Existing law law, the Coast Life Support District Act, establishes the Coast Life Support District and specifies the powers of the district. The district is authorized, among other things, to supply the inhabitants of the district emergency medical services, as specified.

This bill would additionally authorize the district to provide urgent medical care services.

This bill would make legislative findings and declarations as to the necessity of a special statute for the Coast Life Support District.

Existing law establishes the Coast Life Support District and specifies the powers of the district. The district is authorized, among other things, to supply the inhabitants of the district emergency medical services, as specified.

This bill would additionally authorize the district to provide urgent medical care services.

This bill would make legislative findings and declarations as to the necessity of a special statute for the Coast Life Support District.

 THIRD READING 

Bill No: AB 2262

Author:

:

Vote:

SENATE GOVERNANCE & FIN. COMMITTEE: 7-0, 6/13/18

AYES: McGuire, Nguyen, Beall, Hernandez, Hertzberg, Lara, Moorlach

SENATE HEALTH COMMITTEE: 9-0, 6/27/18

AYES: Pan, Nguyen, Beall, Hernandez, Leyva, Mitchell, Monning, Nielsen, Roth

ASSEMBLY FLOOR: 75-0, 4/23/18 - See last page for vote

SUBJECT:

SOURCE: Coast Life Support District

DIGEST:

This bill allows the Coast Life Support District (CLSD) to provide urgent medical care services.

ANALYSIS:

Existing law:

1. Creates CLSD and the CLSD Act, an uncodified special act that provides for the powers and duties of CLSD.
2. Authorizes CLSD to exercise the powers granted in the CLSD Act "for the purpose of supplying to the inhabitants of the district emergency medical services (EMS), including emergency ambulance service, basic life support services, limited advance life services, and advanced life support services, including medical equipment and supplies, within and without the district" subject to the Emergency Medical Services System and the Prehospital Emergency Medical Care Personnel Act.
3. Authorizes, if approved by a majority of the electors, CLSD to exercise the powers granted in the CLSD Act for the establishment, maintenance, and operation of one or more health care facilities at any location within CLSD for the benefit of CLSD.
4. Defines, pursuant to the CLSD Act, "health facility" or "health care facility" to include any facility, place or building duly licensed for the purpose of providing EMS.
5. Requires, pursuant to the CLSD Act, following the formation of the district, the Cortese-Knox-Hertzberg Local Government Reorganization Act of 2000 (Cortese-Knox-Hertzberg Act), of Division 3 (commencing with Section 56000) of Title 5 of the Government Code to govern any change of organization.
6. Authorizes, pursuant to the Cortese-Knox-Hertzberg Act, a local agency formation commission (LAFCO) in each county to control the boundaries and changes of organization of cities, county service areas, and most special districts.

This bill:

1. Expands the powers of CLSD to include, in addition to supplying EMS services to the inhabitants of the district, to also supply urgent medical care services.
2. Revises the definition of a health facility, for purposes of the CLSD Act, to include a facility, place, or building licensed for the purposes of providing urgent medical care services, in addition to those facilities licensed to provide EMS services.
3. Requires the board of CLSD, if it desires to exercise the power granted in this bill to provide urgent medical care services, to first receive the approval of the LAFCO, regardless of whether CLSD has provided similar services prior to the effective date of this bill.
4. Updates the references to the Cortese-Knox-Hertzberg Act to reflect the current statute governing this type of district.

Background

Local agency formation commissions. The Cortese-Knox-Hertzberg Act creates a LAFCO in each county to control the boundaries of cities, county service areas, and most special districts. The courts often refer to LAFCOs as the Legislature’s watchdog over boundary changes. To plan for the future boundaries and service areas of the cities and special districts, a LAFCO must adopt a policy document for each city and district called a sphere of influence. The LAFCO’s boundary decisions must be consistent with the spheres of influence of the affected cities or districts. Spheres must be updated at least every five years.

Local governments can only exercise their powers and provide their services where LAFCO allows them to. A local government that wants to expand its territory must ask LAFCO to annex new territory into the local government’s boundaries. Similarly, local governments that want to exercise new powers must receive LAFCO approval.

Coast Life Support District. The CLSD provides EMS to portions of Sonoma and Mendocino Counties along the coast. Created by the Legislature in 1986 (AB 4227, Hauser), the CLSD Act establishes the powers, duties, and governance of the district. Under the CLSD Act, CLSD can provide the residents of the district with EMS, including emergency ambulance service, basic life support services, limited advance life services, and advanced life support services.

Medical services can be difficult to access within CLSD’s territory: CLSD’s boundaries do not contain a hospital, and from the district’s center, the closest medical facilities with 24-hour medical care are between 90 minutes and two hours travel time. These are some of the longest transports in California to specialist care. To address this gap in health services, the voters in the district have approved several ballot measures to fund the provision of urgent care services—unscheduled services that are broader and more immediate than primary care but do not qualify as presenting an emergency. These measures include:

• Measure O (1997), which imposed a special tax for the provision of "after hours" urgent medical care services;
• Measures B and C (2012) to amend Measure O to eliminate the term "after hours" and, thereby, allow CLSD to provide urgent medical care services without limitation to time of day and with no change in the tax rate; and
• Measure J (2014) to authorize the levy of a special tax on parcels of real property to augment funding for expanding the availability for provision of urgent medical services.

