loss, updated on January 11, 2018, as of 2015, California had 29 hospitals licensed as freestanding APHs and 28 county-based PHFs, which only provide care to individuals with acute behavioral needs. An additional 80 facilities have dedicated psychiatric units within GACHs. California has nearly 440 GACHs, of which about one-fifth have dedicated psychiatric units. Combined, these hospitals supply the 6,610 beds available around the state for individuals in need of short-term, acute level of care, psychiatric inpatient services. Of California's 58 counties, only 33 have inpatient psychiatric beds, and only 14 counties have inpatient psychiatric beds for children and adolescents. The CHA report notes that California has one psychiatric bed for every 5,922 people when the recommendation is one psychiatric bed for every 2,000 people.
   3. Sobering centers. Sobering centers are facilities that provide a safe, supportive, environment for mostly uninsured, homeless or marginally housed publicly intoxicated individuals to become sober. Sobering centers provide services for alcohol-dependent individuals that may have secondary problems such as drug abuse/dependence, mental illness and/or medical issues. Criteria for admission and support services available at the centers vary. The minimum age requirement is 18 with a length of stay from three to 14 hours per visit depending on the program and the program policy. Sobering centers do not require a commitment to abstinence to receive services although referrals for additional services are available. Transportation to the centers is most often by ambulance, sobering center operated vans, or law enforcement. San Francisco has operated a sobering center since 2003 under the San Francisco Department of Public Health, and has cared for 12,000 individuals with over 54,000 visits. The sobering center is a nurse-led program available 24/7 with registered nurse staffing, patient care assistants, medical assistants, and social workers providing case management.
   4. Designated facilities. Individual counties are responsible for determining whether GACHs, PHFs, APHs, and other licensed facilities qualify as designated facilities. While the intent of the LPS Act is for authorized individuals to take a person who has been placed on a 5150 hold to a designated facility, if one does not exist, or a person is suffering from another condition that requires immediate emergency medical services, the person is transported to the nearest facility, which is often a non-designated facility with an ED, which under both EMTALA and state law is required to provide emergency medical services to any individual who presents and requires emergency medical attention. In addition to inpatient facilities, counties can designate certain outpatient facilities under the LPS Act, such as crisis stabilization units. A crisis stabilization unit is generally open 24 hours a day, seven days a week, and provides up to 23 hours of psychiatric urgent care intended to stabilize a patient suffering from psychiatric distress, with the goal of stabilizing the patient and avoiding the need for inpatient care.
   5. Community Paramedicine (CP). According to the U.S. Department of Health and Human Services Health Resources and Services Administration (HRSA) Office of Rural Health Policy, CP is an emerging field in health care where EMTs and Paramedics operate in expanded roles in an effort to connect underutilized resources to underserved populations. Although EMTs and paramedics have operated in expanded roles in several other countries, such as Canada, England, and New Zealand, for many years, in the U.S. the concept first came with the publication of the Rural and Frontier EMS Agenda for the Future in 2004. That document defined CP as an organized system of services, based on local need, which are provided by EMTs and Paramedics integrated into the local or regional health care system and overseen by emergency and primary care physicians. According to HRSA, CP programs might focus on specific medical needs such as diabetic monitoring or on broader health care issues such as mental health.
   6. Current paramedic training. There are three levels of EMTs in California; basic (EMT), advanced (A-EMT), and Paramedic (EMT-P). EMT-Ps must be 18 years of age, have a high school diploma, or the equivalent, and have an EMT certification. Their training consists of 1,090 hours as follows: 450 hours are for didactic and skills labs, 160 hours for clinical; and, 480 hours for field internship. EMT-Ps must have a minimum of 40 advanced life support patient contacts, and must pass the National Registry of EMTs exam which include both written and skills exams, be licensed by EMSA, and have accreditation by their LEMSA. Licenses must be renewed every two years with completion of 48 hours of continuing education units.
   7. LEMSAs and 911 transports. EMSA provides statewide coordination and leadership for the planning, development, and implementation of LEMSAs. California has 33 LEMSAs that are providing emergency medical services for California’s 58 counties. Seven regional EMS systems and 26 single county agencies provide the services. Regional systems are usually comprised of small, more rural, less-populated counties and single-county systems generally exist in the larger and more urban counties. Both single and multi-county LEMSAs develop and submit five-year EMS plans and annual updates to EMSA for a local emergency EMS system according to the state system standards and guidelines. The purpose of the local EMS plans is to meet community EMS needs through the effective utilization of local resources.
      
