(1)Existing law, the Emergency Medical Services System and the Prehospital Emergency Medical Care Personnel Act, governs local emergency medical services (EMS) systems. The existing act establishes the Emergency Medical Services Authority, which is responsible for the coordination and integration of EMS systems. Among other duties, existing law requires the authority is required to develop planning and implementation guidelines for EMS systems, provide technical assistance to existing agencies, counties, and cities for the purpose of developing the components of EMS systems, and receive plans for the implementation of EMS and trauma care systems from local EMS agencies. Existing law makes violation of the act or regulations adopted pursuant to the act punishable as a misdemeanor.

This bill would establish within the act until January 1, 2025, the Community Paramedicine or Triage to Alternate Destination Act of 2018. The bill would authorize a local EMS agency to develop a community paramedicine or triage to alternate destination program, as defined, to provide specified community paramedicine services. The bill would require the authority to develop regulations to establish minimum standards for a program, and would further require the Commission on Emergency Medical Services to review and approve those regulations. The bill would require the authority to review a local EMS agencys proposed program and approve, approve with conditions, or deny the proposed program no later than 6 months after it is submitted by the local EMS agency. The bill would require a local EMS agency that opts to develop a program to perform specified duties that include, among others, integrating the proposed program into the local EMS agencys EMS plan. The bill would require the Emergency Medical Services Authority to contract with an independent 3rd party to prepare a report on community paramedicine or triage to alternate destination programs on or before June 1, 2023, as specified.

The bill would prohibit a person or organization from providing community paramedicine or triage to alternate destination services or representing, advertising, or otherwise implying that it is authorized to provide those services unless it is expressly authorized by a local EMS agency to provide those services as part of a program approved by the authority. The bill would also prohibit a community paramedic from providing community paramedicine services if he or she has not been certified and accredited to perform those services and is working as an employee of an authorized community paramedicine provider. Because a violation of the act described above is punishable as a misdemeanor, and this bill would create new requirements within the act, the bill would expand an existing crime, thereby imposing a state-mandated local program.

(2)Existing law authorizes a county to establish an emergency medical care committee and requires the committee, at least annually, to review the operations of ambulance services operating within the county, emergency medical care offered within the county, and first aid practices in the county. Existing law requires the county board of supervisors to prescribe the membership, and appoint the members, of the committee.

This bill would require the committee to include additional members, as specified, and to advise a local EMS agency within the county on the development of its community paramedicine or triage to alternate destination program if the local EMS agency develops that program. The bill would specifically require the mayor of a city and county, rather than the county board of supervisors, to appoint the membership.

The bill would repeal these provisions on January 1, 2025.

(3)Existing law establishes the Commission on Emergency Medical Services with 18 members. The commission, among other things, reviews and approves regulations, standards, and guidelines developed by the authority.

This bill would increase the membership of the commission to 20 members and modify the entities that submit names for appointment to the commission by the Governor, the Senate Committee on Rules, and the Speaker of the Assembly.

(4)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.

(1)Existing law, the Emergency Medical Services System and the Prehospital Emergency Medical Care Personnel Act, governs local emergency medical services (EMS) systems. The existing act establishes the Emergency Medical Services Authority, which is responsible for the coordination and integration of EMS systems. Among other duties, existing law requires the authority is required to develop planning and implementation guidelines for EMS systems, provide technical assistance to existing agencies, counties, and cities for the purpose of developing the components of EMS systems, and receive plans for the implementation of EMS and trauma care systems from local EMS agencies. Existing law makes violation of the act or regulations adopted pursuant to the act punishable as a misdemeanor.

This bill would establish within the act until January 1, 2025, the Community Paramedicine or Triage to Alternate Destination Act of 2018. The bill would authorize a local EMS agency to develop a community paramedicine or triage to alternate destination program, as defined, to provide specified community paramedicine services. The bill would require the authority to develop regulations to establish minimum standards for a program, and would further require the Commission on Emergency Medical Services to review and approve those regulations. The bill would require the authority to review a local EMS agencys proposed program and approve, approve with conditions, or deny the proposed program no later than 6 months after it is submitted by the local EMS agency. The bill would require a local EMS agency that opts to develop a program to perform specified duties that include, among others, integrating the proposed program into the local EMS agencys EMS plan. The bill would require the Emergency Medical Services Authority to contract with an independent 3rd party to prepare a report on community paramedicine or triage to alternate destination programs on or before June 1, 2023, as specified.

The bill would prohibit a person or organization from providing community paramedicine or triage to alternate destination services or representing, advertising, or otherwise implying that it is authorized to provide those services unless it is expressly authorized by a local EMS agency to provide those services as part of a program approved by the authority. The bill would also prohibit a community paramedic from providing community paramedicine services if he or she has not been certified and accredited to perform those services and is working as an employee of an authorized community paramedicine provider. Because a violation of the act described above is punishable as a misdemeanor, and this bill would create new requirements within the act, the bill would expand an existing crime, thereby imposing a state-mandated local program.

(2)Existing law authorizes a county to establish an emergency medical care committee and requires the committee, at least annually, to review the operations of ambulance services operating within the county, emergency medical care offered within the county, and first aid practices in the county. Existing law requires the county board of supervisors to prescribe the membership, and appoint the members, of the committee.

This bill would require the committee to include additional members, as specified, and to advise a local EMS agency within the county on the development of its community paramedicine or triage to alternate destination program if the local EMS agency develops that program. The bill would specifically require the mayor of a city and county, rather than the county board of supervisors, to appoint the membership.

The bill would repeal these provisions on January 1, 2025.

(3)Existing law establishes the Commission on Emergency Medical Services with 18 members. The commission, among other things, reviews and approves regulations, standards, and guidelines developed by the authority.

This bill would increase the membership of the commission to 20 members and modify the entities that submit names for appointment to the commission by the Governor, the Senate Committee on Rules, and the Speaker of the Assembly.

(4)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.

Under existing law a person is entitled to register to vote if he or she is a United State citizen, a resident of California, not imprisoned or on parole for the conviction of a felony, and at least 18 years of age at the time of the next election. Existing law, for purposes of determining who is entitled to register to vote, defines imprisoned as currently serving a state or federal prison sentence.

This bill would require each county jail to allow at least one organization to provide a voter education program in the county jail. The bill would require that the program include, but not be limited to, providing both written and verbal information about voting rights upon release from jail, providing affidavits of registration to eligible voters, assisting eligible voters with the completion of the affidavits of registration, and assisting eligible voters in returning the completed voter registration cards to the county elections official. By imposing new duties on county jail officials, 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, if the Commission on State Mandates determines that the bill contains costs mandated by the state, reimbursement for those costs shall be made pursuant to the statutory provisions noted above.

Under existing law a person is entitled to register to vote if he or she is a United State citizen, a resident of California, not imprisoned or on parole for the conviction of a felony, and at least 18 years of age at the time of the next election. Existing law, for purposes of determining who is entitled to register to vote, defines imprisoned as currently serving a state or federal prison sentence.

This bill would require each county jail to allow at least one organization to provide a voter education program in the county jail. The bill would require that the program include, but not be limited to, providing both written and verbal information about voting rights upon release from jail, providing affidavits of registration to eligible voters, assisting eligible voters with the completion of the affidavits of registration, and assisting eligible voters in returning the completed voter registration cards to the county elections official. By imposing new duties on county jail officials, 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, if the Commission on State Mandates determines that the bill contains costs mandated by the state, reimbursement for those costs shall be made pursuant to the statutory provisions noted above.

Under existing law a person is entitled to register to vote if he or she is a United State citizen, a resident of California, not imprisoned or on parole for the conviction of a felony, and at least 18 years of age at the time of the next election. Existing law, for purposes of determining who is entitled to register to vote, defines imprisoned as currently serving a state or federal prison sentence.

Under existing law a person is entitled to register to vote if he or she is a United State citizen, a resident of California, not imprisoned or on parole for the conviction of a felony, and at least 18 years of age at the time of the next election. Existing law, for purposes of determining who is entitled to register to vote, defines imprisoned as currently serving a state or federal prison sentence.

This bill would state the intent of the Legislature to enact legislation to provide voter education programs in prisons and county jails, to provide both written and verbal information about voting rights during release from prison or jail, and to educate incarcerated communities about the right to vote upon completion of parole. The bill would make related findings and declarations.

GOVERNOR'S VETO

GV Bill Id:AB 3115

Author:(Gipson)

As Enrolled Ver:September 12, 2018

2/3 vote

(vote not relevant)

Original Committee Reference: PUB. S.

SUMMARY: Establishes the Community Paramedicine or Triage to Alternate Destination Act of 2018 to establish state guidelines to govern the implementation of community paramedicine programs (CPP) or triage to alternate destination programs (TADP) by local Emergency Medical Service agencies (LEMSAs) in California. Sunsets the provisions of this bill on January 1, 2025.

The Senate amendments delete the previous version of this bill and instead:

1. State the intent of the Legislature that a CPP or TADP be designed to improve community health and be implemented in a fashion that is respectful of the current emergency medical system (EMS) and its providers. State that CPPs or TADPs should not be used to reduce personnel costs, harm working conditions of emergency medical and health care workers, or otherwise compromise the emergency medical response or health care system in a way that is focused primarily on containing costs.
2. Define the following terms:
   1. "Alternate destination facility" as a treatment location that is an authorized mental health facility or an authorized sobering center, but not a general acute care hospital (GACH), as defined.
   2. "Authorized mental health facility" as a designated facility, as defined, that has at least one registered nurse (RN) at the facility at all times.
   3. "Authorized sobering center" as a facility that is staffed at all times with at least one RN and is a federally qualified health center (FQHC).
   4. "Community paramedic" as a licensed paramedic who has completed the curriculum for community paramedic training, has received certification on one or more community paramedicine program specialties, and is accredited to provide community paramedic services by a LEMSA as part of an approved community paramedicine program.
   5. "CPP" as a program developed by a LEMSA and approved by the Emergency Medical Services Authority (EMSA) to provide community paramedic services, described below, under the direction of medical protocols developed by the LEMSA that are consistent with the minimum medical protocols established by EMSA. Community paramedic services may consist of the following program specialties:
      1. Providing short-term postdischarge follow-up for persons recently discharged from a hospital due to a serious health condition;
      2. Providing directly observed therapy (DOT) to persons with tuberculosis (TB); and,
      3. Providing case management services to frequent EMS users in collaboration with and by providing referral to existing appropriate community resources.
   6. "Community paramedicine provider" as an advanced life support provider who has entered into a contract to deliver community paramedic services as part of an approved community paramedicine program developed by a LEMSA.
   7. "Triage paramedic" as a paramedic who has completed the curriculum for triage paramedic services, and has been accredited by a LEMSA in one or more of the triage paramedic specialties as part of an approved TADP.
   8. TADP as a program developed by a LEMSA and approved by EMSA to provide triage paramedic assessments consisting of one or more specialties described below, operating under triage and assessment protocols developed by a LEMSA that are consistent with the minimum triage and assessment protocols established by EMSA. Specifies that triage paramedic assessments may consist of the following program specialties:
      1. Providing care and comfort services to hospice patients in their homes in response to 911 calls by providing for the patient's and the family's immediate care needs, including grief support in collaboration with the patient's hospice agency until the hospice nurse arrives to treat the patient; and,
      2. Providing patients with advanced life support triage and assessment by a triage paramedic and transportation to an alternate destination facility.
   9. "Triage to alternate destination provider" as an advanced life support provider authorized by a LEMSA to provide advanced life support triage paramedic assessments as part of a TADP.
3. Require EMSA to develop regulations establishing minimum standards for the development of a CPP or TADP based upon and informed by, the Community Paramedicine Pilot Program under the Office of Statewide Health Planning and Development (OSHPD) Health Workforce Pilot Project No. 173 (HWPP #173) and the protocols and operation of the pilot projects approved under HWPP #173. Requires the regulations to consist of all of the following:
   1. Minimum standards and curriculum for each program specialty for CPPs, describe in 2) d), above. Requires EMSA, in developing the minimum standards and curriculum, to provide for community paramedics to be trained in one or more of the program specialties in the CPP, and approved by the LEMSA;
   2. Minimum standards and curriculum for each program specialty for TADPs, described in 2) g) above. Requires EMSA, in developing the minimum standards and curriculum, to provide for triage paramedics to be trained in one or more of the program specialties in the TADP, and approved by the LEMSA;
   3. A process for verifying on a paramedic's license the successful completion of the training described in a) or b), above;
   4. Minimum standards for approval, review, withdrawal, and revocation of a CPP or TADP in accordance with existing EMS standards. Requires those standards to also include, but not be limited to, both of the following:
      1. A requirement that facilities participating in the program accommodate privately or commercially insured, Medi-Cal, Medicare, and uninsured patients; and,
      2. Immediate termination of participation in the program by the alternate destination facility or the community paramedicine or triage to alternate destination provider, if it fails to provide care based on a patient's ethnicity, citizenship, age, preexisting medical condition, insurance status, economic status, ability to pay for medical services, or any other characteristic.
   5. Minimum standards for collecting and submitting data to EMSA to ensure patient safety that include consideration of both quality assurance and quality improvement. Requires the standards to include, but not be limited to, all of the following:
      1. Intervals for CPP or TADP providers, participating health facilities, and LEMSAs to submit community paramedicine services data;
      2. Relevant program use data and the online posting of program analyses;
      3. Exchange of electronic patient health information between CPP or TADP providers and health providers and facilities. Authorizes EMSA to grant a one-time waiver, not to exceed five years;
      4. Emergency medical response system feedback;
      5. Consideration of ambulance patient offload times for the alternate destination facility, the number of patients turned away, diverted or required to be subsequently transferred to an emergency department (ED), and identification of the reasons for turning away, diverting, or transferring the patient;
      6. An assessment of each community paramedicine or triage to alternate destination program's medical protocols or other processes; and,
      7. An assessment of the impact that implementation of a CPP or TADP has on the delivery of EMS, including the impact on response times in the LEMSAs jurisdiction.
4. Requires EMSA, for regulations adopted pursuant to 3) above, specific to TADPs, to ensure the following:
   1. Require LEMSAs participating in providing patients with advanced life support triage and assessment by a triage paramedic and transportation to an alternate destination facility to ensure that any patient who meets the triage criteria for transport to an alternate destination facility, but who requests to be transported to an ED of a GACH, be transported to the ED;
   2. Require LEMSAs participating as described in a) above, to require a patient who is transported to an alternate destination facility and, upon assessment, is found to no longer meet the criteria for admission to an alternate destination facility, be immediately transported to the ED of a GACH;
   3. Require, for transport to a behavioral health facility, training and accreditation topics relevant to the needs of the patent population, including, but not limited to:
      1. Mental health crisis intervention, provided by a licensed physician and surgeon with experience in the ED of a 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.
   4. Require a LEMSA to verify that the participating paramedic 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;
   5. Require, for transport to a sobering center, a training component that requires a participating emergency medical technician-paramedic (EMT-P) to complete instruction 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 interventions in stabilizing acutely intoxicated patients;
      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.
5. Require EMSA to consult with a committee of advisory members in the fields of public health, social work, hospice, or mental health with expertise commensurate with the program specialty or specialties in CPPs, and physicians and surgeons whose primary practice is emergency medicine, including, but not limited to, LEMSA medical directors, with two each named by the EMS Medical Directors Association of California (EMDAC) and the California Chapter of the American College of Emergency Physicians, and, adopt minimum medical protocols for each CPP specialty, described in 2)e), above, and minimum triage and assessment protocols for TDAP specialties described in 2)h), above.
6. Require the protocols described in 5), above, to be based on and informed by, HWPP #173, and further refinements provided by LEMSAs during the course and operation of the pilot projects.
7. Require EMSA to submit an annual report on the CPP or TADPs operating in California to the relevant policy committees of the Legislature, and to post the report on its Internet Website. Require EMSA to submit and post the first report six months after EMSA adopts the regulations described in 3), above, and every January 1, thereafter for the next five years. Require the report to include all of the following:
   1. An assessment of each program specialty, including an assessment of patient outcomes in the aggregate and an assessment of any adverse patient events resulting from services provided under approved plans pursuant to this bill;
   2. An assessment of the impact that the program specialties have had on the emergency medical system;
   3. An update on the implementation of program specialties operating in LEMSA jurisdictions;
   4. Policy recommendations for improvement of administration of local plans and for the improvement of patient outcomes; and,
   5. All data collected by EMSA to be posted on its Internet Website in a downloadable format with due regard for the confidentiality of information that would identify individual patients.
8. Require EMSA to identify and contract with an independent third-party evaluator to develop the report described in 7), above, and no later than June 1, 2023, EMSA to submit a review report on the CPP or TADPs operating in California to the relevant policy committees of the Legislature and to post the annual report on its Internet Website. Require the report to include all of the following:
   1. A detailed assessment of each CPP or TADP program operating in LEMSA jurisdictions;
   2. An assessment of patient outcomes in the aggregate resulting from services provided under approved plans under the program;
   3. An assessment of workforce impact due to implementation of the program;
   4. An assessment of the impact of the program on the EMS system;
   5. An assessment of how the currently operating program specialties achieve the legislative intent of this bill; and,
   6. An assessment of community paramedic and triage training.
9. Authorize the report described in 7), above, to include recommendations for changes to, or the elimination of, CPP or TADP specialties that do not achieve the community health and patient goals of this bill.
10. Require EMSA to review a LEMSAs' proposed CPP or TADP and to review the program's protocols to ensure the proposed program is consistent with EMSAs regulations and the provisions of this bill.
11. Authorize EMSA to impose conditions as part of the approval of a CPP or TADP that the LEMSA must incorporate into its program to achieve consistency with EMSAs regulations.
12. Require EMSA to approve, approve with conditions, or deny a proposed CPP or TADP no later than six months after it is submitted by a LEMSA.
13. Authorize a CPP approved under OSHPDs' HWPP #173 before January 1, 2019, to operate until one year after the regulations described in 3), above, become effective, and require OSHPD to continue to review, and where appropriate, approve HWPP #173 applications until one year after the regulations described in 3), above, become effective.
14. Authorize a LEMSA to develop a CPP or TADP that is consistent with EMSAs regulations and the provisions of this bill, and submit evidence of compliance with the requirements to EMSA for approval.
15. Require a LEMSA that opts to develop a CPP or TADP to do all of the following:
    1. Integrate the proposed CPP or TADP into the LEMSAs EMS plan;
    2. Develop a process to select community paramedicine providers, to provide services as described in 2)e), above, at a periodic interval established by the LEMSA;
    3. Facilitate any necessary agreements with one or more CPP or TADP providers for the delivery of CPP or TADP destination services within the LEMSAs jurisdiction that are consistent with the proposed CPP or TADP, and require the LEMSA to provide medical control and oversight of the program;
    4. Prohibit any contract to provide CPP program specialties from being included as part of an existing or proposed contract for the delivery of EMS as part of an exclusive operating area;
    5. Review and approve any written agreements for the provision of CPP specialties to ensure compliance with the requirements of this bill, and according to the following:
       1. Require a LEMSA to provide a right of refusal for the public agency or agencies within the jurisdiction of the proposed program area to provide the proposed program specialties. Require the LEMSA to review and approve written agreements with those public agencies if they agree to provide the proposed program specialties;
       2. Require a LEMSA to review and approve agreements with community paramedicine providers that partner with a public agency or agencies to deliver CPP program specialties;
       3. Require a LEMSA, if no public agency chooses to provide CPP specialties, to develop a process to select community paramedicine providers to deliver CPP specialties;
       4. Require a LEMSA, for TADP specialties described in 2)h), above, to continue the use of existing providers operating within the LEMSA jurisdiction, and to do all of the following:
          1. At the discretion of the local medical director, develop additional triage and assessment protocols commensurate with the need of the local programs authorized by this bill;
          2. Require the triage and assessment protocols and decision of the triage paramedic to transport to an alternate destination facility to not be based upon, or affected by, the patient's ethnicity, citizenship, age, preexisting medical condition, insurance status, economic status, ability to pay for medical services, or any other characteristic, except to the extent that a circumstance such as age, sex, preexisting medical condition, or physical or mental disability is medically significant to the provision of appropriate medical care;
          3. Certify and provide documentation and periodic updates to EMSA showing that the alternate destination facility authorized to receive patients has adequate licensed medical and professional staff, facilities, and equipment that comply with the requirements of EMSA's regulations and the provision of this bill which shall include:
             1. Qualified staff to care for the degree and severity of a patient's injuries and needs;
             2. Standardized medical and nursing procedures for nursing staff;
             3. Equipment and services available at an alternate destination facility necessary to care for patients requiring medical services, including, but not limited to, and automatic external defibrillator and at least one bed or mat per individual patient; and,
             4. The time of day and any limitations that may apply for an alternate destination facility to treat patients requiring medical services.
          4. Secure an agreement with the alternate destination facility that requires the facility to notify the LEMSA within 24 hours if there are changes in the status of the facility with respect to the protocols and the facility's ability to care for patients; and,
          5. Secure an agreement with the alternate destination facility attesting that the facility will operate in accordance with existing non-discrimination laws, and that failure to do so will result in the immediate termination of use of the facility as part of the triage to alternate destination facility.
    6. Require a LEMSA to establish the following training pursuant to the requirements established by EMSA and the program specialty that is being propose by the LEMSA:
       1. Establish a process to verify training and accreditation for community paramedics in each of the proposed CPP specialties describe in 2)e), above;
       2. Establish a process for training and accreditation of triage paramedics in each of the proposed TADP specialties described in 2)g), above.
    7. Facilitate funding discussions between a CPP or TADP provider and public or private health system participants to support the implementation of the LEMSAs CPP or TADP.
16. Authorize a pilot program approved under OSHPD's HWPP #173 before January 1, 2019, to deliver CPP services to continue the use of existing providers and to be exempt from the provisions describe in 15)d) and e), above, until the provider elects to reduce or eliminate one or more of those services approved under the pilot program, or fails to comply with the standards required by this bill.
17. Prohibit a person or organization from providing community paramedic or triage to alternate destination services or represent, advertise, or otherwise imply that it is authorized to provide community paramedicine or triage to alternate destination services unless expressly authorized by a LEMSA to provide those services as part of a CPP or TADP approved by EMSA.
18. Authorize a community paramedic to provide community paramedicine services only if they have been certified and accredited to perform those services by a LEMSA and are working as an employee of an authorized community paramedicine provider.
19. Authorize a triage paramedic to only provide triage to alternate destination services if they have been accredited to perform those services by a LEMSA and are working as an employee of an authorized triage to alternate destination provider.
20. Require that the disciplinary procedures for a community paramedic be consistent with those for existing paramedics.
21. Specify that entering into an agreement to be a community paramedicine or triage to alternate destination provider does not alter or otherwise invalidate an agency's authority to provide or administer EMS.
22. Apply the existing limitation on liability of persons who render emergency care, including emergency services personnel, to this bill.
23. Increase the membership of the Commission on Emergency Medical Services from 18 to 20 members, with the two additional members as follows: a physician specializing in the care of individuals with co-occurring mental health or psychosocial and substance use disorders, appointed by the Governor in consultation with the California Psychiatric Association and the California Society of Addiction Medicine; and, a licensed clinical social worker appointed by the Governor in consultation with the California State Council of the Service Employees International Union and the California Chapter of the National Association of Social workers.
24. Specify that nothing in this bill, with respect to TADPs, should be construed to prevent or eliminate any authorities to provide continuous transport of a patient to a participating hospital for priority evaluation by a physician, nurse practitioner, or physician assistant followed by a transport to an alternate destination facility.
25. Specify that the provisions of this bill (except the changes to the Commission on Emergency Medical Services described in 23, above) remain in effect only until January 1, 2025.

FISCAL EFFECT: This bill is substantially similar to SB 944 (Hertzberg) of the current legislative session which was held in the Assembly Appropriations Committee. According to the Appropriations Committee:

1. Staff costs of approximately $400,000 General Fund (GF) to EMSA to promulgate regulations, design a data structure and data collection system, and transition current sites to new rules over the first one to two years.
2. Ongoing staff costs of approximately $300,000, until the January 1, 2025 sunset, to review and approve programs, collect and review data, and develop annual reports GF, assuming 15 CPP programs. There could be additional cost pressure if a higher number of counties authorize and submit programs for EMSA review.

COMMENTS:

1. PURPOSE OF THIS BILL. According to the author, California’s health care needs have evolved over time and the current emergency response system must be updated to reflect this. Community paramedicine and alternate destination programs have proven success in improving access to care by specially-trained paramedics. The author states that EDs have a primary responsibility, which is to serve as a rapid response to crises and disasters. The EMS system is not adequately designed to care for patients who have mental health care needs or those who are inebriated. Frequent 9-1-1 users aren’t able to receive the right care at the right time as our paramedics are currently unable to send patients to medically-staffed mental health and sobering facilities. The author notes that community paramedicine programs allow for greater ease in accessing post-discharge care and observed therapy needs. Specially-trained paramedics can provide appropriate connections to medical professionals who are able to provide individualized care to patients who need assistance in their homes or other facilities. The author concludes that this bill authorizes community paramedicine and alternate destination programs based on strong research and evaluation of the current pilot programs and is a thoughtful measure designed to improve health care for all.
2. BACKGROUND. 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.
   1. 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.
   2. Sobering centers. This bill would permit specially trained EMT-P's, under certain circumstances, to redirect patients to 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. 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.
   3. Designated facilities. This bill would permit specially trained EMT-P's, under certain circumstances, to redirect patients to designated facilities. Individual counties are responsible for determining whether GACHs, psychiatric health facilities, acute psychiatric hospitals, 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 federal 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.
   4. 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.
   5. 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.

The existing 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.

• 1. 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 CPP model at 12 projected sites located throughout the state. Thirteen CPP 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) DOT for TB; 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.

• 1. Evaluation of HWPP #173. A team of evaluators at the Philip R. Lee Institute for Health Policy Studies (Institute) 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 CPP 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 six pilot project components: post discharge follow-up, DOT for persons with TB, hospice care, frequent 911 users, and alternate destinations (both mental health and sobering centers). Below are the report findings for those concepts:
     1. Post discharge follow-up. There were five post-discharge project sites started throughout the state, in the City of Alameda, at UCLA-Glendale, and in the counties of Butte, San Bernardino, and Solano. The UCLA-Glendale site closed because the partner fire department was unwilling to continue funding the project. Together, these projects enrolled 1,401 patients, were effective at reducing the rate of readmissions within 30 days, and identified 229 patients who needed instruction on how to use their medications correctly. The Institute estimated that these projects potentially avoided $1.4 million in costs by reducing hospital readmissions, with most savings accruing to Medicare and Medi-Cal. Most project sites involved an initial home visit. One project site instead called for an initial assessment by phone, but when that was found to be less effective, this project site revised its protocol to always include at least one home visit. In addition to helping a large number of patients who had difficulty understanding how to comply with their medications, community paramedics made at least 188 referrals to a wide range of service providers, using manuals of local resources that they prepared as part of their training, including to primary care, specialists, pharmacists, mental health services, home health providers, drug and alcohol treatment programs, food assistant agencies, housing assistance providers, and transportation assistance providers.
     2. DOT for TB. Ventura County was the only pilot site for the DOT concept. TB is a highly contagious disease that is treated with antibiotics. TB treatment clinics often provide DOT to ensure that people take their medications as directed. In Ventura County, public health officials asked the county's EMS provider to partner with the TB clinic to provide DOT, because the TB clinic does not have sufficient staff to provide DOT to all patients in the county. The TB clinic also utilizes community health workers (CHWs) to administer DOT, but the CHWs only work on weekdays and do not provide DOT on weekends. CPs dispensed appropriate doses of TB medications and monitored side effects and symptoms that could necessitate a change in treatment. Persons with TB who received DOT from CPs were more likely to receive all doses of TB medication prescribed by the TB clinic physician than patients who received DOT from the TB clinic's CHWs. Receiving all doses increases the likelihood that a patient will be cured and will not spread TB to others, or to develop a drug-resistant strain of TB that would be more difficult to treat. The TB clinic leaders indicated that there were conscious decisions to assign patients to either CPs or CHWs based on the likelihood that patients would comply with treatment. CPs were assigned patients who resist treatment or are verbally abusive or sexually inappropriate because CPs have more experience and training in managing persons with such behaviors. They were also assigned homeless persons and other difficult to locate patients. There were no additional costs to the health care system because CPs who provided DOT at the pilot site did so while already on duty to respond to traditional 911 calls. The TB project enrolled a total of 29 patients through September 30, 2016.
     3. Hospice. Ventura County was the only pilot site for the hospice concept. The goal of hospice care is to provide medical, psychological, and spiritual support to persons dying from a terminal illness. Care is provided by a multidisciplinary team of health professionals and volunteers in a patient's home, a residential care facility, a nursing home, or an inpatient hospice facility. Hospice staff members tell hospice patients, their family members, and others caregivers to contact the hospice instead of 911 if they believe there is a medical need or if they become concerned about the patient's comfort. Despite this, some patients and their families call 911 instead of the hospice because they are anxious about the patient's condition, or family members disagree with the patient's decision to obtain hospice care. The standard response to a 911 call made on behalf of a hospice patient is to transport the patient to an ED, which may be upsetting to the patient, and clinicians in EDs may perform medical interventions that the patient would prefer not to receive. Hospice patients who go to the ED also risk losing their hospice benefits. In Ventura County, CPs mainly provided hospice patients and their families with psychosocial support and administered medications from the hospice patients "comfort care" packs when necessary, in consultation with a hospice nurse. No hospice patient who requests transport to an ED is denied transport. According to the Institute, this project responded to 270 calls made on behalf of patients of participating hospice agencies. Hospice patients, family members, or staff of residential or skilled nursing facilities initiated most 911 calls, but hospice nurses made some 911 calls during visits with patients. The reasons for the 911 calls included altered level of consciousness, cardiac arrest, constipation, fall, seizure, shortness of breath, and family concern about hospice care. According to the Institute, prior to the launch of the pilot project, 80% of 911 calls for hospice patients resulted in the transport of a patient to the emergency department. After the pilot project was implemented, the percentage of patients transported decreased to 30% in partner hospices.
     4. Frequent 911/EMS User. There were two frequent EMS user projects: one in Alameda; and, one in San Diego. However, the San Diego project has not enrolled any new patients since December of 2016 because its community paramedics were reassigned to traditional 911 response crews. The two projects used different criteria of frequent EMS users: San Diego’s project primarily enrolls patients with 20 or more ED visits per year, while Alameda’s project (which serves a much smaller city) is open to all patients referred by staff of the local EMS agency or the partner hospital. Community paramedics assessed patients’ physical, psychological, and social needs and provided them with individualized case management to link them with nonemergency services. Among the 37 patients enrolled in San Diego’s project for whom data was available for 12 months prior to enrollment and 12 months following enrollment, the total number of 911 calls decreased from 955 to 625, a decrease of 35%. The average number of calls per person decreased from 26 to 17 per year, and some enrollees had much larger decreases in 911 calls. Among the 33 patients enrolled in Alameda’s project with 12 months of before and after data, the total number of 911 calls decreased from 131 to 110, a decrease of 16%, while the average number of 911 calls per person only decreased from four to three. The Institute suggested that the difference in impact between the two programs reflect the fact that San Diego had a high standard for frequent EMS user.
     5. Alternate destination – mental 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 the 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. Alternate destination – 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.