The CLSD has entered into or funded contracts with health care professionals and otherwise augmented the provision of urgent and immediate care services in Gualala (where the district is headquartered), as well as EMS throughout the district’s territory. Specifically, CLSD contracts with Redwood Coast Medical Services (RCMS), which is a federally-supported clinic centrally located within the district, to receive emergency patients for stabilizing care. Because of the rural nature of the surrounding community—placing residents far from facilities that can provide higher levels of care—RCMS also provides immediate and urgent care services that are more expansive than their urban counterparts.

While voters have authorized the use of funds for urgent care services, and CLSD has contracted with RCMS to provide them, CLSD’s principal act does not explicitly authorize it to do so. The CLSD wants to amend their principal act to explicitly allow it to supply urgent care services.

Comments

Purpose of the bill. Rural areas face particularly sharp challenges when it comes to access to health care services: longer transit times, fewer nearby hospitals, and more limited services. The CLSD serves as an important source of medical care for many residents in Sonoma and Mendocino counties. Current law authorizes CLSD to provide EMS, but it is unclear whether the district may provide lower levels of care, such as urgent care. However, voters in the district have approved funding for urgent care activities because of the need for such services in the district, and CLSD has used these funds to provide those services in the past. AB 2262 clarifies that CLSD can provide urgent care services if it receives approval from the local LAFCO to do so, ensuring that the district is on firm legal footing when providing urgent care services. Voters in the district have shown they want these services and put their money where their mouth is; AB 2262 ensures that their will is fully carried out.

FISCAL EFFECT: Appropriation: Fiscal Com.: Local:

SUPPORT: (Verified 7/3/18)

Coast Life Support District (source)

California Association of Local Agency Formation Commissions

California Hospital Association

Mendocino Local Agency Formation Commission

Redwood Coast Medical Services

Sonoma Local Agency Formation Commission

OPPOSITION: (Verified 7/3/18)

None received

ASSEMBLY FLOOR: 75-0, 4/23/18

AYES: Acosta, Aguiar-Curry, Travis Allen, Arambula, Baker, Berman, Bigelow, Bloom, Bonta, Brough, Burke, Caballero, Calderon, Carrillo, Cervantes, Chau, Chávez, Chen, Chiu, Choi, Chu, Cooley, Cooper, Cunningham, Dahle, Daly, Eggman, Flora, Fong, Frazier, Friedman, Gallagher, Gipson, Gloria, Gonzalez Fletcher, Gray, Grayson, Harper, Holden, Irwin, Jones-Sawyer, Kalra, Kamlager-Dove, Kiley, Lackey, Levine, Limón, Low, Maienschein, Mathis, Mayes, McCarty, Medina, Melendez, Mullin, Muratsuchi, Nazarian, Obernolte, O'Donnell, Patterson, Quirk-Silva, Reyes, Rodriguez, Rubio, Salas, Santiago, Steinorth, Mark Stone, Thurmond, Ting, Voepel, Waldron, Weber, Wood, Rendon

NO VOTE RECORDED: Cristina Garcia, Eduardo Garcia, Quirk

Prepared by:

7/3/18 15:17:45

**** END ****

SENATE COMMITTEE ON HEALTH

Senator Dr. Richard Pan, Chair

BILL NO: AB 2262

SUBJECT: Coast Life Support District Act: urgent medical care services

SUMMARY:

Expands the powers of the Coast Life Support District to include, in addition to supplying emergency medical services to the inhabitants of the district, to also supply urgent medical care services.

Existing law:

1. Establishes the Emergency Medical Services Agency (EMSA), which is responsible for the coordination and integration of all state activities concerning emergency medical services (EMS), including the establishment of minimum standards, policies, and procedures.  [HSC §1797.100, et seq.]
2. Authorizes counties to develop an EMS program and designate a local EMS agency (LEMSA) responsible for planning and implementing an EMS system, which includes day-to-day EMS system operations. [HSC §1797.200, et seq.]
3. Permits, in rural areas, when the use of a hospital having a basic EMS special permit is precluded because of geographic or other extenuating circumstances, the LEMSA to authorize another facility to receive patients requiring EMS if the facility has adequate staff and equipment to provide these services, as determined by the medical director of the LEMSA. [HSC §1798.101]
4. Establishes the Coast Life Support District (CLSD) through the enactment of the CLSD Act, an uncodified statute that was created by AB 4227 (Hauser, Chapter 375, Statutes of 1986).
5. Permits CLSD to exercise certain specified powers for purposes of supplying to the inhabitants of the district EMS services, including emergency ambulance services, basic life support services, limited advanced life support services, and advanced life support services.

This bill:

1. Expands the powers of CLSD to include, in addition to supplying EMS services to the inhabitants of the district, to also supply urgent medical care services.
2. Revises the definition of a health facility, for purposes of the CLSD Act, to include a facility, place, or building licensed for the purposes of providing urgent medical care services, in addition to those facilities licensed to provide EMS services.
3. Requires the board of CLSD, if it desires to exercise the power granted in this bill to provide urgent medical care services, to first receive the approval of the local agency formation commission, regardless of whether CLSD has provided similar services prior to the effective date of this bill. Updates the references to the Cortese-Knox-Hertzberg Local Government Reorganization Act of 2000 to reflect the current statute governing this type of district.