      As noted in 3) in existing law above, the definition of advanced life support requires that 911 callers are taken to an acute care hospital having a basic or comprehensive ED. The location where paramedics can practice, i.e., at the scene of a medical emergency, during transport to an ED, during inter-facility transfer, and while in the ED until responsibility is assumed by hospital staff is also specified in code and regulations. Most other scope of practice definitions specify skills and activities but not location. In transporting patients to EDs, paramedics triage patients using protocols developed by their LEMSA to determine which location is best suited for the patient, for example, an ED with a trauma center, or a hospital specializing in treating stroke victims.
   8. CP Pilot Project - HWPP #173. HWPP #173 was initially approved on November 14, 2014 and two, one-year extensions were approved on November 14, 2015 and November 14, 2016 respectively. The project is sponsored by EMSA and originally allowed for the testing of the CP Program model at 12 projected sites located through the state. Thirteen CP Program projects were launched in 10 areas across the state, testing six different concepts for the practice of community paramedicine. Each concept was developed by a LEMSA to meet the needs of the local community, and implementation was customized based on local circumstances. All sites obtained approval from an institutional review board (IRB) and enrolled patients following consent procedures stipulated by the IRB. The six concepts are as follows: i) Post discharge follow-up; ii) Directly observed therapy for tuberculosis; iii) Hospice patient support; iv) 911 frequent users; v) Alternate destination – behavioral health; and, vi) Alternate destination – medical care.

A new project, San Francisco's alternate destination – sobering center project was approved and began enrolling patients in February 2017. Two projects, the UCLA Center for Pre-Hospital Care's post-discharge project and their alternate destination – urgent care project, have closed due to lack of resources and low enrollment, respectively. On September 22, 2017 OSHPD granted EMSA an additional one-year extension from November 14, 2017 to November 14, 2018.

For purposes of HWPP #173, EMT-Ps were eligible to be trained to perform as community paramedics if they had at least four years of experience, volunteered to participate in the pilot, and were sponsored by their LEMSA. A core curriculum was developed by the California Community Paramedic Educational Taskforce, adapted from a national curriculum to more accurately meet the standards of practice in California and approved by the HWPP prior to the training of community paramedics. The curriculum taught paramedics to address patient care and management from a whole-patient perspective, including psychological and social aspects of the patients' well-being, in addition to medical needs. The curriculum was delivered over a six-week period, and each site also provided clinical instruction on topics related to the CP concept. The curriculum included 48 hours of classroom-based instruction and four hours of clinical, hands-on training. Community paramedic trainees were also required to complete 56 hours of study outside the classroom.

Only the site supervisors from Alternate Destination – Urgent care projects and paramedics recruited to coordinate the Alternate Destination – Sobering project were required to complete the core curriculum because these concepts focus on clinical decision-making in the field regarding where to transport a patient. This is routine practice for paramedics, who must identify which patients to take to specialty care centers, such as stroke centers, that may not be the closest ED.

A team of evaluators at the Philip R. Lee Institute for Health Policy Studies and the Healthforce Center (formerly the Center for the Health Professions) at the University of California, San Francisco (UCSF), serves as the independent evaluator for the CP Program Project. In 2017, UCSF provided a report with data and evaluation for June 2015 through September 2016. An updated report was published on November 16, 2017. It covers the time period from the launch of each of the 14 projects through June 30, 2017. The provisions of this bill address two of the project components: alternate destination – mental health, and sobering centers. Below are the report findings for those concepts:

• • 1. San Francisco Sobering Center. In February 2017, the City and County of San Francisco (SF) joined the pilot project. As noted above, the center has cared for over 14,000 persons since opening in 2003. The center is open 24 hours a day, seven days a week and staffed by RNs who monitor patients throughout their stay. There are also social workers on staff who help patients obtain treatment for alcoholism, housing, Medi-Cal, Supplemental Social Security, and General Assistance. Most patients stay for four to 12 hours. Approximately 33% of patients are treated at the center multiple times a year and approximately 90% are homeless at the time that services are provided. SF has trained all paramedics on 911 crews to screen intoxicated patients to determine if they are eligible to enroll in the pilot project. Patients are deemed eligible for transport to the center if they have acute alcohol intoxication but do not have any medical or mental health needs and are not intoxicated due to consuming a substance other than alcohol. Patients who do not meet eligibility criteria are transported directly to an ED. Ten paramedics who have completed the full community paramedic training augment the paramedics on 911 crews. The community paramedics work with the sobering center's staff to perform quality assurance reviews. The sobering project enrolled 226 patients during its first five months of operation. Enrollment has fluctuated. Twenty-six of the 226 patients (12%) have visited the sobering center more than once. Five patients (2%) were transferred to an ED within six hours of admission to the sobering center. There were no adverse outcomes from secondary transfers. Most patients are white, non-Hispanic males.
       