1. SUPPORT. The Alameda Firefighters (IAFF Local 689) are the sponsors of this bill, and along with the City of Alameda, states that with a CPP pilot program in Alameda, the community and department would greatly benefit from this bill. IAFF Local 689 states that implementing these programs in way that respects the existing system and all stake holders; while ensuring vigorous guidance and oversight, will ultimately provide the foundation need to have long and sustained success of improving patient outcomes and system efficiency.

The California Fire Chiefs Association and the Fire Districts Association of California note that CPPs have been piloted in several jurisdictions and have proved to provide positive services to patients at a reduced cost to local government.

The California Chapter of the American College of Emergency Physicians supports this bill, and state that they are pleased to see that this bill includes authorizing the pilots that aim to reduce ED visits by keeping people well.

1. OPPOSITION. The Emergency Medical Services Administrators of California and the EMDAC oppose this bill because it will erode local medical control of EMS systems and create unnecessary impediments for innovative solutions to the delivery of healthcare by counties and their LEMSAs.

The California Hospital Association is opposed to this bill for four primary reasons: a) the bill requires a sobering center to be designated as an FQHC; b) the bill requires alternate destination facilities to accept all patients; c) the bill would establish duplicative bureaucratic steps for reviewing CPPs; and, d) the bill should be clarified that facilities wishing to participate in TADPs will not be required to pay a fee.

The California Nurses Association opposes this bill, noting that it is based upon two bills that were recently held in the Assembly Appropriations Committee, and is based on the faulty premise that private ambulance companies and public fire departments can provide both continuity of care and high quality health services, in addition to, and during, their traditional EMS roles.

GOVERNOR'S VETO MESSAGE:

This bill would permit local emergency medical services agencies to develop community paramedicine programs under prescribed state rules.

Through the health workforce pilot project started in 2014, local community paramedicine programs are using paramedics to assist in the transportation and care of patients in settings other than an emergency room. While this bill has the good intention of making the pilot project permanent, it restricts the types of facilities to which patients can be transported. It also limits the discretion of local governments to design and manage their projects in the way they think best.

I support these innovative local efforts and believe they should be expanded but without the restrictions contained in this bill. To achieve that, I am directing the continuation of the existing pilot project and encouraging all of the interested parties to work together to make this program permanent.

Analysis Prepared by: Lara Flynn / HEALTH / (916) 319-2097 FN: 0005322

CONCURRENCE IN SENATE AMENDMENTS

CSA1 Bill Id:AB 3115

Author:(Gipson)

As Amended Ver:August 28, 2018

Majority vote

(vote not relevant)

Original Committee Reference: HEALTH

SUMMARY: Establishes the Community Paramedicine or Triage to Alternate Destination Act of 2018 to establish state guidelines to govern the implementation of community paramedicine programs (CPP) or triage to alternate destination programs (TADP) by local Emergency Medical Service agencies (LEMSAs) in California. Sunsets the provisions of this bill on January 1, 2025.

The Senate amendments delete the previous version of this bill and instead:

1. State the intent of the Legislature that a CPP or TADP be designed to improve community health and be implemented in a fashion that is respectful of the current emergency medical system (EMS) and its providers. State that CPPs or TADPs should not be used to reduce personnel costs, harm working conditions of emergency medical and health care workers, or otherwise compromise the emergency medical response or health care system in a way that is focused primarily on containing costs.
2. Define the following terms:
   1. "Alternate destination facility" as a treatment location that is an authorized mental health facility or an authorized sobering center, but not a general acute care hospital (GACH), as defined.
   2. "Authorized mental health facility" as a designated facility, as defined, that has at least one registered nurse (RN) at the facility at all times.
   3. "Authorized sobering center" as a facility that is staffed at all times with at least one RN and is a federally qualified health center (FQHC).
   4. "Community paramedic" as a licensed paramedic who has completed the curriculum for community paramedic training, has received certification on one or more community paramedicine program specialties, and is accredited to provide community paramedic services by a LEMSA as part of an approved community paramedicine program.
   5. "CPP" as a program developed by a LEMSA and approved by the Emergency Medical Services Authority (EMSA) to provide community paramedic services, described below, under the direction of medical protocols developed by the LEMSA that are consistent with the minimum medical protocols established by EMSA. Community paramedic services may consist of the following program specialties:
      1. Providing short-term postdischarge follow-up for persons recently discharged from a hospital due to a serious health condition;
      2. Providing directly observed therapy (DOT) to persons with tuberculosis (TB); and,
      3. Providing case management services to frequent EMS users in collaboration with and by providing referral to existing appropriate community resources.
   6. "Community paramedicine provider" as an advanced life support provider who has entered into a contract to deliver community paramedic services as part of an approved community paramedicine program developed by a LEMSA.
   7. "Triage paramedic" as a paramedic who has completed the curriculum for triage paramedic services, and has been accredited by a LEMSA in one or more of the triage paramedic specialties as part of an approved TADP.
   8. TADP as a program developed by a LEMSA and approved by EMSA to provide triage paramedic assessments consisting of one or more specialties described below, operating under triage and assessment protocols developed by a LEMSA that are consistent with the minimum triage and assessment protocols established by EMSA. Specifies that triage paramedic assessments may consist of the following program specialties:
      1. Providing care and comfort services to hospice patients in their homes in response to 911 calls by providing for the patient's and the family's immediate care needs, including grief support in collaboration with the patient's hospice agency until the hospice nurse arrives to treat the patient; and,
      2. Providing patients with advanced life support triage and assessment by a triage paramedic and transportation to an alternate destination facility.
   9. "Triage to alternate destination provider" as an advanced life support provider authorized by a LEMSA to provide advanced life support triage paramedic assessments as part of a TADP.
3. Require EMSA to develop regulations establishing minimum standards for the development of a CPP or TADP based upon and informed by, the Community Paramedicine Pilot Program under the Office of Statewide Health Planning and Development (OSHPD) Health Workforce Pilot Project No. 173 (HWPP #173) and the protocols and operation of the pilot projects approved under HWPP #173. Requires the regulations to consist of all of the following:
   1. Minimum standards and curriculum for each program specialty for CPPs, describe in 2) d), above. Requires EMSA, in developing the minimum standards and curriculum, to provide for community paramedics to be trained in one or more of the program specialties in the CPP, and approved by the LEMSA;
   2. Minimum standards and curriculum for each program specialty for TADPs, described in 2) g) above. Requires EMSA, in developing the minimum standards and curriculum, to provide for triage paramedics to be trained in one or more of the program specialties in the TADP, and approved by the LEMSA;
   3. A process for verifying on a paramedic's license the successful completion of the training described in a) or b), above;
   4. Minimum standards for approval, review, withdrawal, and revocation of a CPP or TADP in accordance with existing EMS standards. Requires those standards to also include, but not be limited to, both of the following:
      1. A requirement that facilities participating in the program accommodate privately or commercially insured, Medi-Cal, Medicare, and uninsured patients; and,
      2. Immediate termination of participation in the program by the alternate destination facility or the community paramedicine or triage to alternate destination provider, if it fails to provide care based on a patient's ethnicity, citizenship, age, preexisting medical condition, insurance status, economic status, ability to pay for medical services, or any other characteristic.
   5. Minimum standards for collecting and submitting data to EMSA to ensure patient safety that include consideration of both quality assurance and quality improvement. Requires the standards to include, but not be limited to, all of the following:
      1. Intervals for CPP or TADP providers, participating health facilities, and LEMSAs to submit community paramedicine services data;
      2. Relevant program use data and the online posting of program analyses;
      3. Exchange of electronic patient health information between CPP or TADP providers and health providers and facilities. Authorizes EMSA to grant a one-time waiver, not to exceed five years;
      4. Emergency medical response system feedback;
      5. Consideration of ambulance patient offload times for the alternate destination facility, the number of patients turned away, diverted or required to be subsequently transferred to an emergency department (ED), and identification of the reasons for turning away, diverting, or transferring the patient;
      6. An assessment of each community paramedicine or triage to alternate destination program's medical protocols or other processes; and,
      7. An assessment of the impact that implementation of a CPP or TADP has on the delivery of EMS, including the impact on response times in the LEMSAs jurisdiction.
4. Requires EMSA, for regulations adopted pursuant to 3) above, specific to TADPs, to ensure the following:
   1. Require LEMSAs participating in providing patients with advanced life support triage and assessment by a triage paramedic and transportation to an alternate destination facility to ensure that any patient who meets the triage criteria for transport to an alternate destination facility, but who requests to be transported to an ED of a GACH, be transported to the ED;
   2. Require LEMSAs participating as described in a) above, to require a patient who is transported to an alternate destination facility and, upon assessment, is found to no longer meet the criteria for admission to an alternate destination facility, be immediately transported to the ED of a GACH;
   3. Require, for transport to a behavioral health facility, training and accreditation topics relevant to the needs of the patent population, including, but not limited to:
      1. Mental health crisis intervention, provided by a licensed physician and surgeon with experience in the ED of a 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.
   4. Require a LEMSA to verify that the participating paramedic 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;
   5. Require, for transport to a sobering center, a training component that requires a participating emergency medical technician-paramedic (EMT-P) to complete instruction 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 interventions in stabilizing acutely intoxicated patients;
      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.
5. Require EMSA to consult with a committee of advisory members in the fields of public health, social work, hospice, or mental health with expertise commensurate with the program specialty or specialties in CPPs, and physicians and surgeons whose primary practice is emergency medicine, including, but not limited to, LEMSA medical directors, with two each named by the EMS Medical Directors Association of California (EMDAC) and the California Chapter of the American College of Emergency Physicians, and, adopt minimum medical protocols for each CPP specialty, described in 2)e), above, and minimum triage and assessment protocols for TDAP specialties described in 2)h), above.
6. Require the protocols described in 5), above, to be based on and informed by, HWPP #173, and further refinements provided by LEMSAs during the course and operation of the pilot projects.
7. Require EMSA to submit an annual report on the CPP or TADPs operating in California to the relevant policy committees of the Legislature, and to post the report on its Internet Website. Require EMSA to submit and post the first report six months after EMSA adopts the regulations described in 3), above, and every January 1, thereafter for the next five years. Require the report to include all of the following:
   1. An assessment of each program specialty, including an assessment of patient outcomes in the aggregate and an assessment of any adverse patient events resulting from services provided under approved plans pursuant to this bill;
   2. An assessment of the impact that the program specialties have had on the emergency medical system;
   3. An update on the implementation of program specialties operating in LEMSA jurisdictions;
   4. Policy recommendations for improvement of administration of local plans and for the improvement of patient outcomes; and,
   5. All data collected by EMSA to be posted on its Internet Website in a downloadable format with due regard for the confidentiality of information that would identify individual patients.
8. Require EMSA to identify and contract with an independent third-party evaluator to develop the report described in 7), above, and no later than June 1, 2023, EMSA to submit a review report on the CPP or TADPs operating in California to the relevant policy committees of the Legislature and to post the annual report on its Internet Website. Require the report to include all of the following:
   1. A detailed assessment of each CPP or TADP program operating in LEMSA jurisdictions;
   2. An assessment of patient outcomes in the aggregate resulting from services provided under approved plans under the program;
   3. An assessment of workforce impact due to implementation of the program;
   4. An assessment of the impact of the program on the EMS system;
   5. An assessment of how the currently operating program specialties achieve the legislative intent of this bill; and,
   6. An assessment of community paramedic and triage training.
9. Authorize the report described in 7), above, to include recommendations for changes to, or the elimination of, CPP or TADP specialties that do not achieve the community health and patient goals of this bill.
10. Require EMSA to review a LEMSAs' proposed CPP or TADP and to review the program's protocols to ensure the proposed program is consistent with EMSAs regulations and the provisions of this bill.
11. Authorize EMSA to impose conditions as part of the approval of a CPP or TADP that the LEMSA must incorporate into its program to achieve consistency with EMSAs regulations.
12. Require EMSA to approve, approve with conditions, or deny a proposed CPP or TADP no later than six months after it is submitted by a LEMSA.
13. Authorize a CPP approved under OSHPDs' HWPP #173 before January 1, 2019, to operate until one year after the regulations described in 3), above, become effective, and require OSHPD to continue to review, and where appropriate, approve HWPP #173 applications until one year after the regulations described in 3), above, become effective.
14. Authorize a LEMSA to develop a CPP or TADP that is consistent with EMSAs regulations and the provisions of this bill, and submit evidence of compliance with the requirements to EMSA for approval.
15. Require a LEMSA that opts to develop a CPP or TADP to do all of the following:
    1. Integrate the proposed CPP or TADP into the LEMSAs EMS plan;
    2. Develop a process to select community paramedicine providers, to provide services as described in 2)e), above, at a periodic interval established by the LEMSA;
    3. Facilitate any necessary agreements with one or more CPP or TADP providers for the delivery of CPP or TADP destination services within the LEMSAs jurisdiction that are consistent with the proposed CPP or TADP, and require the LEMSA to provide medical control and oversight of the program;
    4. Prohibit any contract to provide CPP program specialties from being included as part of an existing or proposed contract for the delivery of EMS as part of an exclusive operating area;
    5. Review and approve any written agreements for the provision of CPP specialties to ensure compliance with the requirements of this bill, and according to the following:
       1. Require a LEMSA to provide a right of refusal for the public agency or agencies within the jurisdiction of the proposed program area to provide the proposed program specialties. Require the LEMSA to review and approve written agreements with those public agencies if they agree to provide the proposed program specialties;
       2. Require a LEMSA to review and approve agreements with community paramedicine providers that partner with a public agency or agencies to deliver CPP program specialties;
       3. Require a LEMSA, if no public agency chooses to provide CPP specialties, to develop a process to select community paramedicine providers to deliver CPP specialties;
       4. Require a LEMSA, for TADP specialties described in 2)h), above, to continue the use of existing providers operating within the LEMSA jurisdiction, and to do all of the following:
          1. At the discretion of the local medical director, develop additional triage and assessment protocols commensurate with the need of the local programs authorized by this bill;
          2. Require the triage and assessment protocols and decision of the triage paramedic to transport to an alternate destination facility to not be based upon, or affected by, the patient's ethnicity, citizenship, age, preexisting medical condition, insurance status, economic status, ability to pay for medical services, or any other characteristic, except to the extent that a circumstance such as age, sex, preexisting medical condition, or physical or mental disability is medically significant to the provision of appropriate medical care;
          3. Certify and provide documentation and periodic updates to EMSA showing that the alternate destination facility authorized to receive patients has adequate licensed medical and professional staff, facilities, and equipment that comply with the requirements of EMSA's regulations and the provision of this bill which shall include:
             1. Qualified staff to care for the degree and severity of a patient's injuries and needs;
             2. Standardized medical and nursing procedures for nursing staff;
             3. Equipment and services available at an alternate destination facility necessary to care for patients requiring medical services, including, but not limited to, and automatic external defibrillator and at least one bed or mat per individual patient; and,
             4. The time of day and any limitations that may apply for an alternate destination facility to treat patients requiring medical services.
          4. Secure an agreement with the alternate destination facility that requires the facility to notify the LEMSA within 24 hours if there are changes in the status of the facility with respect to the protocols and the facility's ability to care for patients; and,
          5. Secure an agreement with the alternate destination facility attesting that the facility will operate in accordance with existing non-discrimination laws, and that failure to do so will result in the immediate termination of use of the facility as part of the triage to alternate destination facility.
    6. Require a LEMSA to establish the following training pursuant to the requirements established by EMSA and the program specialty that is being propose by the LEMSA:
       1. Establish a process to verify training and accreditation for community paramedics in each of the proposed CPP specialties describe in 2)e), above;
       2. Establish a process for training and accreditation of triage paramedics in each of the proposed TADP specialties described in 2)g), above.
    7. Facilitate funding discussions between a CPP or TADP provider and public or private health system participants to support the implementation of the LEMSAs CPP or TADP.
16. Authorize a pilot program approved under OSHPD's HWPP #173 before January 1, 2019, to deliver CPP services to continue the use of existing providers and to be exempt from the provisions describe in 15)d) and e), above, until the provider elects to reduce or eliminate one or more of those services approved under the pilot program, or fails to comply with the standards required by this bill.
17. Prohibit a person or organization from providing community paramedic or triage to alternate destination services or represent, advertise, or otherwise imply that it is authorized to provide community paramedicine or triage to alternate destination services unless expressly authorized by a LEMSA to provide those services as part of a CPP or TADP approved by EMSA.
18. Authorize a community paramedic to provide community paramedicine services only if they have been certified and accredited to perform those services by a LEMSA and are working as an employee of an authorized community paramedicine provider.
19. Authorize a triage paramedic to only provide triage to alternate destination services if they have been accredited to perform those services by a LEMSA and are working as an employee of an authorized triage to alternate destination provider.
20. Require that the disciplinary procedures for a community paramedic be consistent with those for existing paramedics.
21. Specify that entering into an agreement to be a community paramedicine or triage to alternate destination provider does not alter or otherwise invalidate an agency's authority to provide or administer EMS.
22. Apply the existing limitation on liability of persons who render emergency care, including emergency services personnel, to this bill.
23. Increase the membership of the Commission on Emergency Medical Services from 18 to 20 members, with the two additional members as follows: a physician specializing in the care of individuals with co-occurring mental health or psychosocial and substance use disorders, appointed by the Governor in consultation with the California Psychiatric Association and the California Society of Addiction Medicine; and, a licensed clinical social worker appointed by the Governor in consultation with the California State Council of the Service Employees International Union and the California Chapter of the National Association of Social workers.
24. Specify that nothing in this bill, with respect to TADPs, should be construed to prevent or eliminate any authorities to provide continuous transport of a patient to a participating hospital for priority evaluation by a physician, nurse practitioner, or physician assistant followed by a transport to an alternate destination facility.
25. Specify that the provisions of this bill (except the changes to the Commission on Emergency Medical Services described in 23, above) remain in effect only until January 1, 2025.