FISCAL EFFECT:

This bill is keyed non-fiscal.

PRIOR VOTES:

COMMENTS:

1. Author’s statement. According to the author, in rural areas residents need to travel greater distances to access different points of the health care delivery system, sometimes requiring an overnight hotel stay. The author states that health care facilities in these areas are small, provide limited services, and often, due to geographic distance, extreme weather conditions, lack of public transportation, and challenging roads, rural residents are limited or prevented from accessing health care services. The author notes that current law establishing CLSD authorizes the district to provide EMS, but it is unclear whether CLSD may provide lower levels of care, such as urgent care. The author also notes that, in practice, the issue of whether an individual is, in fact, in an emergency varies by the circumstances, and in some cases, may not be resolved until after ambulance or other transport and examination and diagnosis by an appropriately licensed health professional has occurred. The individual may end up needing immediate or urgent care, but not emergency care as defined in the enabling legislation. The author concludes that, without clarifying the enabling legislation, patients may have to be redirected out of CLSD to receive lower levels of care.
2. Background. AB 4227 (Hauser) from 1986 is uncodified law which establishes CLSD as a Special District to provide EMS to a specified area within Sonoma and Mendocino Counties, covering 60 miles of coastline. There are no hospitals within the district. From its center, the closest medical facilities with 24-hour medical care are a minimum of 90 minutes to two hours travel time traversing the coast highway. These are some of the longest transports in California to tertiary care. CLSD provides ambulance transport (both a 24-7 advanced life support ambulance and an on-call basic life support ambulance), as well as emergency response training for fire departments, and CPR/AED training to the community.
   
   There have been five local ballot measures concerning CLSD: the original ballot measure required by Section 72 of Chapter 375 for the November 1986 ballot, setting an initial appropriation of $300,000; Measure O (1997) which imposed a special tax for the provision of the “after hours” urgent medical care services; Measures B and C (2012) to amend Measure O, to eliminate the term “After Hours” in order to allow CLSD to provide urgent medical care services without limitation to time of day and with no change in the tax rate; and, Measure J (2014) to authorize the levy of a special tax on parcels of real property to augment funding for expanding the availability for provision of urgent medical services.
   

CLSD has entered into, or funded, contracts with health care professionals and otherwise augmented the provision of urgent and immediate care services in Gualala (where the district is headquartered), as well as EMS throughout CLSD. Care is provided at Redwood Coast Medical Services (RCMS), which is a Federally Qualified Health Center (FQHC). Because this FQHC is in a rural area, it also provides immediate and urgent care services that are more expansive than their urban counterparts. RCMS has been approved until 2020, as an Alternative EMS Receiving Facility for the Coastal Valleys EMS Region. In 1997 it began an After Hours Urgent Care program to complement locally provided primary medical care, but it was terminated in 2009 after it was determined to be financially unsustainable. CLSD contracts with TeamHealth to provide after-hours telephone medical advice.

1. What is urgent care? This bill authorizes the CLSD to provide urgent medical care services. This term is not defined in the bill, nor does it appear to be defined elsewhere in statute, at least in regard to the licensing of health facilities. According to the Urgent Care Association (UCA), which was founded in 2004 and publishes the Journal of Urgent Care Medicine, an urgent care center is a medical clinic with expanded hours that is specially equipped to diagnose and treat a broad spectrum of non-life and limb threatening illnesses and injuries. Urgent care centers are enhanced by on-site radiology and laboratory services and operate in a location distinct from a freestanding or hospital-based emergency department. Care is rendered under the direction of an allopathic or osteopathic physician. Urgent care centers accept unscheduled, walk-in patients seeking medical attention during all posted hours of operation. According to UCA, “urgent care services” means: 1) a medical examination, diagnosis and treatment for non-life or limb threatening illnesses and injuries that are within the capability of an urgent care center which accepts unscheduled, walk-in patients seeking medical attention and is supported by on-site evaluation services, including radiology and laboratory services; and, 2) any further medical examination, procedure and treatment to the extent it is within the capabilities of the staff and facilities available at the urgent care center.
2. Double referral. This bill was heard in the Senate Governance and Finance Committee on June 13, 2018, and passed with a 7-0 vote.
3. Support. CLSD states in support that there is no hospital in its district, but it does have an FQHC that has been approved to accept ambulance transports for treatment and stabilization at its urgency care facility. CLSD states that its initial enabling legislation does not specifically authorize the district to provide urgent medical care services, and this bill simply clarifies that it can provide urgent medical care services. RCMS statues in support that because the LEMSA has designated RCMS as an EMS provider allowing them to accept ambulance traffic (one of four in California), it allows the ambulance service provided by CLSD to bring lower acuity patient to RCMS to be treated and released. This minimizes unnecessary transports, avoids clogging already impacted emergency rooms, and allows the paramedic to stay in the area to be available for other emergencies. The Sonoma Local Agency Formation Commission, the Mendocino Local Agency Formation Commission, and the California Association of Local Agency Formation Commissions all support this bill with amendments that were added to ensure CLSD obtains approval of the local agency formation commission to provide services under the new authority pursuant to existing law.