       According to a 2012 Journal of Health Care for the Poor and Underserved article, “Safe Sobering: San Francisco's Approach to Chronic Public Inebriation,” lack of sufficient discharge options negatively influences the ability to create long-term plans for clients. For those seeking sobriety, the wait for a residential rehabilitation bed can be weeks, taking longer than the maximum 21 days allowed at medical detoxification. Therefore, clients are discharged from detoxification to shelters rather than transitioning directly to rehabilitation.
    2. Stanislaus County alternate destination – behavioral health. The Stanislaus pilot provides medical clearance for people with mental health needs and transports them directly to a county-operated mental health crisis center. The Stanislaus pilot developed two protocols/algorithms to use for the behavioral health pilot. The Well Person Algorithm is used by all paramedics to screen patients for need of immediate care and transport to an ED. Patients with vital sign derangements or elevated/low blood sugar should be seen in the ED. If it is determined that the patient’s vital signs are normal and the patient has a psychiatric crisis, the specially trained community paramedic is dispatched, and initiates the second algorithm, which is the Mental Health Clearance algorithm. The leadership of the Stanislaus pilot notes this is not an expansion of paramedic scope, rather an assessment tool for triage to the most appropriate destination. If the patient has no emergent medical needs, is not intoxicated, and is not violent, the community paramedic contacts the mental health crisis center to determine whether the county inpatient psychiatric facility located next door to the crisis center has beds available. If so, the paramedic gives the patient the option of being transported by ambulance to the crisis center instead of an ED. At the crisis center, mental health professionals evaluate the patient to determine what mental health services he or she needs. Eligibility for the pilot is limited to adults who are uninsured or enrolled in Medi-Cal because the county inpatient psychiatric facility does not accept patient with other types of health insurance.
       
       According to the UCSF report the program enrolled 227 persons through June 30, 2017. Most patients enrolled in recent months are "walk in" clients who come to the mental health crisis center for care and need to be screened for acute medical needs before the center can admit them. Enrollment is expected to increase in the near future because the project recently trained additional community paramedics. Only nine of patients enrolled in the project (4%) were transferred to an ED within six hours of arrival at the crisis center. Seven of the nine were subsequently transferred to an inpatient psychiatric facility. The other two were discharged from an ED without transfer. None of the transfers to an ED involved life-threatening conditions and none of the patients transferred were admitted for inpatient medical care. The UCSF evaluation found no evidence of patient harm caused by the alternate destination mental health project.
       
       According to data provided by Stanislaus county, the pilot recently passed 1100 patients in the program, approximately 40% triaged to the ED directly, 35% triaged to the ED (usually because of lack of bed space), and the final 25% triaged to the crisis stabilization psychiatric facility.  
       

1. SUPPORT. CHA and the County of Los Angeles (LA County) are the sponsors of this bill. LA County notes that allowing properly trained paramedics to transport patient to either a sobering center or to a behavioral health facility, if a determination has been made that emergency medical treatment is not necessary, will allow patients more timely access to specialized care, and help to alleviate hospital ED overcrowding. LA County states that this bill has been carefully crafted to ensure patient safety by having facilities appropriately staffed by medical personnel. LA County concludes that the bill would require paramedics to receive additional training in behavioral health crisis intervention, require EMSA to develop standardized triage criteria and assessment procedures for paramedics, and require LEMSAs to collect outcome data for submission to EMSA.
   
   CHA points out that several major cities across the country have developed alternate destination sites for receiving EMS patients with isolated inebriation and behavioral health crises, all with positive safety records. CHA states that patients experiencing an acute behavioral health crisis, with or without psychiatric holds applied, comprise an increasing proportion of EMS calls, and to help address the issue, EMSA, working with OSHPD established HWPP #173. For more than two years, Stanislaus County has participated in this pilot, which provides patients intensive crisis services as well as coordinated long-term mental health services within the community. Results show no adverse patient outcomes, decreased ED usage and costs, and enhanced public safety. The San Francisco Sobering Center, also a participant in the statewide pilot, not only safely observes intoxicated persons, but also connects at-risk individuals to a broader system of community-wide services. This leads to improved long-term care, housing and self-sufficiency. CHA concludes that study results for both pilots show no adverse patient outcomes, decreased ED utilization, lower costs and enhanced public safety.
   