FISCAL EFFECT: This bill is substantially similar to SB 944 (Hertzberg) of the current legislative session which was held in the Assembly Appropriations Committee. According to the Appropriations Committee:

1. Staff costs of approximately $400,000 General Fund (GF) to EMSA to promulgate regulations, design a data structure and data collection system, and transition current sites to new rules over the first one to two years.
2. Ongoing staff costs of approximately $300,000, until the January 1, 2025 sunset, to review and approve programs, collect and review data, and develop annual reports GF, assuming 15 CPP programs. There could be additional cost pressure if a higher number of counties authorize and submit programs for EMSA review.

COMMENTS:

1. PURPOSE OF THIS BILL. According to the author, California’s health care needs have evolved over time and the current emergency response system must be updated to reflect this. Community paramedicine and alternate destination programs have proven success in improving access to care by specially-trained paramedics. The author states that EDs have a primary responsibility, which is to serve as a rapid response to crises and disasters. The EMS system is not adequately designed to care for patients who have mental health care needs or those who are inebriated. Frequent 9-1-1 users aren’t able to receive the right care at the right time as our paramedics are currently unable to send patients to medically-staffed mental health and sobering facilities. The author notes that community paramedicine programs allow for greater ease in accessing post-discharge care and observed therapy needs. Specially-trained paramedics can provide appropriate connections to medical professionals who are able to provide individualized care to patients who need assistance in their homes or other facilities. The author concludes that this bill authorizes community paramedicine and alternate destination programs based on strong research and evaluation of the current pilot programs and is a thoughtful measure designed to improve health care for all.
2. BACKGROUND. 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.
   1. 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.
   2. Sobering centers. This bill would permit specially trained EMT-P's, under certain circumstances, to redirect patients to 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. 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.
   3. Designated facilities. This bill would permit specially trained EMT-P's, under certain circumstances, to redirect patients to designated facilities. Individual counties are responsible for determining whether GACHs, psychiatric health facilities, acute psychiatric hospitals, 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 federal 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.
   4. 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.
   5. 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.

The existing 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.

• 1. 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 CPP model at 12 projected sites located throughout the state. Thirteen CPP 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) DOT for TB; 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.

• 1. Evaluation of HWPP #173. A team of evaluators at the Philip R. Lee Institute for Health Policy Studies (Institute) 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 CPP 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 six pilot project components: post discharge follow-up, DOT for persons with TB, hospice care, frequent 911 users, and alternate destinations (both mental health and sobering centers). Below are the report findings for those concepts:
     1. Post discharge follow-up. There were five post-discharge project sites started throughout the state, in the City of Alameda, at UCLA-Glendale, and in the counties of Butte, San Bernardino, and Solano. The UCLA-Glendale site closed because the partner fire department was unwilling to continue funding the project. Together, these projects enrolled 1,401 patients, were effective at reducing the rate of readmissions within 30 days, and identified 229 patients who needed instruction on how to use their medications correctly. The Institute estimated that these projects potentially avoided $1.4 million in costs by reducing hospital readmissions, with most savings accruing to Medicare and Medi-Cal. Most project sites involved an initial home visit. One project site instead called for an initial assessment by phone, but when that was found to be less effective, this project site revised its protocol to always include at least one home visit. In addition to helping a large number of patients who had difficulty understanding how to comply with their medications, community paramedics made at least 188 referrals to a wide range of service providers, using manuals of local resources that they prepared as part of their training, including to primary care, specialists, pharmacists, mental health services, home health providers, drug and alcohol treatment programs, food assistant agencies, housing assistance providers, and transportation assistance providers.
     2. DOT for TB. Ventura County was the only pilot site for the DOT concept. TB is a highly contagious disease that is treated with antibiotics. TB treatment clinics often provide DOT to ensure that people take their medications as directed. In Ventura County, public health officials asked the county's EMS provider to partner with the TB clinic to provide DOT, because the TB clinic does not have sufficient staff to provide DOT to all patients in the county. The TB clinic also utilizes community health workers (CHWs) to administer DOT, but the CHWs only work on weekdays and do not provide DOT on weekends. CPs dispensed appropriate doses of TB medications and monitored side effects and symptoms that could necessitate a change in treatment. Persons with TB who received DOT from CPs were more likely to receive all doses of TB medication prescribed by the TB clinic physician than patients who received DOT from the TB clinic's CHWs. Receiving all doses increases the likelihood that a patient will be cured and will not spread TB to others, or to develop a drug-resistant strain of TB that would be more difficult to treat. The TB clinic leaders indicated that there were conscious decisions to assign patients to either CPs or CHWs based on the likelihood that patients would comply with treatment. CPs were assigned patients who resist treatment or are verbally abusive or sexually inappropriate because CPs have more experience and training in managing persons with such behaviors. They were also assigned homeless persons and other difficult to locate patients. There were no additional costs to the health care system because CPs who provided DOT at the pilot site did so while already on duty to respond to traditional 911 calls. The TB project enrolled a total of 29 patients through September 30, 2016.
     3. Hospice. Ventura County was the only pilot site for the hospice concept. The goal of hospice care is to provide medical, psychological, and spiritual support to persons dying from a terminal illness. Care is provided by a multidisciplinary team of health professionals and volunteers in a patient's home, a residential care facility, a nursing home, or an inpatient hospice facility. Hospice staff members tell hospice patients, their family members, and others caregivers to contact the hospice instead of 911 if they believe there is a medical need or if they become concerned about the patient's comfort. Despite this, some patients and their families call 911 instead of the hospice because they are anxious about the patient's condition, or family members disagree with the patient's decision to obtain hospice care. The standard response to a 911 call made on behalf of a hospice patient is to transport the patient to an ED, which may be upsetting to the patient, and clinicians in EDs may perform medical interventions that the patient would prefer not to receive. Hospice patients who go to the ED also risk losing their hospice benefits. In Ventura County, CPs mainly provided hospice patients and their families with psychosocial support and administered medications from the hospice patients "comfort care" packs when necessary, in consultation with a hospice nurse. No hospice patient who requests transport to an ED is denied transport. According to the Institute, this project responded to 270 calls made on behalf of patients of participating hospice agencies. Hospice patients, family members, or staff of residential or skilled nursing facilities initiated most 911 calls, but hospice nurses made some 911 calls during visits with patients. The reasons for the 911 calls included altered level of consciousness, cardiac arrest, constipation, fall, seizure, shortness of breath, and family concern about hospice care. According to the Institute, prior to the launch of the pilot project, 80% of 911 calls for hospice patients resulted in the transport of a patient to the emergency department. After the pilot project was implemented, the percentage of patients transported decreased to 30% in partner hospices.
     4. Frequent 911/EMS User. There were two frequent EMS user projects: one in Alameda; and, one in San Diego. However, the San Diego project has not enrolled any new patients since December of 2016 because its community paramedics were reassigned to traditional 911 response crews. The two projects used different criteria of frequent EMS users: San Diego’s project primarily enrolls patients with 20 or more ED visits per year, while Alameda’s project (which serves a much smaller city) is open to all patients referred by staff of the local EMS agency or the partner hospital. Community paramedics assessed patients’ physical, psychological, and social needs and provided them with individualized case management to link them with nonemergency services. Among the 37 patients enrolled in San Diego’s project for whom data was available for 12 months prior to enrollment and 12 months following enrollment, the total number of 911 calls decreased from 955 to 625, a decrease of 35%. The average number of calls per person decreased from 26 to 17 per year, and some enrollees had much larger decreases in 911 calls. Among the 33 patients enrolled in Alameda’s project with 12 months of before and after data, the total number of 911 calls decreased from 131 to 110, a decrease of 16%, while the average number of 911 calls per person only decreased from four to three. The Institute suggested that the difference in impact between the two programs reflect the fact that San Diego had a high standard for frequent EMS user.
     5. Alternate destination – mental 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 the 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. Alternate destination – 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.

1. SUPPORT. The Alameda Firefighters (IAFF Local 689) are the sponsors of this bill, and along with the City of Alameda, states that with a CPP pilot program in Alameda, the community and department would greatly benefit from this bill. IAFF Local 689 states that implementing these programs in way that respects the existing system and all stake holders; while ensuring vigorous guidance and oversight, will ultimately provide the foundation need to have long and sustained success of improving patient outcomes and system efficiency.

The California Fire Chiefs Association and the Fire Districts Association of California note that CPPs have been piloted in several jurisdictions and have proved to provide positive services to patients at a reduced cost to local government.

The California Chapter of the American College of Emergency Physicians supports this bill, and state that they are pleased to see that this bill includes authorizing the pilots that aim to reduce ED visits by keeping people well.

1. OPPOSITION. The Emergency Medical Services Administrators of California and the EMDAC oppose this bill because it will erode local medical control of EMS systems and create unnecessary impediments for innovative solutions to the delivery of healthcare by counties and their LEMSAs.

The California Hospital Association is opposed to this bill for four primary reasons: a) the bill requires a sobering center to be designated as an FQHC; b) the bill requires alternate destination facilities to accept all patients; c) the bill would establish duplicative bureaucratic steps for reviewing CPPs; and, d) the bill should be clarified that facilities wishing to participate in TADPs will not be required to pay a fee.

The California Nurses Association opposes this bill, noting that it is based upon two bills that were recently held in the Assembly Appropriations Committee, and is based on the faulty premise that private ambulance companies and public fire departments can provide both continuity of care and high quality health services, in addition to, and during, their traditional EMS roles.

Analysis Prepared by: Lara Flynn / HEALTH / (916) 319-2097 FN: 0005208

 THIRD READING  

Bill No: AB 3115

Author:

:

Vote:

PRIOR VOTES NOT RELEVANT

SUBJECT:

SOURCE: California Professional Firefighters

Santa Clara County Firefighters, IAFF Local 689

DIGEST:

This bill enacts the Community Paramedicine or Triage to Alternate Destination Act of 2018, which permits local emergency medical services agencies, with approval by the Emergency Medical Services Authority, to develop programs to provide community paramedic or triage to alternate destination services in one of the following specialties: (1) providing short-term postdischarge followup; (2) providing directly observed tuberculosis therapy; (3) providing case management services to frequent emergency medical services users; (4) providing hospice services to treat patients in their homes; and, (5) providing patients with transport to an alternate destination, which can either be an authorized mental health facility, or an authorized sobering center. Sunsets the provisions of this bill on January 1, 2025.

[NOTE: This bill is substantially similar to SB 944 (Hertzberg), which passed the Senate on May 8, 2018 by a vote of 28-8.]

ANALYSIS:

Existing law:

1. Establishes the Emergency Medical Services Authority (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. Permits a county to establish an emergency medical care committee (EMCC), and to prescribe the membership and appoint the members of the EMCC. Requires the EMCC, if established by a county, to annually report to the local EMS agency and EMSA regarding the operations of ambulance services and emergency medical care practices in the county. [HSC §1797.270, et seq.]
3. Establishes an 18-member Commission on EMS, within the California Health and Human Services Agency. Defines the duties of the Commission to include reviewing regulations, standards, and guidelines developed by EMSA; advising EMSA on a data collection system; advise on various aspects of the EMS system; and, to make recommendations for further development of the EMS system. [HSC §1799, et seq.]
4. Defines "Emergency Medical Technician-Paramedic," "EMT-P," "paramedic" or "mobile intensive care paramedic" as an individual whose scope of practice includes the ability to provide advanced life support, as specified, including administering specified medications. EMT-Ps are licensed and regulated at the state level through EMSA. [HSC §1797.84]
5. Establishes the Health Workforce Pilot Projects (HWPP) in the Office of Statewide Health Planning and Development (OSHPD), which states legislative findings that experimentation with new kinds and combinations of health care delivery systems is desirable and that for purposes of this experimentation, a select number of publicly evaluated HWPPs should be exempt from the healing arts practices acts. [HSC §128125, et seq.]