SUPPORT AND OPPOSITION:

Support: California Association of Local Agency Formation Commissions

California Hospital Association

Coast Life Support District

Mendocino Local Agency Formation Commission

Redwood Coast Medical Services

Sonoma Local Agency Formation Commission

Oppose: None received

-- END --

SENATE COMMITTEE ON GOVERNANCE AND FINANCE

Senator Mike McGuire, Chair

2017 - 2018 Regular

Coast Life Support District Act: urgent medical care services

Allows the Coast Life Support District to provide urgent medical care services.

Background

Local agency formation commissions. The Cortese-Knox-Hertzberg Act creates a local agency formation commission (LAFCO) in each county to control the boundaries of cities, county service areas, and most special districts. The courts often refer to LAFCOs as the Legislature’s watchdog over boundary changes. To plan for the future boundaries and service areas of the cities and special districts, a LAFCO must adopt a policy document for each city and district called a sphere of influence. The LAFCO’s boundary decisions must be consistent with the spheres of influence of the affected cities or districts. Spheres must be updated at least every five years.

Local governments can only exercise their powers and provide their services where LAFCO allows them to. A local government that wants to expand its territory must ask LAFCO to annex new territory into the local government’s boundaries. Similarly, local governments that want to exercise new powers must receive LAFCO approval.

Coast Life Support District. The Coast Life Support District (CLSD) provides emergency medical services (EMS) to portions of Sonoma and Mendocino counties along the coast. Created by the Legislature in 1986 (AB 4227, Hauser), the CLSD Act establishes the powers, duties, and governance of the district. Under the Act, CLSD can provide the residents of the district with EMS, including emergency ambulance service, basic life support services, limited advance life services, and advanced life support services.

Medical services can be difficult to access within CLSD’s territory: CLSD’s boundaries do not contain a hospital, and from the district’s center, the closest medical facilities with 24-hour medical care are between 90 minutes and two hours travel time. These are some of the longest transports in California to specialist care. To address this gap in health services, the voters in the district have approved several ballot measures to fund the provision of urgent care services—unscheduled services that are broader and more immediate than primary care but do not qualify as presenting an emergency. These measures include:

• Measure O (1997), which imposed a special tax for the provision of "after hours" urgent medical care services;
• Measures B and C (2012) to amend Measure O to eliminate the term "after hours" and, thereby, allow CLSD to provide urgent medical care services without limitation to time of day and with no change in the tax rate; and
• Measure J (2014) to authorize the levy of a special tax on parcels of real property to augment funding for expanding the availability for provision of urgent medical services.

The CLSD has entered into or funded contracts with health care professionals and otherwise augmented the provision of urgent and immediate care services in Gualala (where the district is headquartered), as well as EMS throughout the district’s territory. Specifically, CLSD contracts with Redwood Coast Medical Services (RCMS), which is a federally-supported clinic centrally located within the district, to receive emergency patients for stabilizing care. Because of the rural nature of the surrounding community—placing residents far from facilities that can provide higher levels of care—RCMS also provides immediate and urgent care services that are more expansive than their urban counterparts.

While voters have authorized the use of funds for urgent care services, and CLSD has contracted with RCMS to provide them, CLSD’s principal act does not explicitly authorize it to do so. The CLSD wants to amend their principal act to explicitly allow it to supply urgent care services.

Proposed Law

Assembly Bill 2262 authorizes CLSD to exercise its powers for the purposes of supplying to the inhabitants of the district urgent medical care services and amends the definition of “health facility” or “health care facility” in CLSD's enabling statute to include any facility, place, or building duly licensed for the purpose of providing urgent medical care services.

AB 2262 also clarifies that CLSD must seek LAFCO approval to exercise its powers, regardless of whether the board has provided services prior to the effective date of the bill and makes additional clarifying and technical changes.

State Revenue Impact

No estimate.

Comments

1. Purpose of the bill. Rural areas face particularly sharp challenges when it comes to access to health care services: longer transit times, fewer nearby hospitals, and more limited services. The CLSD serves as an important source of medical care for many residents in Sonoma and Mendocino counties. Current law authorizes CLSD to provide EMS, but it is unclear whether the district may provide lower levels of care, such as urgent care. However, voters in the district have approved funding for urgent care activities because of the need for such services in the district, and CLSD has used these funds to provide those services in the past. AB 2262 clarifies that CLSD can provide urgent care services if it receives approval from the local LAFCO to do so, ensuring that the district is on firm legal footing when providing urgent care services. Voters in the district have shown they want these services and put their money where their mouth is; AB 2262 ensures that their will is fully carried out.

2. Double-referral. The Senate Rules Committee has ordered a double referral of AB 2262: first to the Senate Governance and Finance Committee to hear issues related to local governments, and then to the Senate Health Committee, which has jurisdiction over health care.

3. Special legislation. The California Constitution prohibits special legislation when a general law can apply (Article IV, §16). AB 2262 contains findings and declarations explaining the need for legislation that applies only to the Coast Life Support District.