   The Emergency Medical Services Administrators Association of California (EMSAAC) and the Emergency Medical Directors Association of California (EMDAC) support this bill stating that allowing prehospital personnel to transport patients to the appropriate care facility the first time, has the added benefit of eliminating secondary transfers, reducing unnecessary ED admissions, and increasing the availability of ambulances to respond to life-threatening emergencies. EMSAAC and EMDAC believe that the past 38 years have demonstrated that LEMSAs, through their expert physician leadership can safely design EMS plans that meet the needs of individual patients and the communities they serve.
   
2. OPPOSITION. The California Nurses Association (CNA) is opposed to the introduced version of this bill. CNA states that this bill threatens patient safety by authorizing the use of paramedics to provide healthcare services currently provided by physicians, registered nurses and social workers. CNA notes that the pilot projects are ongoing, and that the patient population enrolled in the pilot projects does not reflect California's diverse populations. CNA contends that during the review of the pilot projects, most of the data collection focused on cost savings, not patient outcomes. CNA also states that there is no tracking of the number of patients brought to the sobering center but refused admission by the center's staff, and that these numbers are important because they could be an indication that the paramedic made the wrong call out in the field in deciding to divert a patient to the sobering center rather than bringing the patient directly to the ED.
3. SUPPORT IF AMENDED. The California Ambulance Association (CAA) states it can only support this bill if it is amended to include provisions for reimbursement of the services. CAA notes that under existing law and regulations, ambulances must transport patients to acute care hospitals to qualify for payment for ambulance services: transport to alternate destinations such as psychiatric facilities or sobering centers are typically not eligible for reimbursement. CAA concludes that the transports being conducted as part of the pilot program are generally conducted for free and this is not sustainable.
4. OPPOSE UNLESS AMENDED. The California Chapter of the American College of Emergency Physicians (California ACEP) and the California Medical Association (CMA) oppose this bill unless it is amended. California ACEP states that they have significant concerns about an EMTs' ability to safely triage patients in the field and appropriately determine their medical conditions, pointing to a 2013 Journal of American Medicine study that found a nearly 90% overlap between symptoms of emergencies and non-emergencies. California ACEP requests amendments to further define the destinations, require sobering centers to be licensed, add non-discrimination protections for patients transported to sobering centers, and include a two-year sunset. California ACEP has expressed concerns that the training requirements in the bill are very different that those in the pilot program, at that triage protocols are left to each LEMSA to establish without any mention of the pilot program. CMA shares many of the same concerns and additionally notes the bill needs to more clearly define what the proposed scope expansion for EMTs' is, and what additional training requirements need to be fulfilled for EMTS are allowed to divert patients away from EDs.
5. RELATED LEGISLATION. SB 944 (Hertzberg) would create the Community Paramedicine Act of 2018. SB 944 would authorize a local EMS agency to develop a CP program, as defined, to provide specified community paramedic services. The bill would require the authority to review a LEMSA’s proposed CP program and approve, approve with conditions, or deny the proposed program within 6 months after it is submitted by the LEMSA. SB 944 is pending a hearing in the Senate Health Committee.
6. PREVIOUS LEGISLATION.
   1. AB 820 (Gipson) of 2017 would have allowed a LEMSA to transport specified patients to a community care facility, as defined, in lieu of transportation to a GACH. AB 820 was held in the Assembly Health Committee.
   2. AB 1650 (Maienschein) of 2017 would have created the CP Program within EMSA and allowed EMSA to authorize LEMSAs to participate in the CP Program to provide services utilizing EMT-P personnel for the delivery of medical care, as specified. AB 1650 was held in the Assembly Appropriations Committee.
   3. AB 451 (Arambula) of 2017 would have required an APH, and a psychiatric unit of a GACH, to comply with provisions of law requiring emergency services to be provided regardless of a patient’s ability to pay in order to treat a psychiatric emergency medical condition, as defined, regardless of whether the facility operates an ED, consistent with provisions of law requiring patients with emergency medical conditions to be stabilized, including a transfer when necessary to appropriate facilities. AB 451 was held in the Senate Appropriations Committee.
      