This bill:

1. Establishes the Community Paramedicine or Triage to Alternate Destination Act of 2018, and states the intent of the Legislature that, among other things, an alternative destination facility participating as part of a community paramedicine program will always be staffed by a health care professional with a higher scope of practice such as a registered nurse, and that delivery of community paramedicine or triage to alternate destination services is a public good and is complementary to the existing emergency response system.
2. Defines “community paramedicine program,” for purposes of this bill, as a program developed by a local EMS agency and approved by EMSA to provide community paramedicine services consisting of one or more of the program specialties described in this bill under the direction of medical protocols developed by the local EMS agency that are consistent with the minimum protocols established by EMSA. Permits community paramedic services to consist of the following specialties:
   1. Providing short-term post-discharge follow-up for persons recently discharged from a hospital due to a serious health condition;
   2. Providing directly observed therapy to persons with tuberculosis; and,
   3. Providing case management services to frequent EMS users in collaboration with, and by providing referral to, existing appropriate community resources;
3. Defines “triage to alternate destination program,” for purposes of this bill, as a program developed by a local EMS agency and approved by EMSA to provide triage paramedic assessments consisting of one or more specialties described in this bill operating under triage and assessment protocols developed by the local EMS agency that are consistent with the minimum triage and assessment protocols established by EMSA. Permits triage paramedic assessments to consist of the following program specialties:
   1. Providing care and comfort services to hospice patients in their homes in response to 911 calls by providing for the patient’s and family’s immediate care needs, including grief support, in collaboration with the patient’s hospice agency until the hospice nurse arrives to treat the patient; and,
   2. Providing patients with advanced life support triage and assessment by a triage paramedic and transportation to an alternate destination facility.
4. Prohibits anything in the “triage to alternate destination program” provisions of this bill from being construed to prevent or eliminate any authorities to provide continuous transport of a patient to a participating hospital for priority evaluation by a physician, nurse practitioner, or physician assistant followed by a transport to an alternate destination facility.
5. Defines the following additional terms for purposes of this bill:
   1. “Alternate destination facility” is a treatment location that is an authorized mental health facility, as defined, or an authorized sobering center, as defined, but not a general acute care hospital, as defined;
   2. “Authorized mental health facility” is a designated facility, as defined, that has at least one registered nurse onsite at the facility at all times;
   3. “Authorized sobering center” is a facility that is a federally qualified health center that has at least one registered nurse staffed onsite at the facility at all times, including a licensed clinic that is authorized to share clinic space with a government-operated clinic that is exempt from licensure, as specified.
   4. “Community paramedic” is a licensed paramedic who has completed the curriculum for community paramedicine as described in this bill, has received certification in one or more of the community paramedicine program specialties described in this bill, and is accredited to provide community paramedic services by a local EMS agency as part of an approved community paramedicine program;
   5. “Community paramedicine provider” is an advanced life support provider who has entered into a contract to deliver community paramedic services as part of an approved community paramedicine program developed by a local EMS agency;
   6. “Public agency” is a city, county, special district, or other political subdivision of the state that provides first response services, including emergency medical care;
   7. “Triage Paramedic” is a licensed paramedic who has completed the curriculum for triage paramedic services under this bill, has been accredited by a local EMS agency in one or more of the triage paramedic specialties described in this bill; and,
   8. “Triage to alternate destination provider” is an advanced life support provider authorized by a local EMS agency to provide advanced life support triage paramedic assessments as part of an approved triage to alternate destination program specialty.
6. Requires EMSA to develop regulations that establish minimum standards for the development of a community paramedicine or triage to alternate destination program, and requires the Commission on EMS to review and approve the regulations.
7. Requires the regulations to be based upon, and informed by, the Community Paramedicine Pilot Program under HWPP #173, and the protocols and operation of the pilot projects approved under HWPP #173.
8. Requires the regulations to consist of all of the following:
   1. Minimum standards and curriculum for each program specialty described in this bill, which requires community paramedics or triage paramedics to be trained in one or more of the program specialties and approved by the local EMS agency;
   2. A process for verifying on a paramedic’s license the successful completion of the required training;
   3. Minimum standards for approval, review, withdrawal, and revocation of a community paramedicine or triage to alternate destination program, including a requirement that facilities participating in the program accommodate privately or commercially insured, Medi-Cal, Medicare, and uninsured patients, and immediate termination of program participation if a facility or provider fails to operate in accordance with specified provisions of law that require emergency care to be provided to anyone regardless of ability to pay; and,
   4. Minimum standards for collecting and submitting data to EMSA to ensure patient safety that include consideration of both quality assurance and quality improvement. Requires these standards to include, among other things, consideration of ambulance patient offload times for the alternate destination facility, the number of patients that are turned away, diverted, or required to be subsequently transferred to an emergency department, and an assessment of the impact on response times in the local EMS agency’s jurisdiction.
9. Requires EMSA to ensure the following with regards to the regulations adopted relating to a triage to alternate destination program:
   1. Requires local EMS agencies participating in providing patients with advanced life support triage and assessment by a triage paramedic and transportation to an alternate destination facility, to ensure that any patient who requests to be transported to an emergency department will be transported to an emergency department; additionally, requires any patient found to no longer meet the criteria for admission to an alternate destination facility to be immediately transported to an emergency department;
   2. Requires for transport to a behavioral health facility, training and accreditation to include topics relevant to the needs of the patient population, including a requirement that participating paramedics complete instruction on mental health crisis intervention and the assessment and treatment of intoxicated patients, and a requirement that the paramedic has completed training in specified topics such as psychiatric disorders, neuropharmacology, and patient consent;
   3. Requires for transport to a sobering center, a training component that requires a participating paramedic to complete instruction on, among other things, the impact of alcohol intoxication on the local public health and EMS system, health risks and interventions in stabilizing acutely intoxicated patients, and common conditions with presentations similar to intoxication.
10. Requires EMSA to consult with a committee of advisory members in the fields of public health, social work, hospice, or mental health, and physicians whose primary practice is emergency medicine, and adopt minimum medical protocols for each community paramedicine program specialty, and minimum triage and assessment protocols for triage to alternate destination program. Requires the protocols to be based on HWPP #173, and further refinements provided by local EMS agencies during the pilot projects.
11. Requires EMSA to submit an annual report on the community paramedicine or triage to alternate destination programs operating in California to the relevant policy committees of the Legislature, and to post the report on its website. Requires EMSA to submit its first report six months after EMSA adopts the regulations, and every January 1 thereafter for the next five years. Requires this report to include assessments of each program specialty, including an assessment of any adverse patient events, an assessment of the impact on the emergency medical system, and policy recommendations for the improvement of local plans and improvement of patient outcomes.
12. Requires EMSA to identify and contract with an independent third-party evaluator to develop a report on the community paramedicine or triage to alternate destination programs to be submitted to the Legislature by June, 1, 2023, that includes all of the following:
    1. A detailed assessment of each community paramedicine or triage to alternate destination program operating in local EMS agency jurisdictions;
    2. An assessment of patient outcomes in the aggregate resulting from services provided under approved plans under the program;
    3. An assessment of workforce impact due to the program;
    4. An assessment of the impact of the program on the EMS system;
    5. An assessment of how the currently operating program specialties achieve the legislative intent of this bill; and,
    6. An assessment of community paramedic and triage training.
13. Requires EMSA to review a local EMS agency’s proposed community paramedicine or triage to alternate destination program, and review the program’s protocols, to ensure the proposed program is consistent with EMSA’s regulations and the provisions in this bill, and to approve, approve with conditions, or deny the proposed program within six months after it is submitted by the local EMS agency. Permits EMSA to impose conditions as part of its approval that the local EMS agency is required to incorporate into its program to achieve consistency with EMSA’s regulations and this bill.
14. Permits a community paramedicine pilot program approved under OSHPD’s HWPP #173 before January 1, 2019, to operate until one year after the regulations required under this bill become effective. Requires OSHPD to continue to review, and where appropriate, approve HWPP #173 applications until one year after the regulations become effective. Specifies that a community paramedicine pilot program approved under HWPP #173 prior to January 1, 2019 to provide community paramedicine services, is authorized to continue the use of existing providers and is exempt from the requirements in this bill that public agencies get right of first refusal, until the provider elects to reduce or eliminate one of those services approved under the pilot program.
15. Permits a local EMS agency to develop a community paramedicine or triage to alternate destination program that is consistent with EMSAs regulations and the provisions of this bill and submit it to EMSA for approval.
16. Requires a local EMS agency that opts to develop a community paramedicine or triage to alternate destination program to do all of the following:
    1. Integrate the proposed community paramedicine or triage to alternate destination program into the local EMS agency’s EMS plan, as defined;
    2. Develop a process to select community paramedicine providers at a periodic interval established by the local EMS agency;
    3. Facilitate any necessary agreements with one or more community paramedicine or triage to alternate destination providers for the delivery of services within the local EMS agency’s jurisdiction, and to provide medical control and oversight of the program; and,
    4. Prohibits a local EMS agency from including a community paramedic services agreement within an existing or proposed contract for the delivery of EMS within an exclusive operating area, as specified.
17. Requires the local EMS agency, with regard to community paramedicine programs (not triage to alternate destination programs) to review and approve any written agreements for the provisions of those specialties as follows:
    1. Requires a local EMS agency to provide a right of first refusal for the public agency or agencies with the jurisdiction of the proposed program area. If a public agency agrees to provide the proposed specialties, requires the local EMS agency to review and approve written agreements with those public agencies;
    2. Permits the local EMS agency to review and approve agreements with community paramedicine providers that partner with a public agency or agencies to deliver those program specialties; and,
    3. Requires the local EMS agency, if no public agency chooses to provide the proposed community paramedicine program specialties, to establish a process to select a provider to deliver the specialties.
18. Requires a local EMS agency, with regard to triage to alternate destination program specialties, to continue the use of existing providers operating within the local EMS agency’s jurisdiction, and to do all of the following:
    1. At the discretion of the local medical director, develop additional triage and assessment protocols commensurate with the need of the local programs;
    2. Prohibits the triage and assessment protocols and decision of the triage paramedic to transport to an alternate destination facility, to be based upon or affected by the patient’s ethnicity, citizenship, age, preexisting medical condition, insurance status, economic status, ability to pay, or any other characteristic for which existing law prohibits discrimination, unless it is medically significant to the provision of appropriate medical care.
    3. Certify and provide documentation and periodic updates to EMSA showing that the alternate destination facility authorized to receive patients has adequate licensed medical staff, facilities, and equipment that comply with EMSA’s regulations and this bill, which includes qualified staff, standardized medical and nursing procedures for nursing staff, and necessary equipment including an automatic external defibrillator;
    4. Secure an agreement with the alternate destination facility that requires the facility to notify the local EMS agency and EMSA within 24 hours if there are changes in the status of the facility with respect to the protocols and the facility’s ability to care for patients; and,
    5. Secure an agreement with the alternate destination facility attesting that the facility will operate in accordance with provisions of law requiring facilities to provide emergency care without regard to the patient’s ability to pay, and that failure to comply with these provisions of law will result in the immediate termination of use of the facility as part of the triage to alternate destination program.
19. Requires a local EMS agency to establish a process to verify training and accreditation of community paramedics and triage paramedics in each of the proposed program specialties in this bill.
20. Requires a local EMS agency to facilitate funding discussions between a community paramedicine or triage to alternate destination provider and public or private health system participants to support the implementation of the local EMS agency’s programs.
21. Requires a county board of supervisors, if a local EMS agency opts to develop a community paramedicine program, to establish an EMCC, and requires the EMCC to include specified additional members, and to advise the local EMS agency on the development of the community paramedicine program.
22. Prohibits a person or organization from providing community paramedic services unless it is authorized by a local EMS agency to provide those services as part of a community paramedicine program approved by EMSA.
23. Limits the ability of a community paramedic to provide community paramedic services only if he or she has been certified to perform those services by a local EMS agency and is working as an employee of an authorized community paramedicine provider.
24. Requires the disciplinary procedures for a community paramedic to be consistent with specified provisions of existing law related to EMT-Ps.
25. Requires the liability provisions of existing law which limits the liability of persons who render emergency care, including emergency services personnel, to also apply to the provisions of this bill.
26. Expands the Commission on EMS from 18 to 20 members, with the two additional members as follows: a physician specializing in the care of individuals with co-occurring mental health or psychosocial and substance use disorders, appointed by the Governor in consultation with the California Psychiatric Association and the California Society of Addiction Medicine; and, a licensed clinical social worker appointed by the Governor in consultation with the California State Council of the Service Employees International Union and the California Chapter of the National Association of Social Workers. Additionally, revises how certain existing members of the Commission are appointed, by requiring consultation by the California Labor Federation on the registered nurse and the paramedic or EMT-II appointments, and by requiring the emergency medicine physician appointment to be selected from a list of names submitted by the California Chapter of the American College of Emergency Physicians.
27. Sunsets the provisions of this bill (except the changes to the composition of the Commission on EMS) on January 1, 2025.

Comments

Author’s statement. According to the author, California’s health care needs have evolved over time and the current emergency response system must be updated to reflect this. Community paramedicine and alternate destination programs have proven success in improving access to care by specially-trained paramedics. Emergency departments have a primary responsibility, which is to serve as a rapid response to crises and disasters. The EMS system is not adequately designed to care for patients who have mental health care needs or those who are inebriated. Frequent 9-1-1 users aren’t able to receive the right care at the right time as our paramedics are currently unable to send patients to medically-staffed mental health and sobering facilities. Community paramedicine programs allow for greater ease in accessing post-discharge care and observed therapy needs. Specially-trained paramedics can provide appropriate connections to medical professionals who are able to provide individualized care to patients who need assistance in their homes or other facilities. This bill authorizes community paramedicine and alternate destination programs based on strong research and evaluation of the current pilot programs. It is a thoughtful measure designed to improve health care for all.

NOTE: For background on this bill, please refer to the Senate Health Committee analysis of SB 944 (Hertzberg), dated April 16, 2018.

FISCAL EFFECT: Appropriation: Fiscal Com.: Local:

This bill is similar to SB 944 (Hertzberg), which passed the Senate on May 8, 2018 by a vote of 28-8. The Senate Committee on Appropriations provided the following fiscal impact, which is an update to its analysis of SB 944 with a new estimate of this bill’s fiscal impact provided by EMSA:

To implement the bill’s provisions, the EMSA identifies costs of at least $692,000 General Fund in Fiscal Year (FY) 2018-19 and $814,000 General Fund in FY 2019-20, and ongoing, for ongoing staffing, one-time data and programming, contracting an independent evaluator, and additional Commission costs for new membership. These costs would not be absorbed by raising paramedic fees due to the number of community paramedics compared to the rest of the paramedic population.