Assembly Actions

Assembly Health Committee: 14-0

Assembly Local Government Committee: 9-0

Assembly Floor: 75-3

Support and Opposition

(6/7/18)

Support: CALAFCO; California Hospital Association; Coast Life Support District; Mendocino Local Agency Formation Commission; Redwood Coast Medical Services; Sonoma Local Agency Formation Commission.

Opposition: Unknown.

-- END --

ASSEMBLY THIRD READING

ATR Bill Id:AB 2262

Author:(Wood)

As Amended Ver:April 16, 2018

Majority vote

SUMMARY: Authorizes the Coast Life Support District (CLSD) to provide urgent medical care services, after receiving approval from the local agency formation commission, in addition to the emergency medical services (EMS) currently provided.

FISCAL EFFECT: None

COMMENTS: According to the author, in rural areas residents need to travel greater distances to access different points of the health care delivery system, sometimes requiring an overnight hotel stay. The author states that health care facilities in these areas are small, provide limited services, and often, due to geographic distance, extreme weather conditions, lack of public transportation, and challenging roads, rural residents are limited or prevented from accessing health care services. The author notes that current law establishing CLSD authorizes the district to provide EMS, but it is unclear whether CLSD may provide lower levels of care, such as urgent care. The author also notes that, in practice, the issue of whether an individual is, in fact, in an emergency varies by the circumstances, and in some cases, may not be resolved until after ambulance or other transport and examination and diagnosis by an appropriately licensed health professional has occurred. The individual may end up needing immediate or urgent care, but not emergency care as defined in the enabling legislation. The author concludes that, without clarifying the enabling legislation, patients may have to be redirected out of the CLSD to receive lower levels of care.

AB 4227 (Hauser), Chapter 375, Statutes of 1986, is uncodified law which establishes CLSD as a Special District to provide EMS to a specified area within Sonoma and Mendocino Counties, covering 60 miles of coastline. There are no hospitals within the district. From its center, the closest medical facilities with 24-hour medical care are a minimum of 90 minutes to two hours travel time traversing the coast highway. These are some of the longest transports in California to tertiary care.

There have been five local ballot measures concerning CLSD: the original ballot measure required by Chapter 375, Section 72 for the November 1986 ballot, setting an initial appropriation of $300,000; Measure O (1997) which imposed a special tax for the provision of the "after hours" urgent medical care services; Measures B and C (2012) to amend Measure O, to eliminate the term "After Hours" and, thereby, allow the District to provide urgent medical care services without limitation to time of day and with no change in the tax rate; and, Measure J (2014) to authorize the levy of a special tax on parcels of real property to augment funding for expanding the availability for provision of urgent medical services.

CLSD has entered into, or funded, contracts with health care professionals and otherwise augmented the provision of urgent and immediate care services in Gualala (where the district is headquartered), as well as EMS throughout CLSD. Care is provided at Redwood Coast Medical Services (RCMS) which is a Federally Qualified Health Center (FQHC) centrally located within the district. Because this FQHC is in a rural area, it also provides immediate and urgent care services that are more expansive than their urban counterparts. RCMS has been approved until 2020, as an Alternative EMS Receiving Facility for the Coastal Valleys EMS Region.

1. Urgent care. The definition of urgent care varies, but most facilities provide unscheduled care, after-hours access, expanded services compared to primary care, and a lower cost than emergency care. On-site X-ray, intravenous medications and fluids, repair of lacerations, foreign body removal, basic fracture care, and treatment of abscess are the most common services provided. According to a 2012 report published in the American Journal of Clinical Medicine, "Urgent Care Centers, an Overview," several sources have reported that the cost of care for comparable medical problems in urgent care, although slightly more than primary care, is usually between 10% and 33% of the cost of emergency care.
2. CLSD ambulance transports. If urgent care services cannot be provided by RCMS, even if only 10% of the urgent care volume required ambulance transport outside the boundaries of CLSD, it would double CLSDs annual transport volume and would exhaust existing Paramedic and EMT resources.

Analysis Prepared by: Lara Flynn / HEALTH / (916) 319-2097 FN: 0002697

Date of Hearing: April 11, 2018

ASSEMBLY COMMITTEE ON LOCAL GOVERNMENT

Cecilia Aguiar-Curry, Chair

ABPCA Bill Id:AB 2262 (

Author:Wood) – As Introduced Ver:February 13, 2018

SUBJECT: Coast Life Support District Act: urgent medical care services.

SUMMARY: Authorizes the Coast Life Support District (CLSD) to provide urgent medical care services. Specifically, this bill:

1. Authorizes CLSD to exercise its powers for the purposes of supplying to the inhabitants of the district urgent medical care services.
2. Amends the definition of "health facility" or "health care facility" in CLSD's enabling statutes to include any facility, place or building duly licensed for the purpose of providing urgent medical care services.
3. Finds and declares that a special statute is necessary and that a general statute cannot be made applicable within the meaning of Section 16 of Article IV of the California Constitution because of the unique circumstances that the inhabitants of CLSD face in receiving medical care.