7. POLICY COMMENT. Opponents of this bill have expressed concerns that the proposed training requirements do not exactly mirror the training requirements in the pilot program. However, as noted in the background, only the site supervisors from Alternate Destination – Urgent Care projects and paramedics recruited to coordinate the Alternate Destination – Sobering project were required to complete the core curriculum, because these two concepts focused on clinical decision-making regarding where to transport a patient. Therefore, direct duplication of the pilot project training requirements may not be appropriate.
8. SUGGESTED AMENDMENTS. In order to strengthen patient protections and clarify provisions of the bill with respect to some EMSA protocols, the Committee may wish to amend the bill as follows:
   1. To clarify that there must be an RN at a sobering center at all times.
   2. To require, if a patient is transported to a behavioral health facility or to a sobering center, and, upon assessment is found to no longer meet the criteria for admission to a behavioral health facility or to a sobering center, the patient be immediately transported to the ED of a GACH.
   3. As currently drafted this bill does not define sobering centers as clinics, although sobering centers are required to have a contract with a city or county. The bill should be amended to clarify that sobering centers are required to be city and/or county run clinics.

REGISTERED SUPPORT / OPPOSITION:

Support

California Hospital Association (co-sponsor)

County of Los Angeles (co-sponsor)

Adventist Health Feather River

Adventist Health Lodi Memorial

Adventist Health St. Helena

Adventist Health Tehachapi Valley

Adventist Health Ukiah Valley

Alliance of Catholic Health Care

American Civil Liberties Union of California

Association of California Healthcare Districts

Association of Community Human Service Agencies

California Access Coalition

California Chamber of Commerce

California Contract Cities Association

California District Attorneys Association

California Emergency Nurses Association

California Fire Chiefs Association

California Police Chiefs Association

California State Association of Counties

Cedars-Sinai Los Angeles

Chapman Global Medical Center

City and County of San Francisco

City of Glendora

City of Indio

City of Los Angeles

City of Manhattan Beach

City of Santa Monica

City of Torrance

City of Whittier

College Hospital Costa Mesa

County Behavioral Health Directors Association of California

County of Alameda

County of Fresno

County of Kings

County of Los Angeles Fire Department

County of San Mateo

County of Santa Clara

Depression and Bipolar Support Alliance

Dignity Health

Dignity Health Bakersfield

El Camino Hospital

Emergency Medical Services Administrators Association of California

Fire Districts Association of California

Gateway Cities Council of Governments

Hospital Corporation of America

Jerold Phelps Community Hospital

Kings County Board of Supervisors

LA Care Health Plan

LAX Coastal Chamber of Commerce

Legal Services for Prisoners for Children

Los Angeles County Division of the League of California Cities

Los Angeles County Sheriff's Department

Los Angeles Fire Department

Mad River Community Hospital

Madera Community Hospital

Manhattan Beach Chamber of Commerce

Marshall Medical Center

Mayers Memorial Hospital District

MemorialCare

Methodist Hospital Southern California

Mission Community Hospital

National Alliance on Mental Illness Los Angeles County Council

National Association of Social Workers, California Chapter

National Sobering Collaborative

North Bay Healthcare

Orange County Global Medical Center

Peace Officers Research Association of California

PIH Health

Plumas District Hospital

Private Essential Access Community Hospitals

Providence St. Joseph Health

Rideout Health Group

San Gabriel Valley Council of Governments

San Gabriel Valley Economic Partnership

San Joaquin County Health Care Services Agency

San Joaquin Valley Rehabilitation Hospital

Scripps Health

Seneca Healthcare District

Sharp Chula Vista Medical Center

Sharp Coronado Hospital and Healthcare Center

Sharp Grossmont Hospital

Sharp Mary Birch Hospital for Women & Newborns

Sharp Memorial Hospital

Sharp Mesa Vista Hospital

Shasta Regional Medical Center

Sierra View Medical Center

Sonoma Valley Hospital

South Bay Cities Council of Governments

Stanford Health Care

Sutter Coast Hospital

Tenet Healthcare

Torrance Area Chamber of Commerce

United Hospital Association

Valley Children's Healthcare

Valley Industry and Commerce Association

Vista Del Mar Hospital

Watsonville Community Hospital

Wilmington Chamber of Commerce

Opposition
California Nurses Association

Analysis Prepared by: Lara Flynn / HEALTH / (916) 319-2097