SUPPORT: (Verified  8/28/18)

California Professional Firefighters (co-source)

Santa Clara County Firefighters, IAFF Local 1165 (co-source)

Alameda Firefighters, IAFF Local 689

California Chapter of the American College of Emergency Physicians

California Fire Chiefs Association

City and County of San Francisco

City of Alameda Fire Department

City of Murrieta

Fire Districts Association of California

Mental Health America of Los Angeles

National Association of Social Workers, California Chapter

San Diego City Firefighters I.A.F.F. Local 145

The Steinberg Institute

OPPOSITION: (Verified  8/30/18)

Association of California Healthcare Districts

California Ambulance Association

California Association for Health Services at Home

California Hospice and Palliative Care Association

California Hospital Association

California Nurses Association/National Nurses United

California State Association of Counties

County of Fresno

County of Riverside

County of San Joaquin

County of Ventura

Emergency Medical Directors Association of California

Emergency Medical Services Administrators Association of California

Tenet Healthcare

ARGUMENTS IN SUPPORT: This bill is sponsored by the California Professional Firefighters (CPF), which states that the initial analysis and subsequent updates of HWPP #173 have reflected positively on the implementation of community paramedicine pilot programs. According to CPF, absent legislative authorization, the current community paramedicine pilot programs operating in California will sunset in November of 2018. CPF states that community paramedicine can leverage a trusted community resource, firefighter paramedics, to deliver this important resource. According to CPF, this bill proposes a carefully structured process that includes robust legislative direction, state regulatory oversight, and local EMS agency autonomy to develop programs that best fit the needs in the local EMS agency’s jurisdiction. CPF argues that community paramedicine can play an important role in improving California’s health care delivery system. CPF states that implementing this program in a way that respects the current system and all stakeholders and includes robust guidance and oversight will provide the foundation for these programs to have long and sustained success in improving patient outcomes and system efficiency. The California Chapter of the American College of Emergency Physicians (California ACEP) states in support that while there have been several bills introduced attempting to codify the scope expansion that was piloted by HWPP #173, and it has maintained several principles in its approach to these bills, including that scope expansion authorization must replicate what was shown to be safe in the pilot programs, destinations must be defined and licensed, non-discrimination protections must be included, and the bill should require data collection. According to California ACEP, this bill is well crafted to meet these important patient safety protections.

ARGUMENTS IN OPPOSITION: The California Ambulance Association (CAA) states that while it supports the concept of community paramedicine, and has sponsored legislation in the past to extend the current pilot projects operating in California, this bill will result in the termination and end of most, if not all, community paramedic projects across the state. CAA argues that public agencies, who are the beneficiaries of this bill, cannot sustain the services, and yet this bill imposes restrictions on private ambulance companies that will result in the inability of private ambulance companies to provide community paramedic services at all. The California Hospital Association (CHA) opposes this bill, stating that requiring a sobering center to be designated as a federally qualified health center (FQHC) does not make sense, and that there is only one sobering center currently affiliated with an FQHC. CHA also states that requiring all sobering centers and mental health crisis stabilization units to accept all patients would prohibit community paramedics from taking patients to county facilities that are operated with funding designated for Medi-Cal and uninsured patients. The California Nurses Association/National Nurses United (CNA) states in opposition that this bill circumvents the legislative process in order to implement the deeply flawed community paramedicine program which inappropriately increases paramedics’ scope of practice and takes sides in a public versus private turf battle while not adequately considering patient safety. According to CNA, this bill is based on the faulty premise that private ambulance companies and public fire departments can provide continuity of care and high quality health services in addition to, and during, their traditional EMS roles. With regard to the specific projects, CNA argues that the number of enrollees in many of the projects was very low and the evaluation of the projects contained selective use of data. Finally, CNA states that fires and other disasters have stretched EMS resources thin, and it is not clear why these paramedics should be diverted from their primary roles, especially since there is an adequate number of registered nurses and licensed vocational nurses to meet workforce needs. The California Association for Health Services at Home (CAHSAH) states in opposition that this is a clear scope expansion into licensed home care, home health and hospice services by individuals who are neither trained, licensed, nor regulated to provide such services. CAHSAH states that paramedics are not trained in establishing treatment plans and working with physicians on the oversight of patient’s overall health needs, while home health agencies are required to utilize nurses who have at least one year of professional nursing experience. The California Hospice and Palliative Care Association (CHPCA) states in opposition that hospice is a capitated benefit under all payment systems, and therefore the hospice provider is at risk for the costs of care for hospice patients. CHPCA states that hospices cannot, according to Medicare Conditions of Participation, delegate its responsibility to treat hospice patients, and this bill conflicts with this requirement. The Emergency Medical Services Administrators Association of California and the Emergency Medical Directors Association of California states that this bill will erode local medical control of EMS systems and create unnecessary impediments for innovative

olutions to the delivery of healthcare by counties and their local EMS agencies, such as the preferential treatment of public agencies over private entities.

Prepared by:

8/30/18 17:48:33

**** END ****

 THIRD READING  

Bill No: AB 3115

Author:

:

Vote:

SENATE PUBLIC SAFETY COMMITTEE: 5-2, 6/26/18

AYES: Skinner, Bradford, Jackson, Mitchell, Wiener

NOES: Anderson, Stone

SENATE APPROPRIATIONS COMMITTEE: 5-2, 8/16/18

AYES: Portantino, Beall, Bradford, Hill, Wiener

NOES: Bates, Nielsen

ASSEMBLY FLOOR: 45-29, 5/30/18 - See last page for vote

SUBJECT: Jails: voter education program

SOURCE: California State Conference of the NAACP

DIGEST:

This bill requires each county jail to allow organizations to provide a voter education program in the county jail.

ANALYSIS:

Existing law:

1. Requires the California Department of Corrections and Rehabilitation (CDCR) to do both of the following:
   1. Establish and maintain on CDCR’s website a hyperlink to the Secretary of State’s website containing a voting rights guide for incarcerated persons; and
   2. Post, in each parole office where parolees are seen, a notice that contains the Secretary of State’s website containing a voting rights guide for incarcerated persons. (Elec. Code, § 2105.5, subd. (a).)
2. Requires each county probation department to do both of the following:
   1. Establish and maintain on CDCR’s website a hyperlink to the Secretary of State’s website containing a voting rights guide for incarcerated persons; and
   2. Post, in each parole office where parolees are seen, a notice that contains the Secretary of State’s website containing a voting rights guide for incarcerated persons. (Elec. Code, § 2105.5, subd. (b).)
3. Requires CDCR to provide each parolee under the jurisdiction of the department upon the completion of their parole, upon the parolee's request information provided by the Secretary of state regarding voting rights for persons with a criminal history. (Elec. Code, § 2105.6, subd. (a).)
   
4. Encourages each county probation department to notify persons that a printed version of information regarding voting rights for persons with a criminal history who are under the department's supervision is available upon request. (Elec. Code § 2105.6, subd. (b).)
5. Requires each county probation department to provide each person under the department's supervision upon the person's request, information provided by the Secretary of State regarding voting rights for persons with a criminal history. (Elec. Code § 2105.6, subd. (c).)
6. Requires the Legislature to provide for the disqualification of electors while mentally incompetent or imprisoned or on parole for the conviction of a felony. (Cal. Const., Article II, § 4.)
7. Requires that a person be a U.S. citizen, California resident, not in prison or on parole for the conviction of a felony, and at least 18 years of age at the time of the next election to be entitled to register to vote in this state. (Elec. Code, § 2101.)
8. Requires the facility administrator of a local detention facility to develop written policies and procedures whereby the county registrar of voters allows qualified voters to vote in local, state, and federal elections, pursuant to election codes. (Cal. Code of Regulations, Title 15, § 1071.)

This bill:

1. Requires each county jail to allow organizations to provide a voter education program in the county jail.
2. Requires that the program includes, but is not limited to, the following:
   1. Providing both written and verbal information about voting rights upon release from jail;
   2. Providing affidavits of registration to eligible voters;
   3. Assisting eligible voters with completion of the affidavits of registration; and
   4. Assisting eligible voters in returning the completed voter registration cards to the county elections official.
3. Specifies that this bill shall not be construed to compromise the existing security protocols of a jail facility.

Background

Assemblymember Gipson states in his author statement, “Many African-American and Latino voters have been confused at some point about their eligibility to vote due to a criminal conviction because the individuals’ status is continuously changing and are not given adequate information about their rights at each stage of the process or at least complete information from the start. By ensuring that incarcerated people who have the right to register and vote as well as have the support they need to make educated choices and about issues that directly affect them and their communities, we can empower them to feel in control of their futures in a new way and create an incentive for improved behavior while in jail as well as reduce recidivism.”

Prior to 2016, any person who was imprisoned or on parole for a felony conviction was prohibited from voting and elections officials were required to cancel the voter registrations of such individuals. In September of 2016, Governor Jerry Brown signed AB 2466 (Weber), a bill that allowed convicted felons serving time in county jails the ability to vote within jail. Thus, the following individuals with a criminal history may register to vote:

1. Those in county jail serving a misdemeanor jail sentence;
2. Those in county jail serving a felony jail sentence (per realignment);
3. Those in county jail serving a felony on probation for a misdemeanor or felony;
4. Those in county jail awaiting trail;
5. Those on probation;
6. Those on mandatory supervision;
7. Those on post-release community supervision;
8. Those on federal supervised release; and
9. A person with a juvenile wardship adjudication.

Those individuals with a criminal history who cannot register and vote:

1. Those imprisoned in state prison and federal prison;
2. Those serving a state prison felony sentence in county jail or other correction facility;
3. Those in county jail awaiting transfer to a state or federal prison for a felony conviction
4. Those in county jail for a parole violation; and
5. Those currently on parole with CDCR.

This bill requires each county jail to allow at least one organization to provide a voter education program in the jail. This bill also states that the bill shall not be construed to compromise the existing security protocols of a jail facility.

Only two states in the United States, Maine and Vermont, do not remove a person’s right to vote when they are sent to prison. All other states enact a range of voting disenfranchisement while and/or after incarcerated.

The rationale for felony voting restrictions is the longstanding principle that once an offender has “paid their debt,” they should be able to rejoin the community. Exclusion from the electoral processes insinuates that the “debt” could never be paid in full and felony voting disenfranchisement is a lifelong sentence. More than 95% of offenders sentenced to prison will return to the community and encouraging these individuals to civically engage fosters a sense of responsibility.

In 2016, 29% of the California male prison population was Black and Latinx individuals made up 43% of the California male prison population. Many incarcerated people of color are uninformed about voter eligibility and voter registration. This is due to continuous changes to an individuals’ status, not given adequate or accurate information about their rights from the time they are involved in the criminal justice system.

Many individuals are now allowed to civically participate; however, those involved in the criminal justice system are not informed of their voting rights. Inaccurate information about voter registration laws and eligibility requirements, a lack of transparency about voting rights and generally, a lack of knowledge about elections and the voting process confuse the community, create greater distrust in government and mistrust of government officials.

FISCAL EFFECT: Appropriation: Fiscal Com.: Local:

According to the Senate Appropriations Committee, unknown costs, potentially over $50,000 in the aggregate to counties to require an organization to provide a voter education program in its jails. These costs likely would be reimbursable by the state, the extent of which would be determined by the Commission on State Mandates. Costs would require reimbursement even if local jurisdictions were providing the mandated service voluntarily prior to enactment of the requirement. (General Fund, local funds)

If costs to each county were $1,000, the fiscal impact of this measure would surpass this Committee’s Suspense File threshold. While it is expected that there are organizations that would offer the program outlined in AB 3115 at no cost to the jails, there is no requirement in this measure that the organization provide it free of charge. If a county (e.g., one that is remote and sparsely populated) has only one organization seeking to provide the program and would charge the county to do so, under this bill, the jail would be required to allow that organization to provide the service and, consequently, pay the associated fee. These costs, in turn, likely would require reimbursement by the state.

SUPPORT: (Verified 8/16/18)

California State Conference of the NAACP (source)

American Civil Liberties Union of California

California Attorneys for Criminal Justice

California Public Defenders Association

Center on Juvenile and Criminal Justice

OPPOSITION: (Verified 8/16/18)

A New Way of Life Re-Entry Project

California State Sheriffs’ Association

Californians United for a Responsible Budget

Center for Living and Learning

Legal Services for Prisoners with Children

Root & Rebound

ASSEMBLY FLOOR: 45-29, 5/30/18

AYES: Aguiar-Curry, Arambula, Berman, Bloom, Bonta, Burke, Caballero, Calderon, Carrillo, Cervantes, Chau, Chiu, Chu, Daly, Eggman, Friedman, Cristina Garcia, Eduardo Garcia, Gipson, Gloria, Gonzalez Fletcher, Grayson, Holden, Jones-Sawyer, Kalra, Kamlager-Dove, Levine, Limón, Low, McCarty, Medina, Mullin, Muratsuchi, Nazarian, Quirk, Reyes, Rodriguez, Rubio, Santiago, Mark Stone, Thurmond, Ting, Weber, Wood, Rendon

NOES: Acosta, Travis Allen, Baker, Bigelow, Brough, Chávez, Chen, Choi, Cooley, Cunningham, Dahle, Flora, Fong, Gallagher, Harper, Irwin, Kiley, Lackey, Maienschein, Mathis, Mayes, Melendez, Obernolte, Patterson, Quirk-Silva, Salas, Steinorth, Voepel, Waldron

NO VOTE RECORDED: Cooper, Frazier, Gray, O'Donnell

Prepared by:

8/18/18 16:31:01

**** END ****

SENATE COMMITTEE ON

Senator Anthony Portantino, Chair

2017 - 2018 Regular Session

AB 3115 (Gipson) - Jails: voter education program

This bill meets the criteria for referral to the Suspense File.

Bill Summary:

AB 3115 would require every county jail to allow at least one organization provide a voter education program in the jail.

Fiscal Impact:

Unknown costs, potentially over $50,000 in the aggregate to counties to require an organization to provide a voter education program in its jails. These costs likely would be reimbursable by the state, the extent of which would be determined by the Commission on State Mandates. Costs would require reimbursement even if local jurisdictions were providing the mandated service voluntarily prior to enactment of the requirement. (General Fund, local funds)

If costs to each county were $1,000, the fiscal impact of this measure would surpass this Committee’s Suspense File threshold. While it is expected that there are organizations that would offer the program outlined in AB 3115 at no cost to the jails, there is no requirement in this measure that the organization provide it free of charge. If a county (e.g., one that is remote and sparsely populated) has only one organization seeking to provide the program and would charge the county to do so, under this bill, the jail would be required to allow that organization to provide the service and, consequently, pay the associated fee. These costs, in turn, likely would require reimbursement by the state.

Background:

According to the analysis of this bill by the Senate Committee on Public Safety:

Prior to 2016, any person who was imprisoned or on parole for a felony conviction was prohibited from voting and elections officials were required to cancel the voter registrations of such individuals. In September of 2016, Governor Jerry Brown signed AB 2466 (Weber), a bill that allowed convicted felons serving time in county jails the ability to vote within jail. Thus, the following individuals with a criminal history may register to vote:

1. Those in county jail serving a misdemeanor jail sentence;
2. Those in county jail serving a felony jail sentence (per realignment);
3. Those in county jail serving a felony on probation for a misdemeanor or felony;
4. Those in county jail awaiting trail;
5. Those on probation;
6. Those on mandatory supervision;
7. Those on post-release community supervision;
8. Those on federal supervised release; and
9. A person with a juvenile wardship adjudication.

Those individuals with a criminal history who cannot register and vote:

1. Those imprisoned in state prison and federal prison;

1[sic]) Those serving a state prison felony sentence in county jail or other correction facility;

1. Those in county jail awaiting transfer to a state or federal prison for a felony conviction
2. Those in county jail for a parole violation; and
3. Those currently on parole with CDCR.

(Internal citations omitted.)

Proposed Law:

This bill would require each county jail to allow at least one organization to provide a voter education program in the jail that must include providing:

• Providing written and verbal information about voting rights upon release from jail,
• Providing affidavits of registration to eligible voters,
• Assisting eligible voters with the completion of the affidavits of registration, and
• Assisting eligible voters in returning the completed voter registration cards to the county elections official.