EXISTING LAW:

1. Creates CLSD and the CLSD Act, an uncodified special act that provides for the powers and duties of CLSD.
2. Authorizes CLSD to exercise the powers granted in the CLSD Act "for the purpose of supplying to the inhabitants of the district emergency medical services (EMS), including emergency ambulance service, basic life support services, limited advance life services, and advanced life support services, including medical equipment and supplies, within and without the district" subject to the Emergency Medical Services System and the Prehospital Emergency Medical Care Personnel Act.
3. Authorizes, if approved by a majority of the electors, CLSD to exercise the powers granted in the CLSD Act for the establishment, maintenance, and operation of one or more health care facilities at any location within CLSD for the benefit of CLSD.
4. Defines, pursuant to the CLSD Act, "health facility" or "health care facility" to include any facility, place or building duly licensed for the purpose of providing EMS.
5. Requires, pursuant to the CLSD Act, following the formation of the district, the Cortese-Knox Local Government Reorganization Act (Cortese-Knox), of Division 3 (commencing with Section 56000) of Title 5 of the Government Code to govern any change of organization.
6. Authorizes, pursuant to the Cortese-Knox-Hertzberg Local Government Reorganization Act of 2000 (CKH of 2000), a local agency formation commission (LAFCO) in each county to control the boundaries and changes of organization of cities, county service areas, and most special districts.

FISCAL EFFECT: None

COMMENTS:

1. Bill Summary. This bill authorizes CLSD to provide urgent medical care services and makes conforming changes to the CLSD Act. This bill is sponsored by the author.
2. Author's Statement. According to the author, "In rural areas residents need to travel greater distances to access different points of the health care delivery system, sometimes requiring an overnight hotel stay. Health care facilities in these areas are small, providing limited services, and often, due to geographic distance, extreme weather conditions, lack of public transportation and challenging roads, rural residents are limited or prevented from accessing health care services.

"Current law establishing CLSD authorizes the district to provide EMS, but it is unclear whether CLSD may provide lower levels of care, such as urgent care. In practice, the issue of whether an individual is, in fact, in an emergency varies by the circumstances, and in some cases, may not be resolved until after ambulance or other transport and examination and diagnosis by an appropriately licensed health professional has occurred. The individual may end up needing immediate or urgent care, but not emergency care as defined in the enabling legislation. Without clarifying the enabling legislation, patients may have to be redirected out of the CLSD to receive lower levels of care."

1. Background. AB 4227 (Hauser), Chapter 375, Statutes of 1986, created CLSD to provide EMS to a specified area within Sonoma and Mendocino Counties, covering 60 miles of coastline. There are no hospitals within the district. From its center, the closest medical facilities with 24-hour medical care are between 90 minutes and two hours travel time traversing the coast highway. These are some of the longest transports in California to tertiary care.

There have been five local ballot measures concerning CLSD: the original ballot measure required by the CLSD Act for the November 1986 ballot, setting an initial appropriation of $300,000; Measure O (1997) which imposed a special tax for the provision of "after hours" urgent medical care services; Measures B and C (2012) to amend Measure O, to eliminate the term "after Hours" and, thereby, allow CLSD to provide urgent medical care services without limitation to time of day and with no change in the tax rate; and, Measure J (2014) to authorize the levy of a special tax on parcels of real property to augment funding for expanding the availability for provision of urgent medical services.

CLSD has entered into, or funded, contracts with health care professionals and otherwise augmented the provision of urgent and immediate care services in Gualala (where the district is headquartered), as well as EMS throughout CLSD. Care is provided at Redwood Coast Medical Services (RCMS), which is a Federally Qualified Health Center (FQHC) centrally located within the district. Because this FQHC is in a rural area, it also provides immediate and urgent care services that are more expansive than their urban counterparts. RCMS has been approved until 2020, as an Alternative EMS Receiving Facility for the Coastal Valleys EMS Region.

1. Urgent Care. The definition of urgent care varies, but most facilities provide unscheduled care, after-hours access, expanded services compared to primary care, and a lower cost than emergency care. On-site X-ray, intravenous medications and fluids, repair of lacerations, foreign body removal, basic fracture care, and treatment of abscess are the most common services provided. According to a 2012 report published in the American Journal of Clinical Medicine, "Urgent Care Centers, an Overview," several sources have reported that the cost
   of care for comparable medical problems in urgent care, although slightly more than primary care, is usually between 10% and 33% of the cost of emergency care.

If urgent care services cannot be provided by RCMS, even if only 10% of the urgent care volume required ambulance transport outside the boundaries of CLSD, it would double CLSD’s annual transport volume and would exhaust existing Paramedic and EMT resources.

1. Need for This Bill. According to the author's office, "About 2 years ago, members of the Boards of RCMS and CLSD and their advisory groups started to take a closer look at the situation from many perspectives and to work together to create a rural health network by consolidating the health care related resources currently serving the residents of the coastal communities. That led to questions about CLSD’s role in urgent care services, and then to a renewed look at its enabling legislation. From that, it appeared that the ballot measures may have attempted to authorize actions beyond those in the enabling legislation. The opinion was advanced that entities such as CLSD are restricted from taking actions that are beyond the grant of authority in their enabling legislation; and, may not by referendum, initiative or board resolution take action that contradicts the statutes that created them, or the constitution; that no local ballot measure could in fact properly amend a state statute, as the amendment of a state statute is not within a local agency's, or local voter’s authority…

"Consultation by CLSD with the County Counsel confirmed that there could be a legal problem and suggested that one option was to seek state legislation to resolve the matter. This bill is intended to accomplish that goal by clarifying that CLSD may use its resources to contract for, or augment the provision of those needing immediate or urgent care within the District’s boundaries."

1. Role of LAFCO. CKH of 2000 controls how local officials change the boundaries of cities and special districts, and designates a LAFCO in each county to oversee a number of changes. Besides the more common annexations to cities and special districts, LAFCOs also control district formations, consolidations, and dissolutions, as well as city incorporations, consolidations, and disincorporations. LAFCOs also oversee the exercise of new or different functions or classes of services. CKH of 2000 is the successor act to the Cortese-Knox Local Government Reorganization Act, which was enacted in 1985 immediately prior to the creation of CLSD in 1986.
2. Committee Amendments. The CLSD Act references the Cortese-Knox Local Government Reorganization Act, which has been succeeded by CKH of 2000. In addition to updating the CLSD Act to allow the district to provide urgent care, the Committee may wish to additionally update the CLSD Act to refer to CKH of 2000 and to clarify that the new power this bill grants to CLSD is subject to LAFCO review.
3. Arguments in Support. The Coast Life Support District, in support, states, "CLSD is a
   bi-county Special District serving the south western Mendocino County and north western Sonoma County community. We do not have a hospital within CLSD's enabling legislation specified we are authorized to provide district emergency medical services. It does not, however, specifically authorize the district to provide urgent medical services. AB 2262…
   is simply to clarify that CLSD may exercise the powers granted in Statutes of 1986, Chapter 375 for the purpose of supplying to the residents and visitors within the bi-county district boundaries, urgent or immediate care medical services, including providing, funding, and contracting for such care."
4. Arguments in Opposition. The California Association of Local Agency Formation Commissions (CALAFCO), which has an “oppose unless amended” position on this bill, writes, "The Coast Life Support District, formed by special statute, did not originally have the power to provide urgent medical care services. Despite the fact they did not have this power, for a number of years they have been providing this service. AB 2262 seeks to add this power legislatively for the district as more of a formality, given they have already been providing the service.

"The enabling act of 1986 clearly states (in Section 9), 'Following the formation of the district, the Cortese-Knox Local Government Reorganization Act, of Division 3 (commencing with Section 56000) of Title 5 of the Government Code shall govern any change of organization.' Government Code Section 56021 includes 'the exercise of new or different functions or classes of service…'as one of the meanings of 'change of organization.' To CALAFCO, the language in the enabling act is clear that any future change of organization shall be done through the Act, which means the district is subject to LAFCo process pursuant to the Act.

"We acknowledge special legislation is required to add this power for the district. We want to ensure the LAFCo process of approving the exercise of this new class of service is also done. To that end, we respectfully request the addition of this statement: 'It is the intent of the Legislature, by adding this new power, that Coast Life Support District seeks LAFCo approval of the exercise of this power.' Additionally, given the name of the Act has been updated since 1989, we respectfully request the following amendment to reflect the 2000 update:

Following the formation of the district, the Cortese-Knox Local Government Reorganization Act (Cortese-Knox), of Division 3 (commencing with Section 56000) of Title 5 of the Government Code The Cortese-Knox-Hertzberg Local Government Reorganization Act of 2000, of Division 3 (commencing with Section 56000) of Title 5 of the Government Code shall govern any change of organization to the district."

1. Double-Referral. This bill was heard in the Assembly Health Committee on March 20, 2018, where it passed with a 14-0 vote.

REGISTERED SUPPORT / OPPOSITION:

Support

California Ambulance Association

California Hospital Association
Coast Life Support District
Redwood Coast Medical Services

Opposition

California Association of Local Agency Formation Commissions (CALAFCO)

Sonoma LAFCO

Analysis Prepared by: Angela Mapp / L. GOV. / (916) 319-3958

Date of Hearing: March 20, 2018

ASSEMBLY COMMITTEE ON HEALTH

Jim Wood, Chair

ABPCA Bill Id:AB 2262

Author:(Wood) – As Introduced Ver:February 13, 2018

SUBJECT: Coast Life Support District Act: urgent medical care services.

SUMMARY: Authorizes the Coast Life Support District (CLSD) to provide urgent medical care services, in addition to the emergency medical services (EMS) currently provided.