The above requirement should not be construed to compromise the existing security protocols of a jail facility.

Related Legislation:

AB 1344 (Weber, Ch. 796, Stats. 2017) required the Department of Corrections and Rehabilitation (CDCR) and county probation departments to provide specified voting rights information to persons under their jurisdiction upon request of such person.

AB 2243 (Weber, Ch. 899, Stats. 2014) required CDCR to make specified information related to voting rights of incarcerated persons available to the public and parolees under its jurisdiction.

AB 149 (Weber, Ch. 580, Stats. 2013) required each county probation department to either establish and maintain on the department’s website a hyperlink to the Secretary of State’s voting rights guide for incarcerated persons or post a notice with the website address that contains the Secretary of State’s voting rights guide for incarcerated persons in each probation office where probationers are seen.

-- END --

SENATE COMMITTEE ON PUBLIC SAFETY

Senator Nancy Skinner, Chair

2017 - 2018 Regular

Bill No: AB 3115 Hearing Date: June 26, 2018

Subject: Jails: Voter Education Program

HISTORY

Source: California State Conference of the NAACP

Prior Legislation: AB 1344 (Weber), Chapter 796, Statutes of 2017

AB 2243 (Weber) Chapter 899, Statutes of 2014

AB 149 (Weber), Chapter 580, Statutes of 2013

Support: American Civil Liberties Union; California Attorneys for Criminal Justice; California Public Defenders Association; California State Conference of the NAACP; Center on Juvenile and Criminal Justice

Opposition: California State Sheriffs’ Association

Assembly Floor Vote: 45 - 29

PURPOSE

The purpose of this bill is to require each county jail to allow at least one organization to provide a voter education program in the county jail.

Existing law requires the California Department of Corrections and Rehabilitation (CDCR) to do both of the following:

1. Establish and maintain on CDCR’s website a hyperlink to the Secretary of State’s website containing a voting rights guide for incarcerated persons; and
2. Post, in each parole office where parolees are seen, a notice that contains the Secretary of State’s website containing a voting rights guide for incarcerated persons. (Elec. Code, § 2105.5, subd. (a).)

Existing law requires each county probation department to do both of the following:

1. Establish and maintain on CDCR’s website a hyperlink to the Secretary of State’s website containing a voting rights guide for incarcerated persons; and
2. Post, in each parole office where parolees are seen, a notice that contains the Secretary of State’s website containing a voting rights guide for incarcerated persons. (Elec. Code, § 2105.5, subd. (b).)

Existing law requires CDCR to provide each parolee under the jurisdiction of the department upon the completion of their parole, upon the parolee's request information provided by the Secretary of state regarding voting rights for persons with a criminal history. (Elec. Code, § 2105.6, subd. (a).)

Existing law encourages each county probation department to notify persons that a printed version of information regarding voting rights for persons with a criminal history who are under the department's supervision is available upon request. (Elec. Code § 2105.6, subd. (b).)

Existing law requires each county probation department to provide each person under the department's supervision upon the person's request, information provided by the Secretary of State regarding voting rights for persons with a criminal history. (Elec. Code § 2105.6, subd. (c).)

Existing law requires the Legislature to provide for the disqualification of electors while mentally incompetent or imprisoned or on parole for the conviction of a felony. (Cal. Const., Article II, § 4.)

Existing law requires that a person be a U.S. citizen, California resident, not in prison or on parole for the conviction of a felony, and at least 18 years of age at the time of the next election to be entitled to register to vote in this state. (Elec. Code, § 2101.)

Existing law requires the facility administrator of a local detention facility to develop written policies and procedures whereby the county registrar of voters allows qualified voters to vote in local, state, and federal elections, pursuant to election codes. (Cal. Code of Regulations, Title 15, § 1071.)

This bill requires each county jail to allow at least one organization to provide a voter education program in the county jail.

The bill requires that the program includes, but is not limited to, the following:

1. Providing both written and verbal information about voting rights upon release from jail;
2. Providing affidavits of registration to eligible voters;
3. Assisting eligible voters with completion of the affidavits of registration; and
4. Assisting eligible voters in returning the completed voter registration cards to the county elections official.

This bill states that the program shall not be construed to compromise the existing security protocols of a jail facility.

COMMENTS

1. Need for This Bill

The author states:

Many African-American and Latino voters have been confused at some point about their eligibility to vote due to a criminal conviction because the individuals’ status is continuously changing and are not given adequate information about their rights at each stage of the process or at least complete information from the start.

By ensuring that incarcerated people who have the right to register and vote as well as have the support they need to make educated choices and about issues that directly affect them and their communities, we can empower them to feel in control of their futures in a new way and create an incentive for improved behavior while in jail as well as reduce recidivism.

2. Voting Rights and Persons with a Criminal History

Prior to 2016, any person who was imprisoned or on parole for a felony conviction was prohibited from voting and elections officials were required to cancel the voter registrations of such individuals. In September of 2016, Governor Jerry Brown signed AB 2466 (Weber), a bill that allowed convicted felons serving time in county jails the ability to vote within jail. Thus, the following individuals with a criminal history may register to vote:

1. Those in county jail serving a misdemeanor jail sentence;
2. Those in county jail serving a felony jail sentence (per realignment);
3. Those in county jail serving a felony on probation for a misdemeanor or felony;
4. Those in county jail awaiting trail;
5. Those on probation;
6. Those on mandatory supervision;
7. Those on post-release community supervision;
8. Those on federal supervised release; and
9. A person with a juvenile wardship adjudication.^[1]

Those individuals with a criminal history who cannot register and vote:

1. Those imprisoned in state prison and federal prison;
2. Those serving a state prison felony sentence in county jail or other correction facility;
3. Those in county jail awaiting transfer to a state or federal prison for a felony conviction
4. Those in county jail for a parole violation; and
5. Those currently on parole with CDCR.^[2]

This bill requires each county jail to allow at least one organization to provide a voter education program in the jail.

3. Civic Participation and the Criminal Justice System

Only two states in the United States, Maine and Vermont, do not remove a person’s right to vote when they are sent to prison. All other states enact a range of voting disenfranchisement while and/or after incarcerated.

The rationale for felony voting restrictions is the longstanding principle that once an offender has “paid their debt,” they should be able to rejoin the community. Exclusion from the electoral processes insinuates that the “debt” could never be paid in full and felony voting disenfranchisement is a lifelong sentence. More than 95% of offenders sentenced to prison will return to the community and encouraging these individuals to civically engage fosters a sense of responsibility.^[3]

In 2016, 29% of the California male prison population was Black and Latinx individuals made up 43% of the California male prison population.^[4] Many incarcerated people of color are uninformed about voter eligibility and voter registration. This is due to continuous changes to an individuals’ status, not given adequate or accurate information about their rights from the time they are involved in the criminal justice system.

Many individuals are now allowed to civically participate; however, those involved in the criminal justice system are not informed of their voting rights. Inaccurate information about voter registration laws and eligibility requirements, a lack of transparency about voting rights and generally, a lack of knowledge about elections and the voting process confuse the community, create greater distrust in government and mistrust of government officials.

4. Argument in Support

According to the California State Conference of the NAACP:

California incarcerates 80,000 people in its jails and more than half of the people have not been convicted or un-sentenced. This is a large community that has been historically excluded from civic engagement and participation. There is often an assumption by many people that if one has been incarcerated, that they have lost their right to vote, when this is not the case. Due to either misinformation or lack of information, many who are behind bars do not know that they can register to vote or there are systemic barriers in place that do allow people to exercise their right to vote.

California can take a major step forward by having a plan to provide civic education and voter registration for incarcerated communities. AB 3115 would help make sure that more people who have the right to register and vote have the support they need to make educated choices and decisions that directly affect them and their communities while they are incarcerated.

5. Argument in Opposition

According to the California State Sheriffs’ Association:

While we understand the desire to increase inmates' participation in the electoral process, this bill largely ignores any efforts that may be already ongoing within a jail facility. Counties across the state offer inmates assistance with voter registration and the casting of ballots. They often provide registration and ballot materials and assist with the delivery of completed registration cards.

Additionally, AB 3115 fails to consider appropriate security measures for the safety of inmates, staff, and the facility. Under the unambiguous language of the bill, ''each county jail shall allow at least one organization to provide a voter education program in the county jail.'' In the potential scenario where only a single organization comes forward to undertake the actions contemplated by the bill, AB 3115 seems to mandate that this organization must be allowed access to inmates and the facility, irrespective of any other consideration. Even if this particular organization or persons within it were deemed to be a safety risk, it appears the bill would mandate their access to a jail. The safety and security of a correctional facility should not be exposed to this type of ambiguous but possible threat.

-- END –

1. “Voting Rights: Persons with a Criminal History | California Secretary of State,” accessed June 15, 2018, http://www.sos.ca.gov/elections/voting-resources/voting-california/who-can-vote-california/voting-rights-californians/. ↑

2. “Voting Rights: Persons with a Criminal History | California Secretary of State.” ↑

3. Marc Mauer, “Felon Voting Disenfranchisement: A Growing Collateral Consequence of Mass Incarceration Collateral Sentencing Consequences,” Federal Sentencing Reporter 12 (2000 1999): 248–51. ↑

4. “California’s Changing Prison Population,” Public Policy Institute of California (blog), accessed June 18, 2018, http://www.ppic.org/publication/californias-changing-prison-population/. ↑

ASSEMBLY THIRD READING

ATR Bill Id:AB 3115

Author:(Gipson)

As Amended Ver:April 30, 2018

Majority vote

SUMMARY: Requires each county jail to allow at least one organization to provide a voter education program in the county jail, as specified. Specifically, this bill:

1. Provides that the program shall include, but not limited to, providing both written and verbal information about voting rights upon release from jail, providing affidavits of registration to eligible voters, assisting eligible voters with the completion of affidavits of registration, and assisting eligible voters in returning the completed voter registration cards to county elections officials.
2. States that the above requirement shall not be construed to compromise the existing security protocols of a jail facility or to require admittance by organizational personnel deemed to be a safety risk.

EXISTING LAW:

1. Requires the California Department of Corrections and Rehabilitation (CDCR) to do both of the following:
   1. Establish and maintain on the department's Internet website a hyperlink to the Internet website at which the Secretary of State's voting rights guide for incarcerated persons may be found; and
   2. Post, in each parole office where parolees are seen, a notice that contains the Internet website address at which the Secretary of State's voting rights guide for incarcerated persons may be found.
2. Requires each county probation department to do both of the following:
   1. Establish and maintain on the county probation department's Internet website a hyperlink to the Internet website at which the Secretary of State's voting rights guide for incarcerated persons may be found; and
   2. Post, in each county probation department where probationers are seen, a notice that contains the Internet website address at which the Secretary of State's voting rights guide for incarcerated persons may be found.
3. Requires CDCR to provide each parolee under the jurisdiction of the department upon the completion of his or her parole, upon the parolee's request information provided by the Secretary of state regarding voting rights for persons with a criminal history.
4. Encourages each county probation department to notify persons that a printed version of information regarding voting rights for persons with a criminal history who are under the department's supervision is available upon request.
5. Requires each county probation department to provide each person under the department's supervision upon the person's request, information provided by the Secretary of State regarding voting rights for persons with a criminal history.
6. Requires the Legislature to provide for the disqualification of electors while mentally incompetent or imprisoned or on parole for the conviction of a felony.
7. Requires that a person be a United States citizen, California resident, not in prison or on parole for the conviction of a felony, and at least 18 years of age at the time of the next election to be entitled to register to vote in this state.
8. Requires the facility administrator of a local detention facility to develop written policies and procedures whereby the county registrar of voters allows qualified voters to vote in local, state, and federal elections, pursuant to election codes.

FISCAL EFFECT: According to the Assembly Appropriations Committee, unknown, potentially significant reimbursable state-mandated costs, likely in the hundreds of thousands of dollars for county jails to accommodate a voter education program. A county jail will likely need to provide space and security for any program operating in the jail. If each county submitted a mandate claim of $10,000 the total costs to the state will be $580,000.

COMMENTS: According to the author, "California incarcerates 80,000 people in its jails and more than half of the people have not been convicted or are un-sentenced. This is a large community that has historically been excluded from civic engagement and participation. There is often an assumption by many people that if one has been incarcerated, that they have lost their right to vote, when this is not the case. Due to either misinformation or lack of information, many who are behind bars do not know that they can register to vote. There are systemic barriers in place that make it difficult for people to exercise their right to vote while in jail. Current law requires state and local juvenile detention facilities to assist in voter registration for individuals who are of age and are not serving a felony sentence. AB 3115 seeks to educate those who are currently incarcerated in county jails on voter registration and voting rights in hopes of helping them feel more connected to their communities."

Please see the policy committee analysis for a full discussion of this bill.

Analysis Prepared by: Gregory Pagan / PUB. S. / (916) 319-3744 FN: 0003092

Date of Hearing: May 9, 2018

ASSEMBLY COMMITTEE ON APPROPRIATIONS

Lorena Gonzalez Fletcher, Chair

ABPCA Bill Id:AB 3115

Author:(Gipson) – As Amended Ver:April 30, 2018

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

SUMMARY:

This bill requires each county jail to allow at least one organization to provide a voter education program in the county jail, as specified.

FISCAL EFFECT:

Unknown, potentially significant reimbursable state-mandated costs, likely in the hundreds of thousands of dollars for county jails to accommodate a voter education program. A county jail will likely need to provide space and security for any program operating in the jail. If each county submitted a mandate claim of $10,000 the total costs to the state will be $580,000.

COMMENTS:

Background and purpose. Criminal offenders who are serving a felony sentence or are on parole are not eligible to vote. All other offenders are not prohibited from voting based on their criminal history. According to the author:

There is often an assumption by many people that if one has been incarcerated, that they have lost their right to vote, when this is not the case. Due to either misinformation or lack of information, many who are behind bars do not know that they can register to vote. There are systemic barriers in place that make it difficult for people to exercise their right to vote while in jail. Current law requires state and local juvenile detention facilities to assist in voter registration for individuals who are of age and are not serving a felony sentence. AB 3115 seeks to educate those who are currently incarcerated in county jails on voter registration and voting rights in hopes of helping them feel more connected to their communities.

Analysis Prepared by: Jessica Peters / APPR. / (916) 319-2081

Date of Hearing: April 25, 2018

ASSEMBLY COMMITTEE ON ELECTIONS AND REDISTRICTING

Marc Berman, Chair

ABPCA Bill Id:AB 3115 (

Author:Gipson) – As Amended Ver:March 19, 2018

SUBJECT: Jails: voter education program.

SUMMARY: Requires each county jail to allow at least one organization to provide a voter education program in the county jail, as specified. Specifically, this bill requires the voter education program to include, but not be limited to, the following:

1. Providing written and verbal information about voting rights upon release from jail;
2. Providing eligible voters with affidavits of registration; and,
3. Assisting eligible voters with completing and returning affidavits of registration to county elections officials.