EXISTING LAW:

1. Establishes the Emergency Medical Services Authority (EMSA) which is responsible for the coordination and integration of all state activities concerning EMS, and requires EMSA to, utilizing regional and local information, assess each EMS area or the system’s service area for the purpose of determining the need for additional EMS, coordination of EMS, and the effectiveness of EMS. Defines EMS as the services utilized in responding to an emergency.
2. Allows, in rural areas, when the use of a hospital having a basic EMS special permit is precluded because of geographic or other extenuating circumstances, the local EMS agency (LEMSA) to authorize another facility to receive patients requiring EMS if the facility has adequate staff and equipment to provide these services, as determined by the medical director of the LEMSA.
3. Requires a LEMSA which utilizes a facility as described in 2) above, to provide EMSA with protocols addressing patient safety and the use of the non-permit facility which take into account, but are not limited to, the following:
   1. The medical staff, and the availability of the staff at various times to care for patients requiring EMS;

• 1. The ability of staff to care for the degree and severity of patient injuries;
     
  2. The equipment and services available at the facility necessary to care for patients requiring EMS and the severity of their injuries;
     
  3. The availability of more comprehensive EMS and the distance and travel time necessary to make the alternative EMS available; and,
     
  4. The time of day and any limitations which may apply for a non-permit facility to treat patients requiring EMS.
     

FISCAL EFFECT: None

COMMENTS:

1. PURPOSE OF THIS BILL. According to the author, in rural areas residents need to travel greater distances to access different points of the health care delivery system, sometimes requiring an overnight hotel stay. The author states that health care facilities in these areas are small, provide limited services, and often, due to geographic distance, extreme weather conditions, lack of public transportation, and challenging roads, rural residents are limited or prevented from accessing health care services. The author notes that current law establishing CLSD authorizes the district to provide EMS, but it is unclear whether CLSD may provide lower levels of care, such as urgent care. The author also notes that, in practice, the issue of whether an individual is, in fact, in an emergency varies by the circumstances, and in some cases, may not be resolved until after ambulance or other transport and examination and diagnosis by an appropriately licensed health professional has occurred. The individual may end up needing immediate or urgent care, but not emergency care as defined in the enabling legislation. The author concludes that, without clarifying the enabling legislation, patients may have to be redirected out of the CLSD to receive lower levels of care.
2. BACKGROUND. AB 4227 (Hauser), Chapter 375, Statutes of 1986, is uncodified law which establishes CLSD as a Special District to provide EMS to a specified area within Sonoma and Mendocino Counties, covering 60 miles of coastline. There are no hospitals within the district. From its center, the closest medical facilities with 24-hour medical care are a minimum of 90 minutes to two hours travel time traversing the coast highway. These are some of the longest transports in California to tertiary care.

There have been five local ballot measures concerning CLSD: the original ballot measure required by Section 72 of Chapter 375 for the November 1986 ballot, setting an initial appropriation of $300,000; Measure O (1997) which imposed a special tax for the provision of the “after hours” urgent medical care services; Measures B and C (2012) to amend Measure O, to eliminate the term “After Hours” and, thereby, allow the District to provide urgent medical care services without limitation to time of day and with no change in the tax rate; and, Measure J (2014) to authorize the levy of a special tax on parcels of real property to augment funding for expanding the availability for provision of urgent medical services.

CLSD has entered into, or funded, contracts with health care professionals and otherwise augmented the provision of urgent and immediate care services in Gualala (where the district is headquartered), as well as EMS throughout CLSD. Care is provided at Redwood Coast Medical Services (RCMS) which is a Federally Qualified Health Center (FQHC) centrally located within the district. Because this FQHC is in a rural area, it also provides immediate and urgent care services that are more expansive than their urban counterparts. RCMS has been approved until 2020, as an Alternative EMS Receiving Facility for the Coastal Valleys EMS Region.

• 1. Urgent care. The definition of urgent care varies, but most facilities provide unscheduled care, after-hours access, expanded services compared to primary care, and a lower cost than emergency care. On-site X-ray, intravenous medications and fluids, repair of lacerations, foreign body removal, basic fracture care, and treatment of abscess are the most common services provided. According to a 2012 report published in the American Journal of Clinical Medicine, "Urgent Care Centers, an Overview," several sources have reported that the cost of care for comparable medical problems in urgent care, although slightly more than primary care, is usually between 10% and 33% of the cost of emergency care.
  2. CLSD ambulance transports. If urgent care services cannot be provided by RCMS, even if only 10% of the urgent care volume required ambulance transport outside the boundaries of CLSD, it would double CLSDs annual transport volume and would exhaust existing Paramedic and EMT resources.

1. DOUBLE REFERRAL. This bill is double referred: upon passage in this Committee it will be referred to the Assembly Committee on Local Government.
2. SUPPORT. CLSD supports this bill and notes that the district's enabling legislation did not specifically authorize the district to provide urgent medical care services, and this bill will ensure that the FQHC in CLSD that has been approved by the local EMSA to accept ambulance transports for treatment and stabilization at the urgent care facility may also provide urgent care.
   
   RCMS supports this bill noting that they work in collaboration with CLSD serving a bi-county region on the South Mendocino, with the closest hospital transport almost two hours away. RCMS states that the Coastal Valley EMS has designated RCMS as an Emergency Service Provider, allowing them to accept ambulance traffic, accepting lower acuity patients to RCMS to be treated and released locally; more emergent cases, such as cardiac events or traumatic injuries can be treated and stabilized prior to transport by ground or air ambulance. RCMS concludes that this minimizes unnecessary transports, avoids clogging already impacted emergency rooms, and allows the paramedic to stay in the area to be available for other emergencies.

REGISTERED SUPPORT / OPPOSITION:

Support
California Hospital Association
Coast Life Support District
Redwood Coast Medical Services

Opposition
None on file.

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