EXISTING LAW:

1. Specifies that in order to be eligible to vote, an individual must be a United States citizen, a resident of California, not in prison or on parole for the conviction of a felony, not deemed mentally incompetent, and at least 18 years of age at the time of the next election.
2. Requires the California Department of Corrections and Rehabilitation (CDCR) to establish and maintain a hyperlink on its Internet Web site to the Secretary of State's (SOS) voting rights guide for incarcerated persons, and to post a notice that contains the Internet Web site address where the voting rights guide for incarcerated persons may be found in each parole office where parolees are seen.
3. Requires CDCR to provide each parolee under the jurisdiction of CDCR upon the completion of his or her parole, upon the parolee's request, information provided by the SOS regarding voting rights for persons with a criminal history.
4. Requires each county probation department to establish and maintain a hyperlink on its Internet website to the SOS's voting rights guide for incarcerated persons, and to post a notice that contains the SOS Internet Web site address where the voting rights guide may be found in each probation office where probationers are seen.
   
5. Encourages each county probation department to notify persons that a printed version of information regarding voting rights for persons with a criminal history who are under the department's supervision is available upon request.
   
6. Requires each county probation department to provide each person under the department's supervision, upon the person's request, information provided by the SOS regarding voting rights for persons with a criminal history.
7. Requires the Legislature to provide for the disqualification of electors while mentally incompetent or imprisoned or on parole for the conviction of a felony.
8. Requires the facility administrator of a local detention facility to develop written policies and procedures whereby the county registrar of voters allows qualified voters to vote in local, state, and federal elections, pursuant to election codes.

FISCAL EFFECT: Unknown. State-mandated local program: contains reimbursement direction.

COMMENTS:

1. Purpose of the Bill: According to the author:

California incarcerates 80,000 people in its jails and more than half of the people have not been convicted or are un-sentenced. This is a large community that has historically been excluded from civic engagement and participation. There is often an assumption by many people that if one has been incarcerated, that they have lost their right to vote, when this is not the case. Due to either misinformation or lack of information, many who are behind bars do not know that they can register to vote. There are systemic barriers in place that make it difficult for people to exercise their right to vote while in jail. Current law requires state and local juvenile detention facilities to assist in voter registration for individuals who are of age and are not serving a felony sentence. AB 3115 seeks to educate those who are currently incarcerated in county jails on voter registration and voting rights in hopes of helping them feel more connected to their communities.

1. Which Persons with a Criminal History are Eligible to Vote? AB 109 (Budget Committee), Chapter 15, Statutes of 2011, otherwise known as the Criminal Justice Realignment Act (Realignment), among other things provides that low-level felons be sentenced to county jail and/or supervision by the county probation department instead of state prison, and permits the CDCR to make agreements with local governments to house felons in a county jail or correctional facility as specified. Realignment has caused some confusion about voting rights among people who have criminal convictions.

Persons with a criminal history who are eligible to register and vote include those who are incarcerated in a county jail and are serving a misdemeanor sentence (a misdemeanor never affects an individual's right to vote); are jailed as a condition of probation (misdemeanor or felony); are serving a felony jail sentence; and, those who are jailed while awaiting trial. Others who are entitled to vote include those who are on probation; under mandatory supervision; individuals who are on a federal supervised release; and, an individual with a juvenile wardship adjudication. Once an individual has completed parole their right to vote is restored and they can re-register to vote.

Persons with a criminal history who are not eligible to register and vote include: an individual who is currently imprisoned in a state or federal prison, an individual serving a state prison felony sentence in a county jail or other correctional facility, and an individual currently on parole with the CDCR.

1. States and Felon Disenfranchisement: According to the Sentencing Project's 2016 report entitled "State-Level Estimates of Felony Disenfranchisement, 2016," 48 states prohibit inmates from voting while incarcerated for felony offense. Only Maine and Vermont permit inmates who are incarcerated for a felony offense to vote. California is one of 34 states that prohibit felons from voting while they are on parole, and 2016 legislation restored voting rights to people convicted of a felony offense housed in jail, but not in prison. Individuals imprisoned in the county jail for misdemeanor offenses are eligible to vote in California. Furthermore, once an individual completes his or her term of imprisonment and any period of parole for a felony conviction, that person is allowed to register to vote again in California.
2. Argument in Support: According to California Attorneys for Criminal Justice:

In recent years there has been a welcome and justified increase in attention paid to ensuring effective re-entry services to individuals leaving incarceration. Studies repeatedly confirm that education, job training, and housing assistance reap significant dividends in the lives of those who are returning to the community with long-lasting improvements in their quality of lives and in the reduction of recidivism rates.

Rediscovering the right to vote can be a very empowering tool in transitioning to full participation in the community life. Feeling vested in the well-being of the larger community and society fortifies a broad world view that often leads individuals to more productive participation in community events and a greater responsibility for the overall community.

1. Argument in Opposition: According to the California State Sheriffs' Association:

While we understand the desire to increase inmates' participation in the electoral process, this bill largely ignores any efforts that may be already ongoing within a jail facility. Counties across the state offer inmates assistance with voter registration and the casting of ballots. They often provide registration and ballot materials and assist with the delivery of completed registration cards and ballots.

Additionally, AB 3115 fails to consider appropriate security measures for the safety of inmates, staff, and the facility. Under the unambiguous language of the bill, "each county jail shall allow at least one organization to provide a voter education program in the county jail." In the potential scenario where only a single organization comes forward to undertake the actions contemplated by the bill, AB 3115 seems to mandate that this organization must be allowed access to inmates and the facility, irrespective of any other consideration. Even if this particular organization or persons within it were deemed to be a safety risk, it appears the bill would mandate their access to a jail. The safety and security of a correctional facility should not be exposed to this type of ambiguous but possible threat.

1. Previous Legislation: AB 1344 (Weber), Chapter 796, Statutes of 2017, requires the CDCR and county probation departments to provide voting rights information and affidavits of registration to persons under their jurisdiction.

AB 2243 (Weber), Chapter 899, Statutes of 2014, requires the CDCR to make specified information relating to voting rights of incarcerated persons available to the public, and parolees under their jurisdiction.

AB 149 (Weber), Chapter 580, Statutes of 2013, requires each county probation department, where probationers are seen, to establish and maintain a hyperlink on the department’s website to the SOS’s voting rights guide for incarcerated persons, or to post a notice that contains the SOS’s Internet Web site address where the voting rights guide may be found.

1. Double-Referral: On April 10, 2018, this bill was approved by the Assembly Public Safety Committee on a 5-2 vote.

REGISTERED SUPPORT / OPPOSITION:

Support

Alliance for Boys and Men of Color

American Civil Liberties Union of California (ACLU)

American Muslim Council for Prisoners

Asian Americans Advancing Justice – California (Advancing Justice-CA)

California Attorneys for Criminal Justice (CACJ)

California Calls

California State Conference of the NAACP

Center on Juvenile and Criminal Justice (CJCJ)

Council on American-Islamic Relations, California (CAIR-CA)

Criminal Justice Clinic of UC Irvine School of Law

Demos

Ella Baker Center for Human Rights

Indivisible East Bay

Korean American Coalition (KAC)

League of Women Voters of California

Los Angeles County Supervisor Mark Ridley-Thomas

Los Angeles County Supervisor Sheila Kuehl

Los Angeles Regional Reentry Partnership (LAARP)

Mexican American Legal Defense and Educational Fund (MALDEF)

Mi Familia Vota

NAACP Legal Defense & Educational Fund, Inc. (LDF)

National Association of Social Workers, California Chapter (NASW-CA)

OCCORD

Resilience Orange County

Returning Home Foundation

Rock the Vote

Root & Rebound

Rubicon Programs

San Francisco Public Defender Jeff Adachi

Santa Ana Unidos

Opposition

California State Sheriffs' Association (CSSA)

Analysis Prepared by: Lori Barber / E. & R. / (916) 319-2094

Date of Hearing:

Chief Counsel: Gregory Pagan

ASSEMBLY COMMITTEE ON PUBLIC SAFETY

Reginald Byron Jones-Sawyer, Sr., Chair

ABPCA Bill Id:AB 3115

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

SUMMARY: Requires each county jail to allow at least one organization to provide a voter education program in the county jail. The program shall include, but not limited to, providing both written and verbal information about voting rights upon release from jail, providing affidavits of registration to eligible voters, assisting eligible voters with the completion of affidavits of registration, and assisting eligible voters in returning the completed voter registration cards to county elections officials.

EXISTING LAW:

1. Requires the California Department of Corrections and Rehabilitation (CDCR) to do both of the following:
   
   1. Establish and maintain on the department's Internet website a hyperlink to the Internet website at which the Secretary of State's voting rights guide for incarcerated persons may be found; and
      
   2. Post, in each parole office where parolees are seen, a notice that contains the Internet website address at which the Secretary of State's voting rights guide for incarcerated persons may be found. (Elec. Code, § 2105.5, subd. (a).)
      
2. Requires each county probation department to do both of the following:
   
   1. Establish and maintain on the county probation department's Internet website a hyperlink to the Internet website at which the Secretary of State's voting rights guide for incarcerated persons may be found; and
      
   2. Post, in each county probation department where probationers are seen, a notice that contains the Internet website address at which the Secretary of State's voting rights guide for incarcerated persons may be found. (Elec. Code, § 2105.5, subd. (b).)
      
3. Requires CDCR to provide each parolee under the jurisdiction of the department upon the completion of his or her parole, upon the parolee's request information provided by the Secretary of state regarding voting rights for persons with a criminal history. (Elec. Code, § 2105.6, subd. (a).)
   
4. Encourages each county probation department to notify persons that a printed version of information regarding voting rights for persons with a criminal history who are under the department's supervision is available upon request. (Elec. Code § 2105.6, subd. (b).)
   
5. Requires each county probation department to provide each person under the department's supervision upon the person's request, information provided by the Secretary of State regarding voting rights for persons with a criminal history. (Elec. Code § 2105.6, subd. (c).)
6. Requires the Legislature to provide for the disqualification of electors while mentally incompetent or imprisoned or on parole for the conviction of a felony. (Cal. Const., Article II, § 4.)
   
7. Requires that a person be a U.S. citizen, California resident, not in prison or on parole for the conviction of a felony, and at least 18 years of age at the time of the next election to be entitled to register to vote in this state. (Elec. Code, § 2101.)
   
8. Requires the facility administrator of a local detention facility to develop written policies and procedures whereby the county registrar of voters allows qualified voters to vote in local, state, and federal elections, pursuant to election codes. (Cal. Code of Regulations, Title 15, § 1071.)
   

FISCAL EFFECT: Unknown

COMMENTS:

1. Author's Statement: According to the author, "California incarcerates 80,000 people in its jails and more than half of the people have not been convicted or are un-sentenced. This is a large community that has historically been excluded from civic engagement and participation. There is often an assumption by many people that if one has been incarcerated, that they have lost their right to vote, when this is not the case. Due to either misinformation or lack of information, many who are behind bars do not know that they can register to vote. There are systemic barriers in place that make it difficult for people to exercise their right to vote while in jail. Current law requires state and local juvenile detention facilities to assist in voter registration for individuals who are of age and are not serving a felony sentence. AB 3115 seeks to educate those who are currently incarcerated in county jails on voter registration and voting rights in hopes of helping them feel more connected to their communities.
   
2. Background: According to materials submitted by the author, Civic participation can be a critical aspect of successful re-entry and has been linked to reducing recidivism. However, many in California’s criminal justice system are not accurately apprised of their voting rights and correct voting information is not readily accessible.
   
   In California, those who are currently imprisoned in state and federal prison, serving a state prison felony sentence in county jail, currently on parole with the California Department of Corrections and Rehabilitation, or have been deemed mentally incompetent by the court are not able to vote.
   
   Only two states in the United States (Maine and Vermont) do not remove a person’s right to vote when they are sent to prison. The complexity of the laws and a lack of awareness about eligibility requirements have caused confusion among and misinformation shared to formerly incarcerated communities as well as law enforcement, jail officials and the general public.
   
   With more than half and upwards to 80% of African-American and Latino people incarcerated in the CA jail system and one out of three voters, many African-American and Latino, who have a criminal conviction, are confused about voter eligibility. This is due to continuous changes to an individuals’ status, not given adequate or accurate information about their rights from the time they are involved in the criminal justice system.
   
   Inaccurate information about voter registration laws and eligibility requirements, a lack of transparency about voting rights and generally, a lack of knowledge about elections and the voting process confuse the community, create greater distrust in government and mistrust of government officials.
   
3. Argument in Support: According to the American Civil Liberties Union, "Voting is a fundamental, constitutional right. Understanding how the voting process works and having the ability to voice community support and opposition for elected officials and policies that impact the community is a vital component of civic engagement. This is especially true for Californians who are and who have been incarcerated. California incarcerates approximately 80,000 people in its jails and more than half of the people have not been convicted or are unsentenced. Many Californians who are criminal justice system involved or impacted are confused about the status of their voting rights, either because of misinformation or lack of information. Thanks to recent clarifications in law, such as AB 2446 (Weber-2016), many of them are eligible to register and vote if they are awaiting trial or on trial for any crime, in jail for a misdemeanor conviction, in jail on a probation violation, in jail on a felony probation violation, or serving a county jail sentence under Realignment (AB 109).
   
   ''By providing voter education in the jails, AB 3115 will be a major step forward in helping this population that has historically been excluded from civic engagement and participation by providing them with critical information and assistance regarding their voting rights.''
   
4. Argument in Opposition: According to the California State Sheriffs' Association, "While we understand the desire to increase inmates' participation in the electoral process, this bill largely ignores any efforts that may be already ongoing within a jail facility. Counties across the state offer inmates assistance with voter registration and the casting of ballots. They often provide registration and ballot materials and assist with the delivery of completed registration cards.
   

''Additionally, AB 3115 fails to consider appropriate security measures for the safety of inmates, staff, and the facility. Under the unambiguous language of the bill, ''each county jail shall allow at least one organization to provide a voter education program in the county jail.'' In the potential scenario where only a single organization comes forward to undertake the actions contemplated by the bill, AB 3115 seems to mandate that this organization must be allowed access to inmates and the facility, irrespective of any other consideration. Even if this particular organization or persons within it were deemed to be a safety risk, it appears the bill would mandate their access to a jail. The safety and security of a correctional facility should not be exposed to this type of ambiguous but possible threat.''

1. Prior Legislation:
   
   1. AB 1344 (Weber), Chapter 796, Statutes of 2017, requires the California Department of Corrections and Rehabilitation (CDCR) and county probation departments to provide voting rights information, and affidavits of registration to persons under their jurisdiction.
      
   2. AB 2243 (Weber), Chapter 899, Statutes of 2014, requires the CDCR to make specified information relating to voting rights of incarcerated persons available to the public, and parolees under their jurisdiction.
      
   3. AB 149 (Weber), Chapter 580, Statutes of 2013, required each county probation department to either establish and maintain on the department’s website a hyperlink to the Secretary of State’s voting rights guide for incarcerated persons or post a notice with the website address that contains the Secretary of State’s voting rights guide for incarcerated persons in each probation office where probationers are seen.
      

REGISTERED SUPPORT / OPPOSITION:

Support

Alliance for Boys and Men of Color

American Civil Liberties Union

California Attorneys for Criminal Justice

California Calls

California Public Defenders Association

California State Conference of the NAACP

Council on American-Islamic Relations, California

Ella Baker Center for Human Rights
Korean American Coalition

Mi Familia Vota

National Association for the Advancement of Colored People Legal Defense & Educational

Fund, Inc.

OCCORD

Resilience Orange County

Returning Home Foundation

Rock the Vote

Root and Reboun

Opposition

California State Sheriffs' Association

Analysis Prepared by:

Gregory Pagan / PUB. S. / (916) 319-3744